Primary Mental Health Services Research Articles

Eco-anxiety among regional Australian youth with mental health problems: A qualitative study.

In Australia, climate-related disasters disproportionately affect rural, regional and remote young people with effects ranging from severe flooding and catastrophic fires to unbearable heat and yet most studies on eco-anxiety are based on reports by urban youth who do not have direct experiences of such impacts. Furthermore, there is a dearth of research on how eco-anxiety impacts those who already experience mental health problems. The present study aims to address this gap by focussing on the lived experiences of regional Australian youth with recent experience of climate-related disasters alongside clinical insights from those involved in their care. Two groups, a clinician and client group, were recruited through headspace Port Macquarie-a primary youth mental health service in a regional city of New South Wales, Australia. In all, 25 participants took part in focus group discussions, including 13 clinicians and 12 clients of the service. Clients and clinicians responded to a version of the same questions: (1) whether the effects of climate change impact on regional youth with mental health problems, (2) how young people cope with eco-anxiety and (3) how regional communities can help young people cope with eco-anxiety better. Group discussions were audio-recorded and transcribed. Transcripts were analysed according to the principles of Interpretative Phenomenological Analysis using a team approach. Three dimensions of eco-anxiety were identified by clinicians and clients-helplessness in the present, hopelessness about the future and acute stress and anxiety related to experiences of severe flooding and fires. Clinicians and clients also thought that a misalignment between young people and older generations, including government, was a source of eco-anxiety and having a collective voice was seen as important for regional youth as was community support through social media sites. Clinicians thought that eco-anxiety was 'in the background' for their clients, whereas the clients who participated were clearly experiencing eco-anxiety. Whereas clinicians could identify potential coping strategies, clients could not. Eco-anxiety can be experienced by regional youth with mental health problems as both an acute response to natural hazards and a more sustained sense of hopelessness about the future. Impacts of acute anxiety and chronic hopelessness, with its associated depression risk, among young people with pre-existing mental health problems warrants further investigation as this study suggests that it may exacerbate their existing conditions. Clinicians and clients in this region would benefit from specific training and resources related to the identification and treatment of eco-anxiety. Future research on climate-related mental health should be inclusive of the perspectives of those who have direct experience of climate-related adverse events.

A supported education programme implemented in youth mental health services: Outcomes and lessons from the first year of COVID-disrupted delivery.

Educational attainment is consistently highly valued by young people with mental ill health, yet maintenance and completion of education is a challenge. This paper reports on the implementation of a supported education programme for youth mental health. Between 10 October 2019 and 10 October 2020, a supported education programme was delivered within primary and tertiary youth mental health services. A description of the programme, context, and adjustments required due to COVID-19 is presented, and the educational outcomes of young people referred to the programme were explored. Two case studies are also presented. The programme received 71 referrals over this period, of which 70.4% had not yet completed secondary school and 68% were experiencing multiple mental health conditions. Overall outcomes were positive, with 47.5% of the 40 young people who chose to engage with the programme maintaining or re-engaging with education. However, the remainder of those who engaged withdrew from the programme, often reporting challenges due to COVID-19 such as social isolation or increased uncertainty. Additionally, a number of young people declined or disengaged from the programme to focus on employment. This report of the experience of integrating a supported employment programme in Australian youth mental health services reinforces the need for such support, and provides preliminary evidence for its successful implementation as part of routine care. The disengagement in response to COVID-19 highlights the real-world challenges of the pandemic, while young people's voicing of employment goals indicates the need for combined educational and vocational support-to assist transition and progression between these goals.

Something Happened with the Way We Work: Evaluating the Implementation of the Reducing Coercion in Norway (ReCoN) Intervention in Primary Mental Health Care.

Current policies to reduce the use of involuntary admissions are largely oriented towards specialist mental health care and have had limited success. We co-created, with stakeholders in five Norwegian municipalities, the 'Reducing Coercion in Norway' (ReCoN) intervention that aims to reduce involuntary admissions by improving the way in which primary mental health services work and collaborate. The intervention was implemented in five municipalities and is being tested in a cluster randomized control trial, which is yet to be published. The present study evaluates the implementation process in the five intervention municipalities. To assess how the intervention was executed, we report on how its different elements were implemented, and what helped or hindered implementation. We assessed the process using qualitative methods. Data included detailed notes from quarterly progress interviews with (i) intervention coordinators and representatives from (ii) user organisations and (iii) carer organisations. Finally, an end-of-intervention evaluation seminar included participants from across the sites. The majority of intervention actions were implemented. We believe this was enabled by the co-creating process, which ensured ownership and a good fit for the local setting. The analysis of facilitators and barriers showed a high degree of interconnectedness between different parts of the intervention so that success (or lack thereof) in one area affected the success in others. Future implementation should pay attention to enhanced planning and training, clarify the role and contribution of service user and carer involvement, and pay close attention to the need for implementation support and whether this should be external or internal to services. It is feasible to implement a complex intervention designed to reduce the use of involuntary admissions in general support services, such as the Norwegian primary mental health services. This could have implications for national and international policy aimed at reducing the use of involuntary care.

THE BURGEONING BURDEN OF PERINATAL MENTAL HEALTH IN LOWER MIDDLE-INCOME COUNTRIES

THE BURGEONING BURDEN OF PERINATAL MENTAL HEALTH IN LOWER MIDDLE-INCOME COUNTRIES

“Seeing Myself Through Someone Else’s Eyes”: Embodying the Perfect Nurturer in Compassion Focused Therapy

Compassion-focused chairwork has become a recent focus of empirical investigation. This study extended this area of research by exploring how participants with depression experienced the ‘compassionate other’ imagery exercise enacted via chairwork methods. Eight individuals from primary care NHS mental health services were interviewed about their experience of the practice. The resultant data were analysed using interpretive phenomenological analysis (IPA). Three group experiential themes were identified: care that feels real, chairwork processes and encountering challenges on the road to discovery. The findings indicate that the intervention has therapeutic utility both as an intervention for cultivating compassion and as means of assessing for and identifying blocks to compassion. The results also suggest that there is potential value in enacting compassion-focused imagery techniques through chairwork methods, especially for those who have difficulty accessing mental imagery practices. The findings are contextualised within broader theory and literature, and clinical and research implications are discussed.

School social workers’ experiences delivering mental health supports amid COVID-19 school reopening

Child and adolescent mental health needs are at unprecedented rates in the continued wake of COVID-19. While prior research has examined school mental health practice during initial COVID-19 school closures, few studies have examined school mental health practice amid COVID-19 school reopening. This exploratory study investigates school social workers’ perceptions of their mental health service and support delivery during COVID-19 school reopening as well as the facilitators and barriers they experienced to delivering these supports. This study also examines school social worker’s perceptions of the mental health supports they wished were offered. Fifteen current school social workers in one southeastern state who practiced during the first full school year amid COVID-19 school reopening (2020–2021) participated in virtual interviews. Interview data were analyzed using a qualitative content analysis approach. Findings suggest crisis intervention and counseling were primary mental health services provided by school social workers during this time, and barriers to service delivery included the virtual format of service delivery, emerging experiences of burnout, and a lack of mental health providers. Facilitators to providing mental health services included collaboration with school and community-based partners and supervisor support. Participants wished schools had offered additional in-person mental health services and supports and expressed a need for additional school mental health professionals to be hired. Implications are offered for school mental health practice and research with the aim of helping to inform ongoing responses to COVID-19, future crisis response planning, and areas for improvement in current school mental health approaches.

Costs and benefits of scaling psychosocial interventions during the perinatal period in England: A simulation modelling study

BackgroundGlobally, guidance recommends the integration of mental health into maternal and child healthcare to address common maternal mental health problems during the perinatal period. However, implementing this in the real-world requires substantial resource allocations. ObjectiveThe aim of this study was to estimate the likely costs and consequences linked to scaling the delivery of treatment (in the form of psychosocial interventions) during the perinatal period. DesignSimulation modelling. Setting(s)England. MethodsCosts and consequences were modelled for three scenarios of assumed provision of services, whereby one referred to the projected provision under current government plans, with no additional scaling up of treatment. The other two scenarios referred to additional scaling of treatment: in one scenario, this referred to the provision of treatment by midwives and health visitors trained in the routine enquiry about mental health and delivery of psychosocial interventions; in the other scenario this referred to an expanded provision by primary mental health services. For each scenario and in yearly intervals (covering a ten-year period, 2015 to 2024), unit cots and outcomes were assigned to the activities women were assumed to receive (routine enquiry, assessment, treatment, care coordination). All costs were in 2020 pounds sterling. Data sources for the modelling included: published findings from randomised controlled trials; national unit cost source; national statistics; and expert consultation. ResultsIf the projected treatment gap was to be addressed, an estimated additional 111,154 (50,031) women would be accessing treatment in 2015 (2024). Estimated total costs (including cost offsets) in the scenario of projected provision under current government plans would be £73.5 million in 2015 and £95.2 million in 2024, whilst quality-adjusted life years gained would be 901 and 928 respectively. Addressing the treatment gap through provision by trained midwives and health visitors could mean additional costs of £7.3 million in 2015 but lower costs of £18.4 million in 2024. The additional quality-adjusted life years gained are estimated at 2096 in 2015 and 1418 in 2024. A scenario in which the treatment gap would be met by primary mental health services was likely to be more costly and delivered less health gains. ConclusionsFindings from this modelling study suggest that scaling the integration of mental health care into routinely delivered care for women during the perinatal period might be economically viable. RegistrationN/A. Tweetable abstractIntegrating mental health into maternal and child healthcare might generate economic benefits new study by @a_annettemaria and @knappem @CPEC_LSE finds #increasing access to treatment for women with perinatal mental health problems

Integrated Digital Mental Health Care: A Vision for Addressing Population Mental Health Needs.

The unmet need for mental health care continues to rise across the world. This article synthesizes the evidence supporting the components of a hypothetical model of integrated digital mental health care to meet population-wide mental health needs. This proposed model integrates two approaches to broadening timely access to effective care: integrated, primary care-based mental health services and digital mental health tools. The model solves for several of the key challenges historically faced by digital health, through promoting digital literacy and access, the curation of evidence-based digital tools, integration into clinical practice, and electronic medical record integration. This model builds upon momentum toward the integration of mental health services within primary care and aligns with the principles of the Collaborative Care Model. Finally, the authors present the major next steps toward implementation of integrated digital mental health care at scale.

A framework for evaluating the implementation and maintenance of integration within the youth mental health system.

Given the global burden of disease of youth mental disorders, there remains a need to examine how to improve care for this population. Integrated care has been posited as a potential solution, but there is limited evidence on how best to design, staff, and evaluate different models of integrated care for youth mental health. This oral paper presents the findings of a narrative synthesis of the evidence on integrated models of mental healthcare for young people aged 12 to 25 within PubMed, SCOPUS, and PsycINFO databases. Our literature review aimed to: (1) define and summarise the literature on integrated models of mental healthcare for children and young people, and (2) evaluate the effectiveness of integrated models of youth mental healthcare in enhancing mental health outcomes, quality of life, satisfaction with care, and improving health service delivery in young people aged 12-25 years. To be included in our review, studies were English language peer-reviewed and grey literature from January 2001 – October 2021, which included systematic and/or scoping reviews that assess integrated mental healthcare for children and young people aged 12 to 25 years and studies evaluating models of integrated mental healthcare for children and young people using intervention and comparator groups (included in meta-analysis). To synthesise this literature, we generated intial inductive themes describing components of integrated care shared across the youth mental health system including, collaborative care, person centred care, population and evidence-based care, and governance and financing. We incorporated these themes within a deductive framework adapted from the World Health Organisation health system building blocks. These building blocks include service delivery; workforce; information systems and communication; products and technology; and finance along with the cross-cutting themes of leadership, governance, and policy and values. We then mapped these core components of integrated care onto the six intensity levels of integrated care developed by Heath and colleagues providing an overview of how integrated care can be operationalised in terms of health service building blocks. This framework can form a basis for the development of well-articulated models of youth integrated mental health pathways, assisting services identify what operational changes are needed to best implement and sustain integrated care in their own context. Planned future work involving this framework includes using it to map the integration of primary, secondary, tertiary, public, and private youth mental health services within the Australian health system.

Medical consequences of “contingency accommodation” for people seeking asylum: thematic analysis of a survey from professionals working in contingency accommodation

BackgroundConcerns about the housing of migrants and asylum seekers have escalated since the COVID-19 pandemic. From the use of quasi-detention facilities and so-called contingency accommodation to outbreaks of diphtheria in processing centres, there is a worrying trend to normalise potentially damaging conditions. The aim of this study was to assess the health risks posed by contingency housing for asylum seekers in the UK. MethodsIn this cross-sectional survey, a 10-point online questionnaire was sent to professional networks working with refugees and asylum seekers within the UK. Responses were collected between March 4, and April 11, 2022, using a mixture of convenience and snowballing sampling approach. The objectives of the survey were (1) to identify and document unmet needs, (2) to offer practical support, and (3) to map out services and organisation. The survey was designed by six medical professionals with experience of working with migrants and validated by three doctors who had experience running out-reach medical clinics for asylum seekers within contingency accommodation. Background details of geographical location and occupation were collected, and a combination of closed and open questions were used to collect information across five domains (medical, legal social, integration, and basic essentials) using a social determinants of health framework. A code book thematic analysis using a deductive/inductive hybrid approach was used to identify health and social needs as well as specific rights being denied. FindingsThere were 68 responses from around the UK, of which 30 (44%) were health-care professionals, and 38 (56%) were from the wider voluntary sector. 45 (67%) had visited an accommodation site, and 21 (33%) had worked with those living in contingency accommodation in other respects. Respondents reported observations regarding sites across most parts of the UK. Major themes of access to health-care, access to other services, barriers to access, and safeguarding were identified, with subthemes on access to primary care, maternity, and mental health services (eg, “Vast unmet need in mental health provision, several suicide attempts”); access to basic essential services (eg, “Food was not fit for purpose” “[c]hildren often did not receive breakfast”); education, and legal support; and frequent moving and communication. InterpretationThrough several themes we highlight the substantial impact of structural isolation of asylum seekers through contingency housing, its major effects on wellbeing and the exacerbation of health inequities. We are using these results to work with asylum seekers and local non-governmental organisations to campaign for improved housing conditions. Study limitations include sampling bias, and a lack of voices of those with lived experience. FundingNone.

Impact of the mental health reform in Israel on health care and mortality among people with severe mental illness.

Reports show disparities in the health care of people with severe mental illness (SMI). Yet, the moderating effect of mental health reforms on the health care disparities remain unexplored. The current study aimed to investigate the outcomes of the mental health reform in Israel on the use of health services among people with SMI. A case-control epidemiological study comparing the use of health services 3.5 years before and after the mental health reform for service users diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder. Data on health services included: blood cholesterol test (LDL), hemogalobin-A1C test, and visits to general practitioners (GPs) and specialists. Mortality was recorded. Following the reform the number of visits to GPs was decreased among service users of the three SMI groups, as well as visits to specialists among service users with a schizoaffective or bipolar disorder. Following the reform service users of the three SMI groups showed no-change in the performance of LDL test. Complex findings were noted with regard to the performance of Hemoglobin-A1C test. Mortality rates were higher among service users with SMI and the relative risk were similar before and after the reform. Users of the three SMI groups showed no benefits of the mental health reform in terms of use of health services. Improved health care can be attained by a closer collaboration between the primary physicians and community mental health services.

Patterns of emergency department presentations for a youth mental health cohort: data-linkage cohort study.

Primary youth mental health services in Australia have increased access to care for young people, yet the longer-term outcomes and utilisation of other health services among these populations is unclear. To describe the emergency department presentation patterns of a help-seeking youth mental health cohort. Data linkage was performed to extract Emergency Department Data Collection registry data (i.e. emergency department presentations, pattern of re-presentations) for a transdiagnostic cohort of 7024 youths (aged 12-30 years) who presented to mental health services. Outcome measures were pattern of presentations and reason for presentations (i.e. mental illness; suicidal behaviours and self-harm; alcohol and substance use; accident and injury; physical illness; and other). During the follow-up period, 5372 (76.5%) had at least one emergency department presentation. The presentation rate was lower for males (IRR = 0.87, 95% CI 0.86-0.89) and highest among those aged 18 to 24 (IRR = 1.117, 95% CI 1.086-1.148). Almost one-third (31.12%) had an emergency department presentation that was directly associated with mental illness or substance use, and the most common reasons for presentation were for physical illness and accident or injury. Index visits for mental illness or substance use were associated with a higher rate of re-presentation. Most young people presenting to primary mental health services also utilised emergency services. The preventable and repeated nature of many presentations suggests that reducing the ongoing secondary risks of mental disorders (i.e. substance misuse, suicidality, physical illness) could substantially improve the mental and physical health outcomes of young people.

Headache Disorders in VHA Primary Care: Prevalence, Psychiatric Comorbidity, and Health Care Utilization

Military veterans are at increased risk for headache disorders compared to the general population, yet the prevalence and burden associated with headache disorders among veterans is not yet well understood. In this electronic medical record study, we examined the prevalence of headache disorders among veterans seen in a northeastern network of Veterans Health Administration (VHA) primary care during 2017–2018. We also examined rates of psychiatric comorbidity and health care utilization of veterans with headache disorders for the year following the date of the first headache code in the medical record. Of the total population of veterans in the network, 1.3% had a headache disorder and another 3.5% had a possible headache disorder. Migraine and chronic migraine represented the majority of cases. Posttraumatic stress disorder was the most frequent psychiatric comorbidity. Having a headache disorder was associated with higher rates of primary care, neurology, pain clinic, and mental health service use but not higher rates of emergency department or Whole Health (e.g., patient-centered, holistic health services) use. Prevalence findings are comparable to those previously found among veterans, but a substantial proportion of veterans may have been misdiagnosed. Veterans with headache disorders have high rates of psychiatric comorbidity and use several types of health services at higher rates. Findings highlight the need for interdisciplinary care and further education and support for primary care providers. Primary care settings that integrate evidence-based behavioral and Whole Health services may be an optimal way of providing more holistic care for headache disorders.

A multidimensional approach for differentiating the clinical needs of young people presenting for primary mental health care

ObjectivesThere is an ongoing necessity to match clinical interventions with the multidimensional needs of young people. A key step toward better service planning and the design of optimal models of care is to use multidimensional assessment to understand the clinical needs of those presenting to primary mental health care. Methods1284 people aged 12–25 years presenting to primary youth mental health services completed an online assessment at service entry. Latent class analysis was conducted for seven scales assessing anxiety, depression, psychosis, mania, functioning (indexed by Work and Social Adjustment Scale), and suicidality. ResultsA three-class solution was identified as the optimal solution. Class 1 (n = 305, 23.75%), an early illness stage group, had low and mixed symptomatology with limited functional impairment, class 2 (n = 353, 27.49%) was made up of older persons with established depression and functional impairment, and class 3 (n = 626, 48.75%) had very high and complex needs, with functional impairment, suicidality, and at-risk mental states (psychosis or mania). Additional differentiating characteristics included psychological distress, circadian disturbances, social support, mental health history, eating disorder behaviours, and symptoms of post-traumatic stress disorder. ConclusionsA large proportion of help-seeking young people present with symptoms and functional impairment that may exceed the levels of care available from basic primary care or brief intervention services. These subgroups highlight the importance of multidimensional assessments to determine appropriate service pathways and care options.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

IntroductionThe Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon’s health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.MethodsA Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.ResultsWe identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.DiscussionToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

Psychometric validation of the 15-item Questionnaire about the Process of Recovery in Spain (QPR-15-SP).

Reliable and valid instruments are needed to measure the impact of mental health services and programs on the journeys of recovery of service users. The aim of this study was to explore the psychometric properties of the cross-culturally adapted 15-item Questionnaire about the Process of Recovery in Spain (QPR-15-SP). One hundred and ten participants from three locations in Spain (Málaga, Barcelona and Madrid), who were users of primary and specialized mental health services, were interviewed from October 2021 to June 2022. The internal consistency obtained was excellent: ω =.93 and α =.92. Temporal reliability using intraclass correlation coefficients was moderate (ICC=.684, p <.000). Regarding convergent validity, the QPR-15-SP had a moderate correlation with the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) (ρ =-.500, p <.000), a Visual Numeric Recovery Scale (VNRS) (ρ =.591, p <.000), and the Stages of Recovery Instrument (STORI) (r =.566, p <.000). Correlations between advanced stages of recovery and higher QPR-15-SP scores were found (Moratorium: ρ =-.579, p <.000; Awareness: ρ =-.130, p =.189; Preparation: r =-.043, P=.665; Rebuilding: r =.460, p <.000; Growth: ρ =.697, p <.000). In terms of divergent validity, the QPR-15-SP had low correlation with the DUKE-UNC Functional Social Support Scale (ρ =.273, p <.005). The confirmatory factor analysis of the 1-factor structure obtained reasonable goodness of fit indexes. The QPR-15-SP has acceptable psychometric properties, providing support for measuring recovery in Spain and allowing international comparison research.

Client predictors of therapy dropout in a primary care setting: a prospective cohort study

BackgroundTherapy dropout poses a major challenge. Considerable research has been conducted on predictors of dropout, however none in the context of primary mental health services in Norway. The purpose of this study was to investigate which client characteristics can predict dropout from the service Prompt Mental Health Care (PMHC).MethodsWe performed a secondary analysis of a Randomized Controlled Trial (RCT). Our sample consisted of 526 adult participants receiving PMHC-treatment in the municipalities of Sandnes and Kristiansand, between November 2015 to August 2017. Using logistic regression, we investigated the association between nine client characteristics and dropout.ResultsThe dropout rate was 25.3%. The adjusted analysis indicated that older clients had a lower odds ratio (OR) of dropping out compared to younger clients (OR = 0.43, [95% CI = 0.26, 0.71]). Moreover, clients with higher education had a lower odds ratio of dropping out compared to clients with lower levels of education (OR = 00.55, 95% CI [0.34, 0.88]), while clients who were unemployed were more likely to drop-out as compared the regularly employed (OR = 2.30, [95% CI = 1.18, 4.48]). Finally, clients experiencing poor social support had a higher odds ratio of dropping out compared to clients who reported good social support (OR = 1.81, [95% CI = 1.14, 2.87]). Sex, immigrant background, daily functioning, symptom severity and duration of problems did not predict dropout.ConclusionThe predictors found in this prospective study might help PMHC-therapists identify clients at risk of dropout. Strategies for preventing dropout are discussed.

Health Service Protection vis-à-vis the Detection of Psychosocial Risks of Suicide during the Years 2019-2021.

Health services are especially relevant in suicide prevention and intervention, representing a favourable environment in which to implement specific strategies to detect and address suicidal behaviours. Indeed, a significant proportion of people who die by suicide (DBS) present at primary care and mental health services during the last year, month, or even days before committing suicide. The objective of this descriptive and cross-sectional study of all registered cases of death by suicide (N = 265) in Extremadura (Spain) was to determine which of those people who died by suicide had mental health problems (MHP) and what type of assistance they had requested. Diagnoses, previous suicide attempts, type of health service, and last visit before death were explored with univariate analyses and logistic regressions. The proportion of people without MHP was found to be high, and these people had hardly visited the health services at all in their last year. People with MHP, between the ages of 40 and 69, and with previous suicide attempts were more likely to have visited the mental health service in the three months prior to their death. It is, thus, necessary to provide health professionals with tools and training in the prevention of and approach to suicide. Efforts must be directed towards effectively assessing mental health and the risk of suicide since a large proportion of people who die by suicide may go unnoticed.

The Clinical Resource Hub Initiative: First-Year Implementation of the Veterans Health Administration Regional Telehealth Contingency Staffing Program.

Health care systems face challenges providing accessible health care across geographically disparate sites. The Veterans Health Administration (VHA) developed regional telemedicine service focusing initially on primary care and mental health services. The objective of this study is to describe the program and progress during the early implementation. In its first year, the Clinical Resource Hub program provided 244 515 encounters to 95 684 Veterans at 475 sites. All 18 regions met or exceeded minimum implementation requirements. The regionally based telehealth contingency staffing hub met early implementation goals. Further evaluation to review sustainability and impact on provider experience and patient outcomes is needed.

VA Health Connect: A Clinical Contact Center Designed to Enhance Access and Quality of Care for Veterans

Summary The Covid-19 pandemic dramatically catalyzed use of telehealth and other virtual care modalities. Now, as virtual care delivery has become more widely accepted and increasingly used as a primary mode of care delivery, clinical contact centers (CCCs) are emerging as an important venue for access to a growing array of virtual care and other services. The Veterans Affairs Health System (VHS) has found that its call centers, which were historically used to offer patients inbound telephonic communication, have provided a foundation for regional CCCs using technology to offer patients bidirectional, multichannel communication (e.g., voice, video, text, chat) that improves health care accessibility, care coordination, and patient communication. In addition, the VHS has used the CCCs to leverage resources across care settings when managing public health emergencies. In May 2020, the VHS’s Office of Veterans Access to Care led an initiative to modernize and consolidate the 87 individual Veterans Affairs Medical Center (VAMC) call centers into 18 regional CCCs serving all 171 VAMCs. Although still a work in progress, the Veterans Affairs CCC initiative — branded VA Health Connect — has expanded access to primary care, pharmacy services, emergency medicine, and mental health services. VA Health Connect is now responding to more than 40 million inquiries per year, with improvements in speed to answer, abandonment rates, and first-contact resolution. The authors describe some lessons learned in the implementation of VA Health Connect about how to involve people, processes, and technology to enhance patient services. The application of human-centered design can inform technology adoption and configuration of multichannel (omnichannel) communications. Critical to the success of VA Health Connect has been the incorporation of change management, effective mechanisms for deploying care delivery technology, and the importance of standardized data for performance improvement and organizational learning.