Specialty Care Research Articles

Primary Care Support Tools for Digestive Health Care: A Mixed Method Study.

To address the increasing demands for gastroenterology specialty care and increasing wait times, centralized access and triage (CAT) systems, telephone support, and clinical care pathways were implemented to streamline referrals and support management of low-risk gastrointestinal (GI) conditions in the primary care medical home. This study aimed to understand primary care providers (PCPs) and GI specialists' perceptions of these supports, factors that affect support implementation and identify barriers and facilitators for implementing supports from both PCP and GI specialists' perspectives. We conducted a mixed method study including surveys and interviews with PCPs and GI specialists. Online surveys and semistructured qualitative interviews were conducted from July 2022 to September 2022. All interviews were transcribed and coded to perform a thematic analysis. Survey data were analyzed in SPSS version 25. Descriptive statistics were employed to summarize and describe the data collected. Inferential statistics were used to identify associations and relationships within the dataset. T-test and chi-square tests were applied at 95% confidence level, with a p value <0.05 (two-sided) considered statistically significant. A total of 36 PCPs responded to the survey. Most respondents were working full-time (73.5%, n = 25) and were female (73.5%, n = 25). Overall, 42% used the pathways regularly, 48% (n = 16) used them occasionally, and very few (9.1%, n = 3) said they were aware but had not used pathways. Overall, PCPs were satisfied with CAT processes and the use of primary care pathways, recognizing the importance of fair and equitable access to specialty care. Specific processes in CAT for vulnerable populations and patients using walk-in clinics were recognized as a limitation, given the lack of ease in completing the required testing and follow-up needed when utilizing the care pathway. Of the 112 GI specialists who received the survey, 28 (25%) completed it, with males (50.0%, n = 14) and females (39.2%, n = 11), remainder no response. Most participate in CAT (73.9%, n = 17) and were remunerated by an alternative relationship plan (ARP) (53.6%, n = 15). Overall, GIs were satisfied with central triaging and primary care pathways, reducing unnecessary time and resource expenditure for referrals. There were statistically significant differences in perceptions among fee for service and alternative relationship plan GI specialists regarding the effectiveness of CAT in improving access and use of health system resources. Overall, PCPs and GI specialists believe utilizing CAT and primary care pathways improves referral quality, reduces resource expenditure, and provides fair and equitable access to GI specialty services. Improvement in CAT processes with improved pathway awareness may reduce unnecessary referrals.

The Central Sensitization Inventory Measures Thoughts and Emotions.

To determine if the Central Sensitization Inventory questionnaire (CSI) functions as a mental health measure among a cross-section of people seeking musculoskeletal specialty care, we asked: (1) What is the association of CSI total score and item groupings identified in factor analysis with mental health measures? and (2) What is the association between specific CSI items that represent each factor well and specific mental health measures? One hundred and fifty-seven adults seeking specialty care for musculoskeletal symptoms completed the CSI, a measure of catastrophic thinking, and 3 measures of distress (symptoms of health anxiety, general anxiety, and depression). Exploratory factor analysis was used to identify item groupings. Exploratory factor analysis identified 4 item groupings (factors): (1) thoughts and feelings (mental health), accounting for 52% of the variation in the CSI, (2) urinary and visual symptoms (15%) (3) body aches (10%), and (4) jaw pain (8.1%). More than half the variation in both the CSI total score (51%) and the thoughts and feelings factor (57%) were accounted for by variation in measures of catastrophic thinking and distress. Specific items that account for large amounts of the variation in the CSI also had notable correlations with mental health measures. The strong relationship between the CSI and thoughts and emotions suggests that the CSI functions largely as a mental health measure. If the concept of central sensitization is to help people get and stay healthy, it will depend on evidence that central sensitization can be measured and quantified distinct from mental health.

Telemedicine is here to Stay: Success and Utility of Video Consultations in Neonatology

Abstract Background and Objectives: “Synchronous videoconference telemedicine in neonatal office-practice” (SyNTOP) has been a routine practice in our center since the start of the COVID-19-related lockdown. We recently reported our experience with the “success” of this practice in terms of removing the need to visit the hospital over the next 48 h after the teleconsult. Methods: Secondary results of this retrospective descriptive study which analyzed 829 consults are presented in this manuscript. Data from electronic medical records of those who availed teleconsultation facility between March 2020 and April 2021 were retrieved. Relevant information about clinical presentation, findings from the video call, demographic information, decisions made by the clinician, and outcomes were collected. Best efforts were made to obtain follow-up information by the clinical team or guest–patient relations officers. Results: Fever (n = 118) and acute diarrheal disease (n = 58) were the common presenting complaints; most (80.5% and 95.5%, respectively) were resolved without physical examination; 265 developmental assessments were completed by video-facilitated checks. Fast-track vaccination visits where queries were resolved and bills paid online, were an innovation where well babies could avoid queues and possible exposure to crowds. One-fourths of SyNTOP were from outside the district, and 1.4% were from foreign countries. Conclusions: Teleconsults were successfully conducted in neonatal office practice for different health-care enquiries. Strategies such as fast-track vaccinations and online developmental follow-up assessments were performed by leveraging technology. We highlight the benefits of these innovations in our center with a view to enhance their uptake elsewhere. Such approaches have the potential to increase health equity and access to specialty health care.

Establishing a clinically applicable frailty phenotype screening tool for aging dogs.

Frailty is a well-defined clinical syndrome in humans caused by accumulation of impairments which result in loss of reserve capacity and increased vulnerability to disability, dependence, and death. Dogs are of particular interest in studies of frailty due to the similarities they share with people in their environment, lifestyles, and age-related diseases. The aim of this study was to develop a frailty phenotype screening tool, based on previously validated measures in dogs, which could be easily applied in the clinical setting, and which was predictive of all-cause, short term (6-month) mortality. The study was conducted in two phases. In phase 1, a retrospective cohort of 51 dogs was used to identify and evaluate potential measures for the five domains of frailty. This information was then used to develop a simple frailty phenotype based on examination findings and owner directed questions. In phase 2 of the study, this phenotype was evaluated in a prospective cohort of 198 dogs aged 9 years or older from multiple different specialty and primary care services to determine how the phenotype performed across a diverse canine population. The developed frailty phenotype was predictive of all-cause, short-term mortality independent of age, sex, or weight (hazard ratio = 4.71; 95% CI, 2.66-8.8). Of the covariates evaluated only breed was significant, with purebred dogs having 1.85 times higher mortality than mixed breed dogs (95% CI, 1.04-3.31). The frailty phenotype performed similarly across all hospital services from which patients were enrolled. Based on these findings, the defined frailty phenotype represents a valuable screening tool for early risk identification and intervention, and can aid in clinical decision making for owners and veterinarians. Additionally, it will promote further research into the understanding and treatment of frailty in dogs.

Patients with diabetes struggling to afford food and control their HbA1c in food-insecure areas in Bronx, NY.

To characterise the association between risk of poor glycaemic control and self-reported and area-level food insecurity among adult patients with type 2 diabetes. We performed a retrospective, observational analysis of cross-sectional data routinely collected within a health system. Logistic regressions estimated the association between glycaemic control and the dual effect of self-reported and area-level measures of food insecurity. The health system included a network of ambulatory primary and speciality care sites and hospitals in Bronx County, NY. Patients diagnosed with type 2 diabetes who completed a health-related social need (HRSN) assessment between April 2018 and December 2019. 5500 patients with type 2 diabetes were assessed for HRSN with 7·1 % reporting an unmet food need. Patients with self-reported food needs demonstrated higher odds of having poor glycaemic control compared with those without food needs (adjusted OR (aOR): 1·59, 95 % CI: 1·26, 2·00). However, there was no conclusive evidence that area-level food insecurity alone was a significant predictor of glycaemic control (aOR: 1·15, 95 % CI: 0·96, 1·39). Patients with self-reported food needs residing in food-secure (aOR: 1·83, 95 % CI: 1·22, 2·74) and food-insecure (aOR: 1·72, 95 % CI: 1·25, 2·37) areas showed higher odds of poor glycaemic control than those without self-reported food needs residing in food-secure areas. These findings highlight the importance of utilising patient- and area-level social needs data to identify individuals for targeted interventions with increased risk of adverse health outcomes.

Research Progress on Chinese Medicine Specialty Care for Depressed Patients after Stroke

Research Progress on Chinese Medicine Specialty Care for Depressed Patients after Stroke

Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project.

To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. Community. Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. Descriptive, qualitative study. Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.

Project Spotlight: Precast concrete panels bring aesthetic appeal to Chicago surgery center

The University of Illinois Health Specialty Care Building, a new out¬patient surgery center in the heart of Chicago’s Medical District, includes two levels of same-day surgery suites, three levels of specialty clinics, and a ground floor with check-in, pharmacy, and imaging services. Precast concrete panel manufacturer International Concrete Products (ICP) from Germantown, Wis., was brought in very early in the process to work with the design team to find solutions for the facility.

Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report

Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as...

Development of a transition program for emerging adults with type 1 diabetes: A quality improvement initiative

BackgroundEmerging adults with type 1 diabetes (T1D) struggle with glycemic management that can be exacerbated by a disorganized transition process. Substantial gaps in care have been noted during this transition period and have been shown to lead to suboptimal health care utilization, worsening glycemic management, increased incidence of serious complications, and mental health challenges. A formal transition program can help prevent gaps in care, improve disease self-management skills, decrease disease burden, and reduce diabetes complications. PurposeThere is an increased focus within the pediatric community to formally prepare young adults with T1D as they transition to the adult health care setting. The purpose of the quality improvement initiative was to develop a transition program for adolescents with T1D in a pediatric endocrinology clinic within an academic medical center. Methods/interventionsThe Institute for Healthcare Improvement Model for Improvement was used to guide this project. Got Transition's® Six Core Elements of Health Care Transition were adapted to the unique needs of the pediatric endocrinology setting by incorporating diabetes-specific transition guidelines recommended by the American Diabetes Association (ADA). A new program was designed to target patients between the ages of 16–18 offering structured transition visits focused on enhancing knowledge and skills related to the management of T1D and improving the transfer of care process between pediatric and adult providers. Key elements of the program were integrated into the electronic health record. A focus group with clinical partners was used to evaluate the acceptability and practicality of the program. ResultsTransition activity within the clinic increased from 12/32–28/32 on the Current Assessment of Healthcare Transition Activities tool. Four themes were identified from clinical partner feedback supporting the acceptability and practicality of program design. ConclusionsThe integration of the Got Transition® framework and the ADA recommendations supports clinicians in meeting the unique needs of adolescents with T1D. Incorporating the transition activities into the electronic health record facilitated integration into the workflow of the clinic providers. This initiative can serve as a model to expand transition activities across pediatric specialty care settings.

Implementation of Enhanced Recovery after Surgery at a General hospital in Zambia

Background: Enhanced recovery after surgery (ERAS), with its aim of reducing operative stress and accelerating rehabilitation, became a standard perioperative care in multiple surgical specialties in developed world. However, little is known about the implementation of the fast-track pathways in a low-resource environment. The objective of the study was to describe our experience and share lessons obtained in using ERAS protocol in general surgery patients.&#x0D; Methods: In this descriptive study, all consecutive patients with no age restrictions undergoing elective and urgent abdominal surgery were assessed for inclusion in ERAS program. A retrospective analysis encompasses 98 patients aged two weeks to 87 years with male to female ratio of 2.3:1. Outcomes were functional recovery, postoperative complications, and length of hospital stay.&#x0D; Results: All elements of ERAS protocol including minimal incision length laparotomy and accelerated postoperative care were used; however, certain components were modified depending on the availability of the resources and patient’s condition. Postoperative period complicated in 17.4% of cases, seven patients (7.4%) died after urgent operations, and no mortality was recorded after elective procedures. Median length of stay was 4.0 days. Local and systemic septic complications, paralytic ileus and performing of the stoma reversal procedure during the same hospital stay were reasons for delayed discharge.&#x0D; Conclusion: This study indicates that employment of ERAS program for general surgery population at a second level hospital is feasible and safe. Further larger-scale studies are needed.

Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions.

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

PATIENT PRIORITIES CARE FOR VETERANS

Abstract People receiving care in the Veterans Affairs (VA) health system are older, have greater socioeconomic disadvantage, and more chronic conditions than those receiving healthcare outside of VA. PPC is well-suited for older adults with multiple chronic conditions and aligns with the VA’s Whole Health movement. A small VA PPC pilot study demonstrated that those receiving PPC compared to usual care had fewer medications added and more home and community services aligned with priorities. VA primary care is a cornerstone and hub for veteran care utilizing a team-based approach. A two-site randomized controlled trial exploring the implementation of PPC in VA primary care is currently recruiting veterans. The early phase of the project involved semi-structured formative assessment interviews with key stakeholders to obtain feedback and perspectives on PPC implementation in VA primary care. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Concerns elicited were time constraints, follow up and documentation of changes in priorities over time, managing patient expectation, communication between primary care and specialty care, as well as how PPC would impact quality metrics. In response to these findings, the patient priorities note template was shortened and streamlined, and the study communications workflow was adapted to align with clinician preferences. Succinct templated language for care alignment was crafted and shared with study providers. Education for clinicians highlighted ways in which priorities could be used to optimize communication. Study procedures were added to identify quality metric exclusions. The study will explore how PPC impacts veteran care and experience.

INTERPROFESSIONAL HEALTH CARE: INTEGRATING AUDIOLOGY AND GERIATRICS IN INTERNATIONAL SETTINGS

Abstract Hearing is fundamental to communication and important for quality of life and overall health of older adults. Despite a potentially large role in how patients engage in healthcare, its importance is underrecognized in healthcare settings. Decreased patient-provider communication and poor treatment understanding may drive decreased satisfaction with healthcare services and avoidance of routine medical care, resulting in poorer health outcomes for older adults with hearing loss. Additionally, despite a high prevalence of hearing loss, less than 20% of those who could potentially benefit from hearing healthcare use hearing aids, potentially exacerbating sequalae of hearing loss in healthcare settings. Amidst growing recognition of the need for inter-professional healthcare collaboration, this session will focus on how audiologists and hearing specialists may partner with other healthcare providers (pharmacists, nurses, physicians) to address hearing needs in primary care, specialty care and hospital settings. We will include perspectives from the United Kingdom, the United States and Canada. We will describe factors that facilitate and impede communication between pharmacists and patients with hearing loss in the community pharmacy. We will also present results of a mixed-methods study from an interdisciplinary team (gerontology, public health, audiology, and otolaryngology/ear nose throat (ENT)) to inform primary care/ENT physicians about preferences for hearing treatment among Black women in the United States. Within a hospital setting, we will present how audiologist-nurse partnerships impact delirium. We will conclude with a discussion of how policy for hearing aid coverage impacts primary care providers recommendations for hearing healthcare in the United States.

INCREASED SUPPORT FOR OLDER VETERANS AND THEIR CAREGIVERS USING TELEHEALTH SERVICES

Abstract Five million Veterans live in rural areas in the U.S., and about half of those live in the South. Rural Veterans are more likely to be older and have a disability compared with non-rural Veterans. In Texas, Veterans comprise seven percent of the adult population with a median age of 50 years, of those 17% live in rural areas where access to care is a concern for many Veterans and their families. Technology-based services could help close this gap. The GRECC Connect program is one way to reach rural Veterans and their caregivers. GRECC Connect is a multi-disciplinary virtual geriatrics program that provides support for providers to help manage older, rural Veterans through telemedicine. Patient Tele- consultations follow the Age-Friendly Geriatrics 5 M’s framework (Medications, Mentation, Mobility, Multi-complexity, and what Matters most). As a demonstration project at the San Antonio GRECC, we partnered with the Geriatric Extended Care Services (GEC), and the Dementia Caregiver Program (DCP) to educate and support caregivers. We also partnered with the education department to conduct clinic outreach. In Fiscal year 2022, we served 72 Veterans, 66 of those had a caregiver, and the majority (51/66, 77%) were enrolled in the DCP. In Q4 (17/17, 100%) of caregivers were enrolled in the DCP. In addition, Veterans were referred to 248 additional services including palliative care and saved 5,934 miles. The GRECC Connect program decreases barriers experienced by older rural Veterans including transportation, assistance to navigate VA system and access to specialty geriatric and palliative care.

VIRTUAL COMPREHENSIVE GERIATRIC ASSESSMENT FOR VETERANS: AN INTERDISCIPLINARY QUALITY IMPROVEMENT PILOT PROJECT

Abstract The Veterans Millennium Health Care and Benefits Act requires comprehensive geriatric assessments (CGA) to be provided to all older Veterans as part of the Veterans Medical Benefits Package. Access to a CGA may be difficult for Veterans with limited ability to travel. Currently, in the North Florida/South Georgia (NFSG) Veterans Health System, approximately 11,500 older Veterans are recognized to be at high risk for hospitalization or placement in a long-term care facility, yet only 0.09% of them have received a CGA. NFSG Geriatrics and Extended Care (GEC) developed a standardized virtual CGA process to increase access to geriatric specialty care utilizing VA Video Connect (VVC). The project design and implementation included: the development of a standard operating procedure using evidence-based screening tools, templates, clinic grids and flowcharts, communication channels, and the development of a dashboard for data collection. In addition, the VHA National CGA Template was piloted. This novel Tele-Geriatrics virtual interdisciplinary project allows older Veterans and/or caregivers to remain at their homes for all telehealth/virtual sessions completed by the CGA interdisciplinary team, including pharmacy, nursing, social work, occupational therapy, and geriatric providers. The project demonstrates increased access to comprehensive assessments, consequently closing the gap between current practice and the Veterans Millennium Health Care and Benefits Act requirements. The pilot also decreased the health disparities of rural Veterans. Furthermore, this project helped to increase Veteran knowledge of geriatric syndromes, VA resources, participation in telehealth, and access to durable medical equipment (DME) to help Veterans age in place.

TRENDS IN COMMUNITY-BASED CARE STAFFING LEVELS IN OREGON: DIFFERENCES BY FACILITY CHARACTERISTICS

Abstract The COVID-19 pandemic re-centered the workforce crisis across long-term care settings in the U.S. Variation in regulatory requirements, industry practices, staff training, and lack of longitudinal data introduces complexity in understanding workforce trends specific to assisted living and residential care (AL/RC). Pooling five waves of the Oregon Community-Based Care study, we examine trends in AL/RC care staff levels and associations with facility characteristics: license type, Medicaid census, profit status, and rurality. From 2017-2022, 548 unique facilities participated in the study, 55% contributing to four to five waves. The estimated average care staff-to-resident ratio was 0.79 (median= 0.67), increasing between 2017 (0.74) and 2022 (0.87). The average staffing level (care hours per resident per day; hours:minutes) was 3:28 (median= 2:58). We estimated ordinary least squares regression models with robust standard errors, controlling for facility-level characteristics and year. On average, staffing levels were higher by 1:38 in memory care (MC) and 0:42 in nonprofit settings. Compared to non-Medicaid settings, overall staffing levels were about 1:00-1:30 lower in mixed-payer settings, and 2:00 higher in settings providing specialty care (e.g., behavioral health, bariatric) at increased Medicaid reimbursement rates. Licensed nursing staff levels were slightly higher in MC, nonprofit, and special contract Medicaid settings. Certified nursing/medication aide levels were 0:30 higher in nonprofit settings. There were no differences in caregiver levels by profit status or rurality, though mixed-payer setting levels were lower by 0:32-0:44. Reduced occupancy during the pandemic resulted in higher staffing levels, though findings suggest continued disparities in staff mix by facility characteristics.

DIRECT OBSERVATION OF OLDER ADULTS VIDEO TELEMEDICINE CHALLENGES

Abstract Video to home has the potential to increase access to clinical services for older adults that face barriers to in-person care and to specialty care such as mobility and transportation challenges. There is evidence that the digital divide has been increasing rather than shrinking for this population. Twenty older cognitively intact Veterans enrolled in Aim 1 of a study of video visits with clinical pharmacists and allowed the study team to observe them in their homes as they prepared for and attempted to connect for the virtual encounter. Technology challenges were encountered in more than 80%, including 60% that required assistance from the in-person study staff, despite these being highly motivated participants. We will share both quantitative and qualitative data regarding the nature of the challenges observed and discuss the implications for geriatric tech equity.

Confronting the dialectic between quality and access in early psychosis care in the United States: Finding the synthesis by leveraging psychological expertise.

Coordinated specialty care (CSC) is the dominant model for early psychosis care in the United States, representing a proactive recovery-oriented approach to serious mental illness in its early stages. CSC involves broad multidisciplinary support for participants, including from psychologists in some CSC teams, encompassing educational and vocational support, medication management, psychotherapy, case management, peer support, and family interventions. CSC programs have proliferated in the last 20 years, leading to a quality-access dialectic, where increasing access to treatment simultaneously prompts concerns about care quality, particularly in the context of staffing shortages and funding limits. Evidence-based psychosocial treatment, including psychotherapy, is an integral part of CSC, yet workforce training deficits, workforce turnover, and CSC financing pose threats to intervention fidelity and thus CSC participants' ability to access high-quality care. We propose an enhanced role for psychologists as a way of resolving the quality-access dialectic in the area of psychosocial treatment, specifically evidence-based therapy. We describe the potential of psychologists' skills in clinical supervision, formulation, evidence-based interventions and measurement-based care, drawing on practice examples. After considering possible limitations, we outline implementation models, for example, drawing on Early Psychosis Intervention Network and Project Extension for Community Healthcare Outcomes. We conclude with four recommendations: Psychologists should be placed in CSC team or network-leadership roles; psychological expertise should be made available to CSC teams for training, consultation, and technical assistance; psychological expertise should be used to address CSC implementation challenges; and research is needed to demonstrate psychologists' value to stakeholders. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predictors of relapse and engagement in care one year after ending services in an urban safety net coordinated specialty care program for first episode psychosis

ObjectiveThis study aimed to identify risk factors for relapse (psychiatric emergency department visits or hospitalization) and lack of follow-up with outpatient psychiatric care in the 12 months after ending services in an urban safety net coordinated specialty care (CSC) program for first episode psychosis (FEP). MethodsThe study population (n = 143) were individuals with FEP who had any CSC care between 2014 and 2021. To identify risk factors for relapse and follow up after exit, multivariable logistic regression was performed using data from electronic health records and linked insurance claims data. ResultsIndividuals with any emergency department visit or hospitalization 12 months prior to ending CSC (aOR = 4.69, 95 % CI 1.78–12.34) and those who were using cannabis at last CSC contact (aOR = 4.06, 95 % CI 1.56–10.56) had a higher risk of relapse after ending CSC services. Cannabis use at last contact was also associated with lower rates of outpatient psychiatric follow-up (aOR = 0.32, 95 % CI 0.12–0.94), while CSC duration in months had a small positive association with post-CSC psychiatric follow-up. There were no differences in relapse or follow-up by race or ethnicity, primary diagnosis, or medication usage. ConclusionsPrior relapse during CSC predicted relapse in the 12 months after ending CSC services, but not outpatient follow up. Cannabis use predicted both a higher rate of relapse and a lower rate of follow up after ending services. There were no differences by race or ethnicity in our sample, suggesting that once individuals engaged in FEP care there were no evident disparities in the observed outcomes.