Appetite for life.

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...

Objective-Persons with severe mental illness have higher rates of chronic general medical illness compared with the general population.Similarly, compared with the general population, incarcerated persons have higher rates of chronic medical illness; however, there is little information about the synergy between severe mental illness and incarceration and the general medical problems of consumers.To address this gap in the literature this study addresses the following question: are consumers with a history of incarceration at greater risk of general medical problems compared with consumers without such a history?Methods-Administrative data were used to compare the medical problems of 3,690 persons with severe mental illness with a history of incarceration and 2,042 persons with severe mental illness with no such history.Results-Consumers with a history of incarceration were more likely than those with no such history to have infectious, blood, and skin diseases and a history of injury.Furthermore, when analyses controlled for gender, race, age, and substance use disorders, consumers with an incarceration history were 40% more likely to have any general medical problem and 30% more likely to have multiple medical problems.Conclusions-The findings presented here call for better communication among local public health and mental health providers and jails and better integration of primary care and behavioral health care among community mental health providers.Also, research on evidence-based interventions designed to divert persons with severe mental illness from the criminal justice system and facilitate community reentry for persons with severe mental illness who are released from jails and prisons should be accelerated.

Independent foundations' primary focus is grant making.In general, their assets come from the gift of an individual or family.Community foundations' assets usually come from many donors rather than a single source, and grant making is limited to a particular region.Community foundations are usually classified as private charities under the tax law and are subject to different rules and regulations than are other private foundations. Access To CareAccording to 1988 Census Bureau estimates, over thirty-one million Americans are without health insurance.The demographics of these people are diverse, and their ranks continue to grow as the service industry burgeons and as competition in health care increases.Regional disparities in access also exist.Foundation funding in this area ranges from economic analyses of the problem to direct provision of care.

The challenges of COVID-19 for people with dementia with Lewy bodies and family caregivers.

<b>PB-PG-0712-28011 – NIHR Research for Patient Benefit Programme – Final report</b><br /> <br /> <b>Project title: </b>Learning from women’s experiences: improving our understanding of the physical, psychological and emotional health impacts of domestic violence and abuse (DVA), help-seeking trajectories and outcomes<br /> <br /> <b>Authors:&nbsp;</b><br /> Dr Maggie Evans - NHS Bristol CCG&nbsp;&nbsp;<br /> ProfessorGene Feder - University of Bristol<br /> Dr Fiona Duxbury - Blackbird Leys Health Centre<br /> Dr Helen Salisbury - University of Oxford<br /> Professor Sue Ziebland - University of Oxford<br /> <br /> <b>Plain language summary</b><br /> <br /> It is estimated that 1 in 4 women experience Domestic Violence and Abuse (DVA) during their lifetime and may approach multiple agencies before they get help. On average women try to leave abusive relationships 7 or 8 times, but may encounter repercussions from their partner and difficulty in disclosing their situation to family members, friends, health care or other professionals. This can lead to extreme social isolation. We aimed to develop a web-based resource which gives real-life accounts of women's experiences of DVA and their outcomes. This may help to increase the options for women in an abusive relationship, suggest ways to improve their self-care, where to seek help and how to make plans to leave.<br /> <br /> We conducted in-depth video- and audio-taped interviews with 40 women across the UK, with a range of ages and ethnic backgrounds, who have experienced DVA, asking about the impacts on their physical and mental health, their help-seeking experiences, outcomes and any barriers experienced. The interviews are being used to develop (i) a web-based resource for women experiencing DVA, family members and friends, as part of www.healthtalkonline.org. (ii) a training resource for medical and allied health and social care professionals. Participants were recruited through Patient and Public Involvement groups, advertisements in the media, a dedicated website and specialist third sector agencies. Women were interviewed at a safe location by an experienced female researcher.<br /> <br /> We were very careful to ensure participants’ safety. Women who felt uncomfortable about videos or audio-recordings being available online are represented by actors, and real names of people and places are deleted.<br /> We found consistent themes in the women’s narratives, which have been written up as Topic Summaries for the website. For example, the data provide new insights into the experience of Coercive Control which is now a criminal offence but is poorly understood. We found new insights into the difficulties and dangers faced by women who want to leave an abusive relationship, which counter the often asked question: ‘Why didn’t you just leave’. We also found that women themselves were so isolated and controlled in the abusive relationship that they generally did not understand that they were experiencing DVA. Our study highlights the need for wide-ranging education into the reality of DVA, which will be part of the dissemination process.<br /> <br /> <b>Keywords</b><br /> Domestic Violence, Domestic Abuse, Women's Narratives, Women's Help-seeking, Women's Health, Qualitative study, Website study.<br /> <br /> <b>Summary of research findings</b><br /> <br /> Methods<br /> <br /> We recruited a purposive sample of 40 women across the UK who have experienced DVA. They had a range of ages and ethnic backgrounds. Women were recruited via DVA support agencies, patients at GP practices which operate the IRIS model for the identification and referral of women to DVA support agencies, a website set up for our study, twitter and FaceBook.<br /> <br /> Women were interviewed in a safe, convenient location using a topic guide that covered all aspects of their experience of DVA. Interviews were video- and/or audio- recorded. Women could chose the form in which clips of their interview will appear on the website, either video, audio, written or spoken by an actor. Three women decided not to have their data included on the website. All participants had the opportunity to check and give approval for the use of their interview data, making deletions if they wished to.<br /> <br /> Interviews were transcribed, anonymised and the data were entered into NVIVO software. The research team carried out a thematic analysis which was used as the basis for writing 27 Topic Summaries for the website, illustrated by clips from the interviews. These summaries represent the full range of women’s experiences of DVA, and reflect the most important themes. The topic summaries and associated clips are being processed by the technical team at the DiPEx charity in order for them to appear on the website. All video and audio tapes will be professionally edited.<br /> Some of the participants, DVA professionals and GPs, along with the research team formed an Advisory Panel that met twice during the study, to comment on the process and to advise on the content of the proposed Topic Summaries. They evaluated the material that had been prepared by the research team in June 2016 and, as a result, major changes were made to the format and content of the Topic Summaries, feedback that was valuable in developing the finished product.<br /> <br /> Key Findings<br /> <br /> We found consistent themes in the women’s narratives, which formed the Topic Summaries for the website. For example, the data provide new insights into the experience of Coercive Control which is now a criminal offence but is poorly understood. We found new insights into the difficulties and dangers faced by women who want to leave an abusive relationship, which counter the often asked question: ‘Why didn’t you just leave’.<br /> <br /> Women's narratives confirmed the devastating impacts of DVA on their mental health and also on that of their children, impacts that did not stop when the relationship ended. Specialized therapy may be needed to help women and their families recover from the trauma of DVA, and yet women's accounts reveal a widespread lack of understanding or appropriate support across a range of key professionals in healthcare, the police and children's services including CAFCASS.<br /> <br /> We also discovered a number of significant barriers to women in seeking help, which form a Topic on the website entitled ‘Obstacles to seeking help’. Women across all educational levels revealed a lack of knowledge about DVA, so they were not able to understand their partner’s behaviour. Women described being manipulated into believing their partner’s behaviour was their fault and therefore they had no ‘right’ to ask for help.<br /> <br /> Other constraints to asking for help included a deep fear amongst women that they might lose custody of their children if their home situation was known about by professionals. Women also said that it was hard for them to open up to anybody about their experiences and urged professionals, family and friends to ask more questions but to be non-judgmental. The very real repercussions in terms of violence from their partner when a woman left was highlighted in the interviews and underlines the need for greater support at this time. For many women, getting a place in a women’s refuge was impossible owing to lack of availability and the need to be eligible for public funding. This was particularly difficult for first generation migrant women.<br /> <br /> Our study highlights the need for wide-ranging education into the reality of DVA, which will be part of the dissemination process. Our participants frequently experienced being let down by, for example, the police who had, in the participants’ view, little understanding of DVA beyond physical violence.<br /> <br /> Expected impact<br /> <br /> The study will be published online as part of the award-winning website www.healthtalkonline.org, a growing resource that specialises in disseminating qualitative studies of experiences of health and illness. The impact of a website is difficult to measure. The site currently covers over 70 health conditions and receives over 5 million hits per month. Following the launch of the DVA module, which is likely to be in March 2017, we will undertake dissemination work to maximise potential impact. We will receive regular bulletins of the number of hits per page from the website charity, so that we can monitor usage over time.<br /> <br /> We plan to expand on dissemination and impact measurement following the launch which will include a Press release and media coverage. We are working closely with Women’s Aid to facilitate dissemination. The DVA module will be introduced on the website by some video clips from key informants in the field of DVA. We have made an introductory video of Jenni Murray, Patron of Women’s Aid and presenter of Radio 4 Woman's Hour. Radio 4 has been covering DVA in the last two years through a storyline in the radio series ‘The Archers’ and Women’s Hour has made several reports on the topic. We hope to use this forum to advertise the website module.&nbsp;<br /> <br /> We have already taken steps to include findings and video clips in teaching modules for medical students and in academic and non-academic conferences and events. Clips and data from the DVA module will be incorporated in the training for the IRIS model for GPs and other staff in primary care (see www.irisdomesticviolence.org.uk). We hope that the range of topics addressed in the DVA module will strengthen the likelihood that primary health care and other commissioners will commission IRIS and other DVA resources. Small cards and/or posters giving the web address of the DVA module will be available to be distributed to interested parties, for example GP practices, hospitals, police stations, DVA agencies, other public places. Attempts till be made to disseminate into other professional areas such as the training of police or the education of young people. One potential method for doing this is to create a piece of ‘verbatim theatre’ in which actors speak the words of women survivors of DVA, taken from their narratives, and developed into a piece of theatre. We plan to apply for funding for dissemination and impact assessment work.<br /> <br /> The balance of the grant (under &pound;4,000) will be retained for 12 calendar months so that we can undertake planned dissemination work, which will include professionals' study and information days and attending international conferences about DVA (please see spreadsheet for details).<br /> <br /> Conclusions<br /> <br /> A resource such as the www.healthtalk.org&nbsp; module about DVA could be used in a variety of health care, social care and educational settings, to increase public and professional understanding of DVA. Most of the women said that, had they known about DVA in all its various forms, they might not have stayed so long in an abusive relationship, and they would have sought help earlier.<br /> <br /> A positive outcome was the number of women who experienced support from other survivors of DVA. For many women, simply talking to someone else who understood, was the beginning of their own journey away from abuse. Providing and evaluating information, resources and training to facilitate women in setting up and advertising peer support groups could be valuable future research proposals.<br /> <br /> <br /> <b>Patient and public involvement</b><br /> <br /> Working with our PPI group of women survivors of DVA has been essential to the success of the study. I feel strongly that PPI representation should not be tokenistic, such as one or two PPI members on a steering group that mainly comprises academics and other professionals, which will enable only the more confident or articulate to participate. I also resist the move towards the 'semi-professionalisation' of PPI members that I see in evidence around me, whereby individuals with a particular illness condition are recruited because of current or past professional skills that are relevant to the research rather than for their personal experience of the condition that is being studied. I have witnessed formal application forms and interviews for PPI positions, which I wholly disagree with. Our role as professionals is to objectify the condition under study and as far as PPI members are concerned it is important to prioritise their subjective experiences, not their confidence or articulate-ness or professional skills.<br /> <br /> With this in mind, we recruited a group of women survivors, some of whom had worked with us on previous studies, and who met regularly during the lifetime of the study. Meetings were held at the University, pre-paid taxis were booked to enable women to attend, lunch was provided and shopping vouchers of &pound;20 were provided in appreciation of their time and contribution. Four members of this group volunteered to join the project Advisory Panel that also included professionals from Women's Aid, the local DVA agency, the IRIS programme, GPs with expertise in DVA and the core research team.<br /> <br /> PPI members were involved in developing the funding application, helping to prioritise the research aims and develop the methodology. They provided important insights into issues of confidentiality and safety in terms of recruitment, data collection and use of the data on the website. When funding was secured, PPI members assisted in the development of participant information resources, commenting on the design and wording of all research documents such as participant information sheets, consent forms and topic guides. We agreed to implement a safety button on each page that instantly closes the website down should a woman be disurbed while One innovation that arose from this process was the design and use of a coloured flyer which was widely disseminated. It showed a woman's face with speech bubbles asking key questions to identify DVA. This was used as the initial stage of recruitment, before the full information sheets were provided. Another example was the agreement to include a safety button on each page that quickly closes the website down if a woman is disturbed while accessing the site.<br /> <br /> We held two Advisory Panel meetings during the lifetime of the study, which were lengthy working sessions. All members were sent data in advance and invited to comment. At the second of the two meetings, we drafted the Topic Summaries for the website and we had a very lively meeting following which I changed the focus of the data analysis in line with the feedback from the survivors. Drawing on their own experience they were able to steer the way in which the data was analysed, so that we reduced the emphasis on some topics and expanded others. One example of this is the use of a large amount of data in the interviews relating to the effects of DVA on children, some very long-term, and women's struggles to get help and support for their children. We had not originally processed this data as it seemed to take the focus off the women and we also feel that we have enough data on children to potentially write another healthtalk module! However,&nbsp; all the women felt that impact on children was one of their prime concerns. When we analysed the data we realised that the impact on children was both a reason for women to stay in an abusive relationship and also a reason for women to get away. Although the analysis and processing of this data provided a lot of extra work, we feel that the module is better as a result. Our panel representative from the HERG unit at Oxford (which leads the research for the website) commented that it was one of the best, well attended and inclusive meetings she had attended.<br /> <br /> The PPI women continue to be involved, some have offered to proof-read the material for the website, others are personally attending conferences and meetings to speak about their experiences of DVA and their experiences as research advisors. When the module is ready, we will involve PPI women in a short evaluation and checking, followed by the&nbsp; launch. We will continue to consult and involve the women in our dissemination plans.<br /> <br /> <b>Data sharing statement</b><br /> See link <a href="https://www.nihr.ac.uk/documents/nihr-position-on-the-sharing-of-research-data/12253">[https://www.nihr.ac.uk/documents/nihr-position-on-the-sharing-of-research-data/12253</a>] for the NIHR position of the sharing of research data.&nbsp; The NIHR strongly supports the sharing of data in the most appropriate way, to help deliver research that maximises benefits to patients and the wider public, the health and care system and which contributes to economic growth in the UK.&nbsp; All requests for data should be directed to the award holder and managed by the award holder.<br /> <br /> <b>Disclaimer</b><br /> This project is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0712-28011). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.<br /> <br /> This project was carried out between September 2014 and November 2016 . This final report has not been peer-reviewed. The report was examined by the Programme Director at the time of submission to assess completeness against the stated aims.

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

Family Physicians Sue to Shine Light on RUC Deliberations, Claim Specialists Skew Reimbursement Against Primary Care

Janet Kinson practised as a Diabetes Specialist Nurse in Birmingham and demonstrated a remarkable commitment to diabetes education by developing a programme to support what was then the newly-emerging profession of diabetes specialist nursing. She was forward thinking and saw the potential to do things differently, but insisted on high quality. As the nominated speaker for the Janet Kinson lecture I want to reflect upon my own experiences of working in diabetes and of some important changes that have happened over the last 25 years based on an ethos and value system which is fundamentally patient centred. If we consider the perspective of an individual with a long-term condition such as diabetes (Figure 1), it reminds us that all of the important activity to manage and look after diabetes takes places outwith the 20–30-minute, two to three times a year consultation (Figure 1: orange lines). And yet, as health care professionals, we sometimes expect that these regular visits to clinics will be enough to enable the person to manage their own health, claiming credit when people do ‘well’ and throwing our arms up in despair when targets aren't being achieved. In reality, we aren't in charge, we have a relatively limited role in managing diabetes, and outcomes are by and large driven by the person. I qualified as a dietitian in 1989 with a keen interest in diabetes, and I wanted to make a difference. However, I found my early career hugely frustrating because at that time there were no specialist diabetes posts and dietetics was usually delivered separately from the rest of diabetes care, with very little clinical information to draw upon to support decision making or to feed back to the person. People were sent to the dietitian as a form of punishment and as a last resort. I certainly didn't feel valued and I can't imagine the people who used the service found it as useful as it could be. It didn't really utilise any of the knowledge or skills I had spent four years learning at university. For me this all came to a head when I arrived at a general practice clinic and was faced by a receptionist who had forgotten I was coming and hadn't booked a clinic room. She showed me to the cleaning cupboard! I felt I might leave dietetics altogether. However, in 1994 I went for an interview at North Tyneside for a newly-created diabetes specialist dietitian post – one of the first of its kind. The post had been created following a local (unpublished) study which had developed a new role called a ‘Diabetes Advisor’. In the study, people with type 2 diabetes had been randomised to ongoing care with a nurse or a dietitian which turned out to be equally effective and acceptable to patients. Interestingly, the funding for this study had been obtained from Kellogg's since the usual sources of research funding felt it unethical to allow dietitians to be responsible for individual patient care. It was here that I met Dr Sue Roberts, who has been an inspiration to me and to so many people who have worked alongside her. The service she developed was unique and there were always opportunities to challenge the way things were done. There was a strong focus on organised and systematic care, with good links between primary and specialist care, facilitated by training and close working relationships. There were clear pathways; everyone knew their role and how things worked and we spent time examining data, reflecting on practice and tending to our training needs. The philosophy, principles and aims of the service were clear and written down (Figure 2). Every year we went to the local lighthouse and had a productive awayday. It was also an effective service, and I suspect one of the first examples of a properly integrated diabetes service. In 2004, one of the local GPs published data from the comprehensive diabetes register, which demonstrated that the outcomes across the whole population were as good as the intensively-controlled arm of the UKPDS trial.1 However, this was achieved with significantly less weight gain than expected. In our model of care, not only were dietitians seeing people and supporting lifestyle change, they were also supporting and up-skilling general practice staff in diabetes while keeping the specialist service appraised of what was happening in routine primary care. The team of nurses, doctors, podiatrists, physiologists and administrators were committed and passionate about what they did. What really stood out was the way the team talked about and related to patients, with a huge amount of respect for the way they chose to manage their lives. We tried to use psychological rationale to understand behaviours and health beliefs to help us best know how to support people. I learnt a new phrase – unconditional positive regard. This was exemplified by the training and support we received from our psychologists: Dr Peter James and Dr Yvonne Doherty. They trained the whole team to understand and deliver much more psychologically-informed services and consultations. This wasn't just about motivational interviewing. We all had to develop new ways of consulting with people and a whole host of methods to maintain positive therapeutic relationships with patients and to challenge and support different ways of thinking. Working in this way has cemented for me the critical nature of high-quality consultation and communication skills within diabetes and long-term conditions care. This is demonstrated in our local Dove Data which show a strong association between patient involvement, good glycaemic outcomes and lower costs for prescribing. Perhaps as a result of this environment, I began to think about people who were starting insulin and the local and national data that showed people weren't seeing the improvements they expected. It's a huge step for someone to make the transition to an injectable therapy and so, if it doesn't work, it reduces their confidence in making a difference to their own outcomes. It also diminishes their trust and relationship with the diabetes team. So I led the trial of a very structured approach which we called a ‘pre-insulin assessment’. This included a detailed assessment, giving consistent messages and information about choices, leading to a plan to maximise all current therapy (lifestyle and medication). At the same time, we learnt about the concerns the individual might have about current and future treatment – a form of supported shared decision making. The impact was clear – only 50% of people needed to start insulin and, for those who did, glycaemic goals were achieved with much less weight gain than predicted.2, 3 This is now part of our routine care pathway for people with type 2 diabetes. Our dietitians make decisions to directly refer people to groups or 1:1 injectable starts, avoiding unnecessary appointments and delays and freeing up space in outpatient clinics for people who really need to see a consultant. This was developed in specialist care but now happens in general practice and has become a ‘next steps assessment’ due to the broader range of therapeutic options now available. The next steps assessment is an example of several dietetically-led initiatives which have improved the outcomes and involvement of those with diabetes in our patch – our expertise is about food, but we integrate that into discussions about other diabetes treatments and medicines and psychological approaches which are, in turn, integrated into the rest of routine diabetes care. As a result of leading on this, I became the first consultant diabetes dietitian. This is all in stark contrast to my beginnings as a newly-qualified dietitian (trying to avoid the cleaning cupboard!), but it does demonstrate that dietitians can make a huge contribution to the overall work in diabetes and how important it is to ensure this sometimes underutilised group of professionals are integrated into routine diabetes care and given the chance to develop and lead. We now have 10 whole-time-equivalent dietitians working across primary and specialist care, and the team continues to develop new effective approaches based on our learning. One of these, which had a huge impact on our professional group, was structured patient education, starting with DAFNE. At the time, we were first looking at the intensified insulin programme developed by Michael Berger's team in Germany; carbohydrate counting had been assigned to the dusty shelves of history. At that point, carbohydrate counting was associated with very restrictive, inflexible diets in which a daily prescription of carbohydrate was made up from a fairly limited ‘exchange’ list. These diets were not in keeping with nutritional guidelines for the general population. As a result, the dietetic profession had shunned the approach and instead focused on qualitative dietary regimens (low glycaemic index and healthy eating). In addition, the food messages for both type 1 and type 2 diabetes were the same. The Dusseldorf team had demonstrated that their programme supported people to achieve clinically-significant improvements in glycaemic control without an increase in severe hypoglycaemia.4 Our visiting team from King's, Sheffield and Northumbria observed their type 1 training programme, which focused entirely on carbohydrate counting and insulin dose adjustment to achieve both flexibility and better clinical outcomes. We were amazed at how well it worked. On our return, although we were very enthusiastic, the dietetic profession was unsure and took a lot of persuading and retraining to take on the approach. Carbohydrate counting is now the acknowledged dietary strategy and evidence-based practice in terms of nutritional therapy in type 1 diabetes and is recommended in all national and international guidelines.5 DAFNE was accepted by professionals because we were able to use the UK feasibility study to show that it improves glycaemic outcomes without a deterioration in weight and cardiovascular risk.6 It also improves quality of life, and has subsequently been shown to reduce unplanned health care utilisation.7 However, what makes DAFNE important to me is that it gives people with diabetes the knowledge, skills and confidence to manage their diabetes on a day-by-day basis. I was asked to join a kick-off meeting for type 2 structured education and was keen to use my experience from DAFNE to support people with type 2 diabetes. At a local level we wanted to retain a high-quality approach but the numbers of those with type 2 diabetes were increasing significantly. In developing the DESMOND programme, we were particularly aware of the impact of health beliefs and behaviour change in the management of type 2 diabetes. We therefore focused on a patient-centred philosophy and underpinning psychological theories. The programme uses an approach in which people are given information and are supported to make their own decisions around goals and actions in order to manage their own diabetes.8 In the same way that Janet Kinson had applied rigorous standards to the training of diabetes nurses, both the DESMOND and DAFNE group felt that the same principles should apply to the development and roll-out of structured education. In order to do this we developed rigorous methods of training and quality assuring the programmes. In my role as chair of the DAFNE educator group, I worked alongside a strong team who developed a train-the-trainer and quality assurance process for educators and DAFNE courses.10 This was supported by the development of national guidelines for structured education.11 Sadly, the importance of standards in education is still not accepted everywhere. We would never prescribe half doses of medication; it is still common practice to deliver education programmes which do not meet national standards and have no evidence. From a personal perspective I find it hard to believe that my daughter has had more hours of driving lessons than my nephew, who has type 1 diabetes, has received in education about how to manage his diabetes. North Tyneside joined the Year of Care programme in 2007. I was keen to get involved as it seemed to fit with the ethos and values of our diabetes service, and also seemed the next logical step to support people who have attended structured education. I had also seen at first hand the impact of Quality and Outcomes Framework on the behaviours and attitudes of professionals towards people with diabetes. In some instances, the focus on ticking boxes seemed to dominate the need to develop good therapeutic relationships with patients. It felt as if the focus had shifted away from supporting people with their diabetes and talking about their concerns, health beliefs or ideas. I saw the Year of Care approach as a means to address this. I am now the National Director for this programme and our small team of trainers, clinical leads and programme managers has worked with a significant number of organisations to provide support, training and practical tools to implement this approach in primary and specialist care. If you consider the perspective of a person living with a long-term condition, highlighted in Figure 1, it emphasises the significance of the person being in the driving seat of their own care, with a need for the system and the professions within it to support the person to be in charge of their own health and wellbeing. The Year of Care approach was designed with people living with diabetes who wanted to get more out of the time they spend with health care professionals. The approach introduces care and support planning and links with support for self-management. This is enabled by a change in how care is organised and through training of health care professionals. The changes that need to take place at both a practice and system level are detailed in the Year of Care house (Figure 3). Care and support planning requires a redesign of the traditional annual review, splitting it into a two-step process (Figure 4). This involves an initial disease surveillance review with a trained health care assistant (where all care processes are completed in a single appointment) and then a conversation a few weeks later focused entirely on involving and supporting the individual.12 The whole process is enabled by the sharing of information with the patient between the disease surveillance review and the care and support planning conversation. One of the key differences with this approach is the introduction of information sharing where agenda-setting prompts and routine results are shared with the person with diabetes before their care and support planning conversation. While some practitioners can be sceptical about this additional step, people with diabetes and other long-term conditions find this really helpful and feel it makes them more equal to the health care professional during the care and support planning conversation. It saves time, helps people see what is happening and reminds us all about who these results actually belong to. Some of the comments from people with diabetes who have experienced care and support planning are shown in Box 1. The purpose of changing the process is to create the space for a more useful conversation for the person with a focus on planning. People find it a completely different experience and it supports their understanding of their condition. The impact has been positive in terms of how valuable it feels for both the staff involved and the individuals with diabetes. It has improved care process completion and has improved outcomes. However, not all health care professionals find these new conversations easy and our training and support programme aims to help with this. The approach is now being used for many other conditions, including those relating to people who live with multiple long-term conditions. I have learnt some key lessons as I have tried to develop my role and that of my dietetic colleagues, while considering how best to go about supporting people with diabetes. These apply at a number of levels and are exemplified in the Year of Care house (Figure 3). The house needs all elements to be embedded and happening systematically, with care delivery and systems designed with the focus of people with diabetes as the central care givers.13 If we think about ‘whose diabetes it is’, we are more likely to design and deliver services which recognise that individuals with diabetes take on most of the actions that can deliver better outcomes in diabetes. This can therefore be supported by activities around the left-hand wall of the house (engaged, informed patient) with routine implementation of high-quality care and support planning so that people can have better conversations about their health. Education should be embedded into core care pathways and throughout the patient's journey. We should also be aware that support and activities embedded in communities can have a profound impact on how people live well with their diabetes. For health care professionals (right-hand wall of the house), all of our effort and activities should be geared towards supporting the person to understand and manage their diabetes. Having a patient-centred philosophy of care and good communication skills is as important as being up to date with the evidence base. Teams need to work together and squeeze out the contribution of all team members. Creating systems (the roof and the foundation of the house) that support improving the knowledge, skills, confidence and motivation of people with diabetes to live their lives and manage their conditions will make the biggest difference to health care. Outcomes ultimately depend on the individual; however, our systems of care and quality of care can be barriers or enablers. The most important people in a service are those with diabetes and so our systems of care need to be designed around the central role that people with diabetes play in managing their own care.

Back to table of contents Previous article Next article Clinical & ResearchFull AccessHow to Overcome the Limitations of Diagnosis in PsychiatryPatrick McGorry, M.D., Ph.D.Patrick McGorry, M.D., Ph.D.Published Online:27 May 2021https://doi.org/10.1176/appi.pn.2021.3.23AbstractClinical staging beginning at the earliest period before acute symptoms appear can help psychiatry break out of the "straitjacket" of applying rigid diagnostic categories to over-determined syndromes.Diagnosis is a cornerstone of medical practice, succeeding only to the extent that it provides an accurate roadmap to treatment and, to a lesser extent, outcome. At best it is an imperfect process of applying shorthand labels to complex conditions by subgrouping patients according to their differential treatment needs.In general medicine, diagnosis has been enhanced through two refinements: accurate staging of illness and accurate understanding of the biology of disease. But even within general medicine, individual variation within classes of patients means that the shorthand doesn't always work optimally. There is an element of uniqueness about every patient. Judged purely by utility, diagnosis works fairly well in general health care, at least where a range of effective treatments is available, and even if it is not, then for prognostic and palliative purposes.How about in psychiatry?The fundamental problem for psychiatry is that diagnosis remains largely syndromal. Syndromes inevitably are produced by a range of causal mechanisms, and conversely each causal mechanism can produce a range of syndromes. Hence the link between the syndrome and the treatment may not be as tight as within more diagnostically evolved domains of medicine. Psychiatry aspires to this more advanced stage but has arguably taken a premature shortcut by equating syndromes (often weakly and polythetically formulated) with discrete diseases. This wishful thinking has created a kind of spurious precision, encouraged by drug regulators who require specific indications for licensing medications.How can we break out of this straitjacket?Arguably, clinicians already have, though they are criticized for doing so. This is reflected in the use of multiple medications in patients with a single hierarchical diagnosis and multiple comorbid subsyndromes that clinicians treat with different medications. Derided as polypharmacy, there is a real downside to this approach, and it lacks rigor and a scientific basis. However, at another level, it is responding to a perceived reality, and the notion that any of the current medications are specific to single DSM-defined categories is just not credible. How can we do better?The first step is to appreciate the complexity of mental disorders and that the distress and psychopathology that we recognize are overdetermined. At one extreme, we have the pure psychotherapeutic stance in which every single person is unique. While it is partly true, it also implies that what we learn about one individual patient cannot be translated to the experience of other patients or to how we as clinicians treat them.At the other extreme, we have a premature neurobiological reductionism that equates syndromes with diseases; by itself, this reductionism can never do justice to the mind or the social world of the patient. Neurobiology is certainly altered in mental illness, but the changes may be primary or secondary and recovery may be achieved with or without medications. But in every case, a secure therapeutic relationship and psychosocial interventions are necessary, even when medications are essential.How can diagnosis, which enables subclassification, be refined in a way that really contributes to holistic care of mental illness? Based on my clinical and research experience with people with emerging mental distress and mental illness, a transdiagnostic approach supported by a sequential or clinical staging framework is one part of the answer.A second pillar of collaboration with the patient is to develop a comprehensive clinical formulation that draws upon the life history and social context of the person. This concept is, of course, by no means new and has been part of the training of psychiatrists and mental health professionals for decades. Yet sadly, health care systems continue to undervalue this and constrain psychiatrists and mental health professionals to a frustratingly narrow professional role and seriously shortchange patients and families.Staging involves recognition at the point of engagement of where a patient sits along a continuum of (potential) illness progression.It is an optimistic and preventive conceptual framework, not a deterministic concept, and progression or remission is possible at each stage. A staging approach seeks to proactively reduce the rate of progression to the next stage. Those who don't progress are sometimes seen as "false positives," and critics then argue that treatment was unnecessary. However, increasing this false-positive rate can also be seen as an index of success. The chances of remission typically reduce as progression occurs, but remission can still occur at any stage in psychiatric syndromes, including schizophrenia. The other cardinal principle is while almost all effective treatment involves some risk, the benefits must outweigh the risks at each stage. What does this look like in real life?Since most of the mental disorders that impact across the decades of adult life emerge during the transition from childhood to adulthood (roughly 12 to 25 years), clinical staging works well in youth mental health settings designed for them to guide prevention and early intervention. A focus on young people in this age range has become increasingly important since we have witnessed a global trend for a worsening in their mental health, a trend that is likely to accelerate sharply in the wake of the COVID-19 pandemic for socioeconomic reasons. Over the past decade, youth-friendly and enhanced "one-stop-shop" primary care services for young people have been developed in Australia and a growing number of other high-income countries, and there is growing clinical experience of and exposure to the earliest stage of what may progress to acute mental illness.The staging model ranges from stage 0 to stage 4. Stage 0 is the pre-illness stage when symptoms and impairment are not present, but there is a variable level of risk or vulnerability. This is the stage when prevention strategies, either universal ones for the whole population or targeted ones for high-risk groups, are indicated.Stage 1 typically involves emotional distress, with anxiety and lowered mood, resulting in impact on social and educational functioning and often triggered by social or developmental stress such as bullying (stage 1a). Until these new primary youth mental health care services were created, patients at this stage were rarely seen. A subset of these young people (stage 1b) have warning signs of other syndromes, such as psychosis, mania, OCD, or the borderline syndrome. The interventions to be offered at stage 1 are simple: They include problem-solving for immediate stressors and predicaments, emotional and practical support, and monitoring of risk and progress over a period of a few weeks.A transdiagnostic approach and the largely subsyndromal nature of the psychopathology mean that assigning a specific diagnostic label is not necessary to deliver stage-specific care, and medication is very rarely a first-line option. If the distress, impairment, and need for care do not subside or the warning signs are prominent or worsen, then more intensive psychosocial interventions—notably cognitive-behavioral therapy, dialectical-behavior therapy (DBT), and individual placement and support/vocational support—can be flexibly drawn upon, depending on the complexion of the presenting features. These are still offered from a transdiagnostic perspective, though the emphasis might intuitively shift for a variety of reasons, including patient preference and engagement. The risks of offering treatment in this way to help-seeking individuals with a light diagnostic touch in stigma-free youth primary care settings are greatly outweighed by the risks of not offering care, as well as by the benefits.Either because they respond to transdiagnostic psychosocial interventions or due to natural remission, fortunately only a minority of stage 1 patients progress to stage 2. Stage 2 is marked by a worsening in severity of one or more of the major syndromes, such as psychosis, depression, mania, borderline syndrome, or other symptom dimension and increasingly impaired functioning, indicating a change in treatment. Hence the threshold for recognizing stage 2 psychosis is the point at which antipsychotic medication is indicated, or in the case of depression, a more intensive psychosocial intervention or the addition of an antidepressant. Ultimately, sequential clinical trials are needed to provide a firmer evidence base for this in several areas. For mania, the transition to a full manic episode would be the indicator that stage 2 had been attained.Stages 3 and 4 are marked by varying levels of recurrence and persistence of syndromes of increased clarity, one or more of which may have become most prominent or dominant. At this stage, the illness will resemble more traditional diagnostic concepts such as schizophrenia and bipolar disorder. However, even during these later stages, comorbidity is very common, and the early clinical features of anxiety and depression are especially tenacious. The treatment needs of people in these later stages are diverse and involve medications, expert psychosocial care, and high-quality general medical care to prevent and treat these patients for the medical illnesses that they are at very high risk of developing. This preventive mindset for physical illness and premature death must be adopted from stage 1.Clinical staging in psychiatry aspires to evolve into clinicopathological staging via the inclusion of pathophysiological biomarkers, so that diagnosis can be further refined and personalized. This is a longer-term project, but this objective lies at the heart of the ground-breaking Accelerating Medicines Partnership Schizophrenia Project funded by the National Institute of Mental Health. This project aims to identify promising biological and behavioral markers that can help identify those at risk of developing schizophrenia as early as possible, track the progression of symptoms and other outcomes, and define targets for treatment development. Senior investigators at Orygen, our research institute in Australia, and our global collaborators (including the funders and partners at the National Institute of Mental Health/Foundation for the National Institutes of Health) are proud to be playing a leadership role.The other way we can personalize care and balance the current limitations of psychiatric diagnosis right now is the clinical formulation, which captures the unique story and context of each patient. This must be developed collaboratively with the patient. The therapeutic process will be further enriched and strengthened if continuity of care, with one or more key mental health professionals, can be assured over time for as long as mental health care is required. Continuity of care is typically given scant regard in most systems of mental health care globally, yet it is the cornerstone upon which diagnosis and treatment rest. ■ReferencesMcGorry PD, van Os J. 2013. Redeeming diagnosis in psychiatry: Timing versus specificity. Lancet 381(9863):343-345.McGorry PD, Hickie IB (Eds). Clinical Staging in Psychiatry: Making Diagnosis Work for Research and Treatment. Cambridge: Cambridge University Press, 2019.McGorry PD, Hartmann JA, Spooner R, Nelson B. 2018. Beyond the "at risk mental state" concept: Transitioning to transdiagnostic psychiatry. World Psychiatry 17:133-142.McGorry PD, Nelson B. 2016. Why we need a transdiagnostic staging approach to emerging psychopathology, early diagnosis, and treatment. JAMA Psychiatry 73:191-192.McGorry PD, Goldstone SD, Parker AG, Rickwood DJ, Hickie IB. 2014. Cultures for mental health care of young people: An Australian blueprint for reform. Lancet Psychiatry 1:559-568.Hetrick SE, Bailey AP, Smith KE, Malla A, Mathias S, Singh SP, O'Reilly A, Verma SK, Benoit L, Fleming TM, Moro MR, Rickwood DJ, Duffy J, Eriksen T, Illback R, Fisher CA, McGorry PD. 2017. Integrated (one-stop shop) youth health care: Best available evidence and future directions. Medical Journal of Australia 207(Suppl 10):S5-S18.Parker AG, Hetrick SE, Jorm AF, Mckinnon AJ, McGorry PD, Yung AR, Scanlan F, Stephens J, Baird S, Moller B, Purcell R. 2016. The effectiveness of simple psychological and physical activity interventions for high prevalence mental health problems in young people: A factorial randomised controlled trial. Journal of Affective Disorders 196:200-209.McGorry PD, Keshavan M, Goldstone S, Amminger GP, Allott K, Berk M, Garner B, Lavoie S, Pantelis C, Yung AR, Wood S, Hickie IB. 2013. Biomarkers and clinical staging in psychiatry. World Psychiatry 13:211-223.Patrick McGorry, M.D., Ph.D., is a professor of youth mental health at the University of Melbourne and executive director of Orygen, the National Centre for Excellence in Youth Mental Health in Melbourne, Australia. He is known worldwide for his development and scaling up of early intervention and youth mental health services and for mental health innovation, advocacy, and reform. ISSUES NewArchived

As primary health care (PHC) evolves from its original conceptual level enunciated in 1978 at Alma-Ata to its present formal body of knowledge and practice, 2 definitional problems arise: whether PHC is a transient jargon or label attached to nothing or whether the older, more restricted term primary care (PC) is the same as PHC. The 1st problem has been rendered irrelevant, but the 2nd remains unsolved. Some controversy exists in both literature and practice. Some health care professionals, especially general practitioners, use the terms interchangeably. This may be because of historic traditions based on the biomedical model of education and practice. The term primary care is credited to the Lord Dawson report of 1920, concerned with the reorganization of medical services in England which resulted in the setting up of health centers. Since 1960 under the National Health Service, general practitioners provided curative and preventive services on a 1st-contact medical basis and by 1962 the term was used to denote general practice. This tradition could have then spread to other western countries, including the US and to developing countries. To humanize this biomedical model, Engel proposed the biopsychosocial model which takes into account the biomedical aspects of disease, the patients' social context, their perception of illness and the interaction of the physician and the health care system. This increased health awareness contributed to the evolution of PHC, which evolved from small-scale experiments. A graphic representation of the relationship between primary (medical) care and primary health care illustrates the various consumer levels and the health care system. The multi-disciplinary concept of primary health care is not interchangeable with primary care.

Pulmonary Complications and Chronic Conditions of Down Syndrome during Childhood: An Agenda for Clinical Care and Research

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Introduction: The Norwegian Coordination Reform was implemented January 1. 2012 with a changed distribution of tasks and responsibility between primary and specialist health care. For the specialist health care the aim was to concentrate to a greater extent on their specialized tasks. Aim: The aim of this study was to examine how health care professionals in a university hospital have experienced the implementation of the Coordination Reform. Method: A qualitative study with three focus group interviews and 3 individual interviews with nurses, physicians and hospital managers. Results: Lack of information within the hospital concerning the Coordination Reform made the informants feel unprepared for the changes that followed, especially in terms of the new guidelines for notifying the municipalities about patients in need of municipal follow-up after discharge. The informants experienced an increased focus on economy, because errors in the notification process led to less income for the hospital. The impression among the informants was that patients without complex care needs were faster received by the larger municipalities, unlike those with complex care needs. According to the informants this affected their work in relation to use of resources and lead to poorer communication. Discussion: Other studies on implementation of the implementation of the Norwegian Coordination reform in primary care have found that their main focus is on their ability to receive patients ready for discharge. The reason is that they have to pay the hospital more than $600 per day if there is a delayed discharge. Both the findings in this and the other studies indicates that the organisations focus is on this topic rather than other aspect of the coordination reform like treating more patients in primary care, health promotion and competency transfer. Conclusion: The key findings was that the aim for the specialist health care to focus more on their specialist competence and an improved coordination with the primary health care has not yet been achieved according to the informants in this study. Lessons learned: The economic incentives to reduce the number of patients ready for discharge in the hospitals have overshadowed other central aspects of the Norwegian Coordination reform. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116611– http://www.ijic.org/ Limitations: The sample only included informants from one large department at one university hospital. Suggestions for future research: This study indicates that there is a further need for examining health care professionals in relation to the implementation of the Coordination Reform. One interesting aspect concerns the hospitals and specialization – more specialization or are they specialized enough. Another aspect is the work with developing patient pathways and ICTsolutions what are the effects on communication between the hospitals and the municipalities?

Information about mental health systems is essential for mental health planning to reduce the burden of neuropsychiatric disorders. Unfortunately, many low- and middle-income countries lack systematic information on their mental health systems. The objectives, scope, structure, and contents of mental health assessment and monitoring instruments commonly used in high-income countries may not be appropriate for use in middle- and low-income countries. The World Health Organization (WHO) has recently developed the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), a comprehensive assessment tool for mental health systems designed for middle- and low-income countries. WHO-AIMS was developed through an iterative process that included input from in-country and international experts on the clarity, content, validity, and feasibility of the instrument, as well as a pilot trial. The resulting instrument, WHO-AIMS 2.2, consists of six domains: policy and legislative framework, mental health services, mental health in primary care, human resources, public information and links with other sectors, and monitoring and research. These domains address the ten recommendations of the World Health Report 2001 through 28 facets and 155 items. All six domains need to be assessed to form a basic, yet broad, picture of a mental health system, with a focus on health sector activities. WHO-AIMS provides essential information for mental health policy and service delivery. Countries will be able to develop information-based mental health policy and plans with clear baseline information and targets. Moreover, they will be able to monitor progress in implementing reform policies, providing community services, and involving consumers, families, and other stakeholders in mental health promotion, prevention, care and rehabilitation. This article provides an overview of the rationale, development process, and potential uses and benefits of WHO-AIMS.