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- Psychiatry Embraces Patient-Centered Care
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Current Psychiatry Reviews 9, Rudnick, A. Recovery from Schizophrenia: A Philosophical Framework. American Journal of Psychiatric Rehabilitation 11, Roe, D. Psychiatric Rehabilitation Journal 30, Serious mental illness: person-centered approaches. London: Radcliffe Publishing. Recovery of people with mental illness: Philosophical and related perspectives.
Oxford: Oxford University Press. Nuechterlein, K. Schizophrenia Bulletin 10, Eack, S. Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis. Schizophrenia Bulletin 33, Relationships between psychiatric symptomatology, work skills, and future vocational performance. Psychiatric Services 46, Lazarus, R. Stress, appraisal, and coping. New York: Springer Publishing.
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The relation of social support-seeking to quality of life in schizophrenia. Journal of Nervous and Mental Disease , Martins, J. A re-analysis of the relationship among coping, symptom severity and quality of life in schizophrenia.
Schizophrenia Research 89, Supported reporting of first person accounts: assisting people who have mental health challenges in writing and publishing reports about their lived experience. Schizophrenia Bulletin 37, Thompson, N. Perspectives in Psychiatric Care 44, Burden of caregivers of mentally ill individuals in Israel: A family participatory study. International Journal of Psychosocial Rehabilitation 9, Pharoah, F. Family intervention for schizophrenia. Rotenberg, M. American Journal of Psychiatric Rehabilitation 14, Kitson, A.
What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. Journal of Advanced Nursing 69, The goals of psychiatric rehabilitation: An ethical analysis. Psychiatric Rehabilitation Journal 25, Coercion and psychiatric rehabilitation: a conceptual and ethical analysis. BMC Psychiatry 7, S Processes and Pitfalls of Dialogical Bioethics. Health Care Analysis 15, Informal ethics consultations in academic health care settings: A quantitative description and a qualitative analysis with a focus on patient participation.
Journal of Clinical Ethics 9, Kurtz, M.
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Neuropsychology Review 11, McGurk, S. American Journal of Psychiatry , Corring, D. Using mobile technology to promote independence: an innovation in psychiatric rehabilitation — a feasibility study. Research Insights 12, Abdulrazak, B. Berlin: Springer. Mowbray, C. Supported education for adults with psychiatric disabilities: an innovation for social work and psychosocial rehabilitation practice. Social Work 50, Bond, G. At individual care home level, the decision regarding participation was largely driven by the care home manager, and personal contact between the research team and care home managers in following up initial invitations to participate was effective in securing care home sign up.
The time to recruitment for care homes was calculated according to the number of days between the initial approach from the research team to the care home manager, and the receipt of local ethical approval permitting recruitment of residents to begin in that care home. The mean number of days taken to recruit care homes was Of these, The proportion of eligible residents varied from Recruitment rates from individual care homes ranged from Recruiting 34 individuals in total equates to a mean of 6.
The number of individuals recruited to the study represented Several additional potential participants were identified in the last care home recruited, but there was not enough time remaining in the study period to complete follow-up so these residents were not recruited. Time to recruit study participants was calculated from the number of days between ethical approval being granted for recruitment to begin in each care home, and the point at which the last participant at that care home was recruited to the study.
Obtaining consent was straightforward in homes predominantly supported by a single general practice with strong links between the practice and the home care homes , , It was considerably more challenging in care homes supported by multiple practices care home supported by 4 practices and by 2 practices. In care home it took over 3. In care home , it was impossible to obtain GP consent for 2 recruited participants, for whom the personal consultees had assented, despite the earlier strategic approach.
None of the five care homes withdrew from the study. Five study withdrawals Attrition rates by care home ranged from 67 to Participant retention through the study. Flow chart detailing participant retention throughout the study. It took a mean of The protocol was amended so that the participant baseline assessment was repeated if the recommendation was not implemented within eight weeks of the medication review.
Consort diagram of medication review. Consort diagram detailing number of medication reviews and implementation. Four GPs were trained on the phone one per training session ; whereas 18 staff received training in five face-to-face sessions mean of 3. This paper reports expectations and experiences of the feasibility study. Participants found both the training and the medication review aspects of the feasibility study beneficial:. Participants identified that after the training they were more likely to adopt a holistic approach with less reliance on medication:.
Before it would be 'go to the nurse', it would be 'what meds can we give? The practical training approach promoted adoption of patient-centred care, which underpinned this more holistic approach to care:. The holistic approach, to the medication review, with the focus on quality and safety, rather than cost also promoted adoption of the intervention:. Different approach from the MEDREV pharmacist…very much geared around using the evidence to increase the quality of care GPs identified that participation placed little burden on them, although some GPs identified barriers including time taken to implement the medication review:.
Overall, providing care staff with additional tools and skills to address behaviours that challenge appeared to have a positive impact on the attitudes and practices of care home staff:. Increasing care home research is a key priority, and to the best of our knowledge this is the first study to report in detail the feasibility of a dual-purpose care home study involving staff training and medication review. Overall, recruitment was challenging and time-consuming, securing GP engagement was difficult, drop-out rates were high and, where substantial recommendations in relation to medication were made, these took a long time to implement, if implemented at all.
Like other care home research, recruitment was challenging [ 20 , 21 , 22 , 23 ]. This resulted in the need for five substantial ethical amendments during the study, which contributed to delays. Amendments included expanding the recruitment area, introducing the re-baseline procedure to account for the delay in implementation and in the final two care homes removing the six month follow-up due to time limitations.
Our initial response rate of 3. This was possibly because care home managers, the key decision makers, welcomed the offer of cost-free training, but were less likely to welcome a medication review, which could potentially lead to discontinuation of medication for behaviour that challenges. Like other researchers, recruiting GPs from multiple practices who provide care to participants living in a single care home was particularly challenging [ 22 ]. Our strategic approach to GP engagement was only partially successful and should be developed further for any larger trial.
The actual figures were On reflection, recruitment might have been improved by organising further meetings with relatives and greater involvement of care home staff in recruitment, although further training may be required for the care home staff. Recent NICE guidance recommend that care providers should provide face-to-face training and mentoring to staff who deliver care and support to people living with dementia [ 24 ]. This training should include the management of behaviours that challenge including the appropriate use of medication [ 24 ]. MEDREV successfully developed and evaluated an acceptable and feasible training package, which was well received.
Furthermore, by combining staff training with a specialist medication review, the use of psychotropics was reduced [ 25 ].
Person-centered care in psychiatric practice Dave S, Boardman J - Indian J Soc Psychiatry
The qualitative research and the reflective comments, obtained from GPs were very supportive of both the training and medication review. Staff were positive about both elements. The Behavioural Change Intervention appeared to train the care staff in person-centred care so that they would understand why reducing psychotropics is beneficial and support implementation of the recommendations from the medication review.
The pharmacists who trained the GPs also reported good interaction particularly in face-to-face training, which encouraged greater participant engagement and reached more GPs. Other similar studies have found similar rates; for example one study found that Informal feedback, obtained in the reflective comments, identified a perceived lack of integration with other secondary care medication reviews. The likelihood and speed of implementation may have increased with direct communication between the pharmacist and GP either by phone or face-to-face.
Another possible avenue to explore is utilising the model of a practice-based pharmacist as a liaison between the specialist pharmacists conducting the medication reviews and the GP. Other studies have found that GPs were broadly supportive of pharmacist medication reviews for BPSD and the implementation rate is similar to other studies involving clinicians implementing recommendations from a pharmacist [ 27 , 28 ].
The relatively low uptake could be due to the additional time and effort needed to amend the prescription. Other studies suggest that GPs believe reducing anti-psychotic prescribing for BPSD could be achieved by increased availability of non-pharmacological approaches and staffing levels [ 28 ]. Even when supported, the medication review recommendations took on average This may have clinical and medico-legal implications.
It also creates methodological problems for future studies: because it was impossible to know when the recommendation was likely to be implemented, collecting outcome data was challenging. One possible reason for the delay was the use of pre-prepared medication administration packs, which are prepared every month, for care homes. Care home staff also attributed the delay in implementation of recommendations to a general low priority for healthcare for older people; this needs further exploration in future research.
Whilst problems relating to medication optimisation in care homes and in people living with dementia are widely acknowledged, there is very little research on interventions to optimise medication in care home residents [ 29 , 30 , 31 ]. The homes in our study already received regular medication reviews from CCG pharmacists; suggesting that CCG pharmacists may lack expertise to review psychotropics. Furthermore, the GPs, in our study, appreciated the clinical and quality focus of the medication reviews.
This study was conducted in a single region in the UK and had a limited number of participants. However, we recruited and retained a range of care homes with differing characteristics type of home, sociodemographic characteristics of local area. The original aim was to recruit a representative sample of staff from each home. However, only three members of staff were recruited from the final two homes, due to the difficulty and subsequent delay in recruiting these homes. Only three GPs were recruited despite efforts to recruit more.
No pharmacists were interviewed; however the feasibility issues in relation to the medication review were captured in the interviews with care staff and GPs, and the reflective comments received.
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Healthcare policy must continue to focus on optimising medication usage in care homes, including the appropriate treatment of BPSD. MEDREV developed an acceptable and feasible training programme which included the appropriate use of medication, in line with NICE guidance, suggesting that this may be a promising policy approach [ 24 ].
Since this study, NHS England has invested in pharmacy to support medication optimisation in care home [ 33 ]. This research suggests, that to successfully optimise medication, these pharmacy staff need to develop robust ways of working across organisational boundaries linking primary, secondary and social care. There are also implications for research policy makers. Recruiting the care homes and people with living dementia was time-consuming and difficult, confirming other studies.
The NIHR and other funders have prioritised high quality research both in care homes, and on medication optimisation in older people [ 31 , 34 ]. Yet despite this, there is limited research on medication optimisation in care homes [ 35 ] perhaps because care home research involving medication optimisation is uniquely challenging, as we found.
Psychiatry Embraces Patient-Centered Care
This suggests that research into medication optimisation in care homes needs to be a specific priority. One of the key challenges in this study was the delay in implementation of recommendations. Whilst our solution, of repeating the baseline measurements, might work for a single location feasibility study, when the chief investigator is able to work closely with the Clinical Study Officers, it is less likely to work for a larger multiple centre study.
Expert recommendations on medication optimisation did not appear to be implemented in a significant minority of residents; this needs further investigation. From the care home point of view, it may be a question of who has the greater authority, the GP or the pharmacist and established relationships. GP engagement could be improved by holding an initial event very early in the study. This event should carry Continuing Professional Development accreditation from the appropriate Royal College and include education from expert speakers, ideally with international reputations, in addition to information on the study.
Specialist pharmacists may not have had time to build a good relationship with the GP and without good communication and trust implementation of the recommendations may be challenging as we found. Since this study began, there has been significant investment in primary care clinical pharmacy including within care homes [ 36 , 37 , 38 ].
These practice-based pharmacists PBP are perhaps ideally placed to deliver the medication review; they have access to records and the autonomy to change the repeat template particularly if an independent prescriber. Involving such PBPs in the delivery of the medication review could address some of the feasibility issues identified and is a hypothesis for a future trial. Yet this area may be outside the scope of their practice and competency. Future research should explore the best way for pharmacy staff to deliver this specialist medication review and the training requirements.
The feasibility study contained two linked elements; staff training and medication review. We found it feasible to develop, deliver and evaluate a well-received staff training programme both in the care home and the GP surgery. The dual intervention appeared to increase the ability of care staff to manage BPSD appropriately with less reliance on medication.
Although we found a clear need for specialist medication review of psychotropics for care home residents with dementia, the medication review would require significant modification for full trial. Department of Health. Accessed 30 Aug Dementia: a public health priority; A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics the DART-AD trial.
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Person-Centered Psychiatrists in Omaha, NE
What is a pilot or feasibility study? A review of current practice and editorial policy. Developing and evaluating complex interventions: new guidance. Accessed 28 Oct The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Qual Life Res. Measurement of health-related quality of life for people with dementia.
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