Bridging the Gap between Primary Care and Specialized Mental Health Care. A mixed method study of the quality of referral information and the referral letters’ potential impact on quality of care
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Background. A major cause of adverse events in health care is insufficient information transference between health professionals. Despite the cardinal role of referral letters as the means of communication between primary care and specialized mental health care, earlier studies have shown that these letters often lack essential information. The impact of this lack of communication on patient care is unknown. The present study primarily aims to explore what information referral letters from primary health care professionals to specialized mental health care services for adults ideally should include. Secondly, an instrument to measure the quality of these letters will be developed and tested. Finally, indicators to measure the impact of referral letters on the quality of specialised mental health care will be created.
Design and methods. Using a mixed method design, we employed qualitative group interview methods, literature reviews and quantitative rating technics. In addition to health professionals we involved patient representatives and managers in all steps of the study. We adapted the RAND/UCLA Appropriateness Method to develop indicators of specialised mental health care quality. The study was conducted in western Norway.
Results. Nineteen information items were regarded as essential in referral letters from primary care providers to specialized mental health care professionals, including personal information, case history and social situation, present state and results, somatic health, treatment efforts and involved professional network, as well as the patient's own goals and preferences. The instrument developed to measure the quality of the referral letters was found to be both valid and reliable. For assessing the impact of the referral letters, we found appropriateness of priority decisions and delays to be essential factors of mental health care quality. Thus, we recommend four indicators: correctness of priority between patients, delay in assessing referral, delay to onset of care, and appropriateness of referral.
Discussion. The present study recommends a greater emphasis on information to facilitate coordination of care interventions and services and on patient involvement than existing standards for referral letters to specialised mental health care. The developed indicators on potential impact of referral letter quality are in accordance with the existing literature on quality of the referral process. However, our results only include process indicators, not outcome indicators. Limitations in the generalizability of the selection of the most essential information items and indicators are possible.
Conclusion. Based on the international definition of quality in health care and on reported challenges to health care regarding coordination, cooperation and timely access, our study indicates that sufficient referral communication is a key factor that enhances high quality health care. Compliance to the recommended 19 information items is expected to improve timely access and decrease delays in the process of care. The developed measurements enable both exploration of the referral information's impact on mental health care quality and provision of valid data for systematic improvement to practice. However, the challenges we experienced in defining valid indicators highlight the importance of thorough preparation of measurements and process evaluation as recommended by new guidelines for research into complex health service interventions. Further research is needed to explore a) the strength of the association between referral information, our recommended process indicators, and patient outcome; b) the effects of systematic interventions to improve the content of referral letters; and c) to what degree our results are valid to other contexts and for other patient groups than those explored in the present study.
Paper I: Hartveit M, Thorsen 0, Biringer E, Vanhaecht K, Carlsen B, Aslaksen A. Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multiperspective study. BMC Health Service Research 2013, 13:329. The article is available in BORA at: http://hdl.handle.net/1956/7463
Paper II: Hartveit M, Aslaksen A, Vanhaecht K, Thorsen 0, Hove 0, Haug K, Assmus J, Biringer E. Development and testing of an instrument in Western Norway to measure the quality of referral information from primary care to specialised mental health care. International Journal of Care Coordination 2015. This article is not available in BORA. The published version is available at: 10.1177/2053434515589012
Paper III: Hartveit M, Thorsen 0, Biringer E, Haug K, Vanhaecht K, Aslaksen A. Quality indicators for the referral process from primary to specialised mental health care: an explorative study in accordance with the RAND appropriateness method. Submitted BMC Health Service Research. Manuscript. This article is not available in BORA.
Paper IV: Hartveit M, Biringer E, Vanhaecht K, Haug K, Aslaksen A. The Western Norwegian mental health interface study: a controlled intervention trial on referral letters between primary care and specialist mental health care. BMC Psychiatry 2011, 11:177. The article is available in BORA at: http://hdl.handle.net/1956/8772