BACKGROUND:Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). OBJECTIVE: The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. DESIGN:The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCPreported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. PARTICIPANTS: 191 VHA PCPs from one regional network were surveyed (54 % response rate), and 41 VHA PCPs and primary care staff were interviewed. MAIN MEASURES/APPROACH: PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. KEY RESULTS: Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral.CONCLUSIONS: Primary-specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.

No abstract

Abstract:Background. There is limited evidence for effective interventions in the treatment of posttraumatic stress symptoms within individuals diagnosed with schizophrenia.Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of posttraumatic stress symptoms specifically within individuals diagnosed with schizophrenia.Method. A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6-months (post-treatment) and 12 months (follow-up) was conducted. Sixtyone participants diagnosed with schizophrenia and exhibiting posttraumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of posttraumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation(CAPS-S). Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale (PANSS) and the Psychotic Symptom Rating Scale (PSYRATS).Results. Both the treatment and control groups experienced a significant decrease in posttraumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes.Conclusions. The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.