Background Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies. Methods This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed. Results At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes. Conclusions To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.

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BackgroundThis study evaluates implementation of the Quebec Mental Health (MH) Reform (2005–2015) which aimed to improve accessibility, quality and continuity of care by developing primary care and optimizing integrated service networks. Implementation of MH primary care teams, clinical strategies for consolidating primary care, integration strategies to improve collaboration between primary care and specialized services, and facilitators and barriers related to these measures were examined.MethodsEleven Quebec MH service networks provided the study setting. Networks were identified in consultation with 20 key MH decision makers and selected based on variation in services offered, integration strategies, best practices, and geographic criteria. Data collection included: primary documents, structured questionnaires completed by 25 managers from MH primary care teams and 16 respondent-psychiatrists working in shared-care, and semi-structured interviews with 102 network stakeholders involved in the reform. The study employed a mixed method approach, triangulating the three data sources across networks.ResultsWhile implementation was not fully achieved in most networks, the Quebec reform succeeded in improving primary care services with the creation of adult primary care teams, and one-stop services which increased access to care, mainly for clients with common MH disorders. In terms of clinical strategies implemented, the functions provided by respondent-psychiatrists had a greater impact on the MH primary care teams than on general practitioners (GPs) in medical clinics; whereas the implementation of best practices were indirect outcomes of another reform developed simultaneously by the Quebec substance use disorders program. The main integration strategies used for increasing continuity of care and collaboration between primary care and specialized services were those involving fewer formal procedures such as referrals between teams and organizations. The lack of operational mechanisms and protocols governing new services and structures were important barriers to primary care consolidation and service integration, as was the lack of interest and involvement of most GPs in MH.ConclusionsSuccessful and sustained healthcare reform requires attention to process and outcomes as well as structural change or service reorganization. Six recommendations for more successful implementation of the Quebec MH Reform are provided, with implications for healthcare reform internationally.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1832-5) contains supplementary material, which is available to authorized users.

In light of growing demands for public accountability, the broadening scope of health technology assessment organizations (HTAOs) activities and their increasing role in decision-making underscore the importance for them to demonstrate their performance. Based on Parson's social action theory, we propose a conceptual model that includes four functions an organization needs to balance to perform well: (i) goal attainment, (ii) production, (iii) adaptation to the environment, and (iv) culture and values maintenance. From a review of the HTA literature, we identify specific dimensions pertaining to the four functions and show how they relate to performance. We compare our model with evaluations reported in the scientific and gray literature to confirm its capacity to accommodate various evaluation designs, contexts of evaluation, and organizational models and perspectives. Our findings reveal the dimensions of performance most often assessed and other important ones that, hitherto, remain unexplored. The model provides a flexible and theoretically grounded tool to assess the performance of HTAOs.

This study explored barriers and facilitators in mental health (MH) patient management in four Quebec (Canada) emergency rooms (ERs) that used different operational models. Forty-nine stakeholders (managers, physicians, ER and addiction liaison team members) completed semi-structured interviews. Barriers and facilitators affecting patient management emanated from health systems, patients, organizations, and from professionals themselves. Effective management of MH patients requires ER access to a rich network of outpatient, community-based MH services; integration of general and psychiatric ERs; on-site addiction liaison teams; round-the-clock ER staffing, including psychiatrists; ER staff training in MH; and adaptation to frequent and challenging ER users.