Increasing Passive Case Finding for Mental Illness and Epilepsy Using Internal Facility Referrals: A Quality Improvement Project at the Neno District Hospital, Malawi

Abstract

Purpose: Care for mental illness is scarce and underfunded globally. Data suggests 1 in 5 people will experience mental illness at some point in their lives with over 10% of the disability adjusted life years attributed to mental illness worldwide (WHO, 2008). In Malawi, lack of funding, human resources, and treatment along with stigma and poor mental health awareness lead to poor case finding. In Neno District, Abwenzi Pa Za Umoyo/Partners In Health and the Ministry of Health have built access to care for mental health and epilepsy patients, but national prevalence estimates some patients remain out of care. The aim of this project was to link patients to longitudinal integrated chronic disease clinic. Methods: A modified Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Baseline assessment included review of 2 years of past enrollment in the outpatient integrated chronic care clinic (IC3) for mental illness and epilepsy, observations of referrals and clinic practice, and interviews with mental health clinicians and the nurse, acute care clinicians, IC3 clerks, pharmacists, and hospital leadership. A multipronged approach to increase referrals to longitudinal care was initiated addressing three main perceived areas of growth: 1) missed opportunities to refer patients from acute care at the outpatient department (OPD) to IC3; 2) linkage to care for patients referred to IC3; and 3) lack of provider knowledge on mental illness and epilepsy. The interventions were 1) to enlist OPD providers and pharmacy personnel to refer patients with mental health complaints or those prescribed medications for mental illness or epilepsy directly to IC3 for longitudinal follow up, 2) to utilize a mobile health application (CommCare, Dimagi) to facilitate patient follow up for missed appointments if enrolled in IC3, and 3) to create and provide clinical trainings, quick reference job aids, and one-on-one mentorship for OPD providers. Results: From August to December 2019, 34 patients with mental illness and epilepsy were referred to IC3, at least 10 of whom were identified through the project pathways. The average total of newly identified patients referred to IC3 increased from 0.94 to 6.8 patients per month following the roll out of the project, and the percentage linked to and enrolled in IC3 of those referred in CommCare increased from 55% to 70%. Conclusions: Implementation of provider trainings and mentorship led to an increase in referrals to outpatient chronic care follow up for mental illness and epilepsy with improved linkage to care. Additional work is still needed with future work in streamlining and error proofing the system of referral and maintaining patients in care.