Download the right mental health care, at the right time, by the right team

THE RIGHT MENTAL HEALTH CARE, AT THE RIGHT
TIME, BY THE RIGHT TEAM
The 2010 Revision of the Position Paper on Collaborative
(Shared) Mental Health Care - For Discussion
EXECUTIVE SUMMARY
The last 10 years has seen a burgeoning interest in building collaborative partnerships between
primary care and mental health providers, including the integration of mental health providers and
programs within primary care settings. These programs have been able to improve access to mental
health care and increase the capacity of primary care to manage these problems and are consistent
with other trends in Canada’s healthcare system and the expanding role of primary care.
Successful projects in Canada and other places have demonstrated better clinical outcomes, cost
savings to the system, a more efficient use of resources and an enhancement of the experience of
seeking or receiving care. These initiatives appear to work best when they link two or more
interventions, when they follow a “stepped” approach, when care is shared and when they are
supported by a redesign of the clinical systems in which they are introduced.
There are many steps that can be taken by any primary care or mental health program to promote
collaboration and improve access to mental health care, including the integration of mental health
personnel into primary care sites. Regional and provincial planners need to support this by looking
for opportunities to introduce collaborative projects in their strategies and fund new projects that
will broaden the scope and knowledge base of collaborative care.
Academic departments must prepare learners to work in collaborative partnerships and there is a
need for targeted research to address specific questions that will further our understanding of the
potential of these new models. To take full advantage of the potential collaborative care offers,
professional associations and provincial governments need to implement some specific policy
changes that will make it easier for this kind of work to take place. Above all, consumers and
consumer groups must be active partners in collaborative partnerships, when receiving care and in
the design and evaluation of programs and services.
If this can be accomplished, we have the opportunity to bring about significant improvements for all
Canadians in their overall wellbeing. We can increase the capacity of our mental health and primary
care systems to assist individuals with mental health problems reach the services they need, when
they need them and use existing resources more efficiently. And we will have demonstrated the
benefits of collaborative partnerships between specialized services and primary care in Canada’s
health care systems.
BACKGROUND
In 1997 the College of Family Physicians of Canada (CFPC) and the Canadian Psychiatric
Association (CPA) produced a groundbreaking paper on shared mental health care in Canada (1)
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Following the publication of the position paper, the two organisations established a collaborative
working group on shared mental health care, to foster and support collaboration between the two
sectors, focusing specifically on psychiatrists and family physicians.
Much has changed in the past twelve years. (2,3) A remarkable expansion in collaborative activities
involving primary care and mental health and addiction care providers and, more recently, consumers
has taken place. Collaborative mental health care is now seen as an integral component of provincial
and regional planning. There are networks of colleagues at all levels, able to learn from each other’s
experiences and the collaboration achieved by mental health services has become a model for other
specialties interested in working more closely with primary care.
The same time period has also seen many changes in Canada’s health care systems. The way primary
health care is delivered is being transformed, in different ways, in every province and territory;
collaborative care is being adopted as one way to meet the complex needs of patient populations;
resources are being shifted from hospital to community delivery systems; new approaches are being
introduced to improve the outcomes for individuals with chronic diseases; information technology,
including electronic medical records, is becoming an integral component of care; and we are
exploring new ways to support patients to better manage their own conditions. Above all, leaders in
Canada’s health care systems are recognizing the importance of continuous quality improvement and
practice efficiency as driving forces in system redesign to get better patient outcomes.
Central to many of these changes is a recognition of the key role primary care must play in Canada’s
mental health care systems and the importance of improving collaboration between providers
working across the entire health care system, but especially between specialized services and primary
care. These trends, and the policies that are being developed to support them, offer many exciting
opportunities for collaborative mental health care.
This updated position paper reviews these trends and opportunities, and recommends ways in which
mental health and primary care providers and services can work together to advance this agenda, as
well as meet the needs of populations and communities that traditionally have difficulty accessing
mental health and addiction services. And if these innovations are to be sustained, we need not only
to prepare and support providers to work in these new models, but also to train future practitioners for
a new style of practice, so that they can take advantage of the benefits that these new approaches to
collaboration can offer.
WHAT WE HAVE LEARNED SO FAR
Experiences from Canadian projects and other initiatives at the provincial or regional health authority
level, and a review by Craven and Bland (4) has helped to identify key enablers for successful
collaborative partnerships in mental health care. Such partnerships should be:
o based upon mutual respect, trust and a recognition of each partner’s potential roles
and contributions
o responsive to the changing needs of patients, their families, other caregivers, and
resource availability
o shaped by the context and culture in which care takes place
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o relevant and responsive to local resource availability, and the skills and interests of
participating partners
o based upon effective and evidence-informed practices
There is also evidence that co-location is advantageous for both providers and people using services
(4) and mental health services that are embedded within primary care practices services can serve as
the foundation of an integrated continuum of mental health services with complementary roles (5).
At the same time, collaborative relationships between primary care and mental health providers
require time and work (4) and the degree of collaboration does not, in and of itself, predict
improved clinical outcomes. Collaboration alone has not been shown to produce skill transfer and
enduring changes in primary care physician knowledge or behaviours (4), so needs to be supported
by other changes in systems of care (6-9).
There is convincing evidence as to the benefits of collaborative partnerships, in both the shorter
term - 1-2 years (6-50) and up to 4 or 5 years (23,24,39,40), as measured by symptom improvement
(5,35,36), functional improvement (41), reduced disability days (38), increased workplace tenure
(33) , increased quality adjusted life years (33) and increased compliance with medication (23).
These benefits have also been identified for other populations such as youth (43), Seniors (17),
individuals with addiction problems (46) and first nations populations (48).
There is also evidence that these programs are cost effective and can lead to savings in health care
costs due to a) a more efficient use of medications (34) b) reduced utilization of other medical
services, especially for individuals with chronic medical conditions, (40) c) more efficient use of
existing resources (34), d) a greater likelihood of a return to the workplace (42). At the same time,
authors have pointed out the need for initial investment in these new services, if savings are to be
achieved down the road (23,35,37).
Increasingly, the most effective collaborative programs increasingly include multiple linked
intervention components and redesign existing processes of care, and emphasise quality
improvement (49). Reviewing the key ingredients of success of these programs, four general
lessons can be learnt.
1) There are some common components to successful programs. These can include:
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The use of a care coordinator or case manager (8,17,19,20,23,37)
Access to psychiatric consultation (10,15)
Enhanced patient education or access to resources (8,18,20,21,33,34)
The introduction of evidence-based treatment guidelines (8, 15, 27, 29)
Screening individuals with chronic medical conditions for depression or anxiety (38)
Skill enhancement programs for primary care providers (17,33)
Access to brief psychological therapies (19,32,50) motivational interviewing (46)
2) There is a need to re-organise / redesign existing systems of care to support these
interventions and optimize their benefits, such as:
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Team-based care and clarity in the roles of different providers (11,15,17,22,41,51,52)
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Systematic (proactive) follow-up (35,41,49)
Improving coordination of care (13,18,20)
Self-management support (42)
Telephone follow-up (12,45,53)
Improved communication / team meetings (10,37,41)
3) The use of a stepped care approach (8,17,27,29). In these models, best developed for
depression, treatment follows a series of steps that may overlap, according to symptom severity
or need. These steps can include:
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Watchful waiting and monitoring by primary care providers.
Self management support, lifestyle changes and supportive counseling.
Psychological and family interventions by primary care providers and mental health
personnel working in primary care, including problem-solving therapy, CBT, and
motivational interviewing.
Use of medication.
Referral to specialized care within or outside the primary care setting.
4) Using models where care is shared. This refers to situations where primary care and mental
health staff work together, communicate regularly and support one another, sharing in the care
of individuals they are caring for, with responsibilities being divided according to their
respective skills and comfort as well as resource availability.
CHANGING ROLES
For all of the progress that has been made, several challenges still need to be overcome to ensure that
those afflicted with mental illness receive the quality services they are entitled to have in a timely
manner. Family physicians continue to be – and will remain - the most responsible providers for
many individuals dealing with a mental health problem or illness, yet many of these individuals
experience significant delays in problem recognition, diagnosis and initiation of treatment.
Primary care is ideally positioned to be the first point of care for individuals with mental health and
addiction problems and monitor them over time. Improving access to the services individuals need
when they need them, and the quality of care they receive, however, requires additional support from
and collaboration with psychiatrists and other mental health providers, and strong links between
mental health and primary care services. Achieving this demands the following changes in roles:
Primary Care
With additional collaborative support, primary care can provide the following functions.
Early detection.
 Simple screening tools can assist with detecting mental health problems, including co-morbid
problems in individuals with general medical conditions. (see www.shared-care.ca for tools)
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It can be aided by training office staff to recognize individuals with mental distress requiring
prompt attention (such as Mental Health First Aid for Medical Office Assistants in primary
care)
Early intervention / initiation of treatment
This can be improved by
 The use of evidence-based treatment algorithms
 The integration of mental health providers and visiting psychiatrists within primary care teams
 Development of closer relationships with the community sector; peer support; link with
appropriate consumer organizations
Support Self Management
This should be an integral component of all care and can include:
 Supporting consumers to better manage their own illness
 Providing relevant, easy to understand information on their problem
 Ensuring every consumer has a treatment plan and is given a copy
 Encouraging lifestyle changes, including physical activity
Monitor and Follow Up of individuals with mental health problems
This is a key part of the role of primary care, including follow-up after discharge from a
mental health service, and can be helped by
 A registry to track individuals over time and identify populations with a specific problem who
are not currently receiving the services they need.
 Proactive recall and reminder / notification system
 Medication reconciliation
Integrate physical and emotional care
This can be achieved by
 Treatment plans that include interventions aimed at both emotional and physical health
 Assessing and treating individuals with enduring medical conditions for depression and
anxiety
Co-ordinate care:
This can be assisted by
 The use of staff with a dedicated role to assist patients to navigate the health care system;
 Integration of specialized mental health services in primary care/family practice
 More effective use of referrals to specialised services
Support families and other caregivers
The needs of families caring for someone with a mental health problem or illness are often
overlooked but primary care is uniquely positioned to support and assist these individuals
Secondary and tertiary mental health services
To support these roles, secondary and tertiary services should be able to
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provide rapid access to consultation and advice
prioritise those individuals who cannot be managed within the primary care setting either
because of problem complexity or a lack of necessary resources
stabilize individuals who have mental health and addiction problems, and then hand their care
(based upon a comprehensive plan that has been developed) back to primary care providers
for ongoing management and monitoring,
continue to be available to the primary care team after care for an individual is returned to
their primary care provider.
Collaborative linkages with mental health and community services, including the integration of
specialized staff within primary care settings, will also enable individuals to reach and receive the
services they need as smoothly and quickly as possible, by:
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improving communication and personal contacts between staff working in different setting
facilitating the flow of patients from one service to another and provide continuity of care
providing support and advice that will enable both sectors to increase their capacity for
consumer and family centered care.
Ensuring the integration of physical and mental health care
These links are based upon “stepped” models of care (see earlier) where primary care providers are
supported by mental health and addiction services to deliver as much care as possible within their
levels of skill and comfort, and then involving specialized services, either within primary care or in a
community mental health program for those individuals who require more than they are able to offer.
These services are, in turn, supported by access to sub-specialised mental health and addiction
services when required.
Community Services, Schools, and the Workplace
Collaborative partnerships at the interface between family practice/specialized mental health services/
and the workplace / schools / community agencies, can play an important role in the re integration of
persons with mental health issues/addictions at work / school and in their community..
STEPS TO IMPROVING COLLABORATION
While there is wide variation in the many innovative programs that have been developed, all share
one or more of the following goals:
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To enhance the experience of an individual seeking and receiving care
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To increase the capacity of mental health and primary care services to deliver effective care
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To improve access to services, reducing waiting times and increasing system efficiency
Achieving these goals requires supported change by all stakeholders:.
By Primary Care Providers
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All family physicians should possess core competencies in mental health care. This does
not mean that every physician should be an expert in diagnosing and treating persons with
mental health issues, but all family physicians should have the necessary skills to screen for
and detect mental illness, initiate treatment where appropriate, develop appropriate links
with other partners in care and organize their practice to ensure that those with mental
illness and addictions are treated with respect and sensitivity to their often complex needs
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Much can be learned from the way systems of care have been redesigned to better
manage individuals with enduring physical illnesses such as diabetes, asthma, congestive
heart failure, that can be applied to the management of mental health problems. In primary
care this could include:
o Incorporating guideline-based care and treatment algorithms
o Developing a list (registry) of patients in a practice who have a specific problem (e.g.
depression). Such list can then be used to support: planned visits; proactive recall;
relapse prevention and early detection strategies.
o Ensuring that individuals with mental health problems have clear treatment plans, based
upon the patient’s own goals, with a copy of these provided to the patient.
o The use of new technologies in health care for managing information is a key element of
primary care transformation. Components can include:
o A common electronic medical record and evidence guided algorithms to enhance
collaboration and efficient data-collection and analysis;
o registries are essential to support a move to pro-active population-based care;
o telepsychiatry, which offers new ways to link providers, enhance collaboration and
provide consultation to underserved communities
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Primary care providers should routinely screen individuals with general medical
disorders for depression and anxiety and initiate treatment or referral as required. If
necessary, further assessment, treatment and referral can be initiated. Primary care providers
are more likely to detect these problems if they have access to support; without access to
treatment, screening has no impact on outcomes (Harriett). Collaborative partnerships can
help to address these issues.
 Enhancing the patient experience by :
o
o
o
o
Supporting self-management as an integral component of all care plans.
Ensuring every consumer has a copy of their own care plan
ensuring care is consumer and family-centered
Including people with lived experience and families in the planning and evaluation
of new projects and services
o The use of consumer and family satisfaction with care questionnaires
o Developing strategies that will reduce stigma and discrimination by educating
providers about how these issues can affect the care individuals with mental health
and addiction problems and their families / caregivers receive in primary care and
how to counter these
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Developing strategies to ensure that individuals with mental illnesses and addictions have
access to appropriate and comprehensive primary health care, (54) including
incorporating primary care personnel (nurses, nurse practitioners, physician assistants, and
family physicians) into mental health programs.
By Psychiatrists
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Psychiatrists need to recognize the valuable role primary care plays in delivering mental
health services and see consultation and support to their family medicine colleagues as
an integral part of their clinical activity.
Communication to primary care needs to be timely, relevant and useful, whether in person,
in writing or by phone.
By mental health services
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There are many changes that any mental health service can make to better respond to the
needs of primary care providers. Examples of this include:
o Making Intake Processes efficient and user (referral source) friendly
o Providing telephone back-up to family physicians
o Offering a rapid consultation service, with individuals being placed on waiting lists
for ongoing treatment if necessary
o Involving family physicians in discharge planning and the completion of the plan
o Routine telephone follow-up with a consumer after discharge to ensure they were
following through with the plan
o Rapid transmission of reports and plans at admission and after discharge
o Producing one page newsletters that updates family physicians on services offered /
new programs.
o Involving family physicians in the planning and evaluation of services and programs
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Mental health providers, including psychiatrists should explore innovative ways to work
more closely with primary care partners, including delivering services within primary care
setting
By Health care systems
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Priority should be given to collaborative projects that offer opportunities for
o early detection and intervention, and ongoing monitoring of children and youth, with
mental health problems, and their caregivers
o early detection and intervention, ongoing monitoring and relapse prevention of seniors
with mental health problems and the needs of their caregivers
o meeting the needs of populations that may be marginalized or have particular
difficulty in accessing services, including our aboriginal populations, and those who
are homeless.
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Ensuring care is genuinely consumer and family focused and that our activities add value to
the person using the service
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As personal contacts are central to building collaborative partnerships, there can be many
benefits from organizing events that bring together mental health and primary care
personnel such as joint clinical rounds, joint educational rounds and formal CPD events.
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Developing networks of providers, information technology experts, researchers and
consumers interested in collaborative mental health care to enable participants to exchange
ideas, share experiences, and work together to develop new projects.
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Including an evaluation component in every project to answer key questions arising from
collaborative partnerships, which can drive further improvements in services. This will also
increase the pool of Canadian data. Questions to study include:
o
o
o
o
o
The outcomes of these projects
the cost benefits of these approaches;
the impact of these approaches on referral patterns, wait times and access;
the benefits of working in collaborative partnerships for health care providers;
the satisfaction of people using services with these models.
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Establishing a central information point for providers, planners and consumers interested
in collaborative care which will include descriptions of programs, resources and assistance
for training programs and individuals starting new projects and can support learning
communities.
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As more providers start working in collaborative partnerships, they need to be prepared
adequately for this work. This can include assistance with project design, workshops and/
training sessions, visits to existing projects with similar models, access to relevant materials
and resources, and ongoing support once programs are underway.
By people using these services
Central to the success of future collaborative projects will be the ability of health services to
include people using these services as partners in their own care, and in the planning and
evaluation of collaborative projects. The development of new projects needs to be based upon
what we can learn from people with lived experience as to where aour systems are failing them and
how these deficiencies could be improved
By Provincial/Territorial Governments and Regional Health Authorities
 As ultimate funders and policy makers, they must be cognizant of the value of
collaborative models of care and must ensure policy alignment and funding support. In
particular, team development, the integration of mental health professionals who
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traditionally worked in institutions at the primary care level, and recognition of the
importance of indirect care must be addressed.
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Supporting leaders (individuals and services) who have the potential to deliver innovative
programs.
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Linkages between mental health and primary care planners at the provincial and RHA
levels will increase the likelihood of well-co-ordinated collaborative initiatives
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Provinces / Territories and Regions should test demonstration projects that provide data
on the role that collaborative projects can play in addressing common problems faced by
health care systems including:
o
o
o
o
o
Meeting the needs of underserved populations
Serving individuals in isolated communities
Improving outcomes for individuals with chronic medical conditions
Reducing waiting times and improving access to care
Improve physical health outcomes for individuals with mental disorders
By the CPA and CFPC
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To continue to promote as an important activity with their members, and in the broader
Canadian health care community
By Provincial medical associations and other professionals negotiating bodies
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These organizations should promote appropriate payment schemes that support
collaborative practice
By Non Governmental Organizations, Consumer Groups representing persons with lived
experience of mental illness
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Several of these already have an excellent track record of involvement in initiatives or
projects with creation of tools and resources that can be very useful to people with lived
experience of mental illness. They are and will be called upon to play a greater role in the
creation/expansion of peer support, and self management. In time, it is hoped that they will
become better integrated at all levels of care.
By Academic institutions, universities, departments of psychiatry and family medicine in
particular
A key to the long-term sustainability of collaborative partnerships is to prepare learners to work
in collaborative models. This includes strengthening the place of collaborative partnerships within
the curricula of residency and undergraduate programs, so it become second nature to future
practitioners; finding ways for learners from different disciplines to learn together and from each
other; involving people with lived experience in educational sessions.
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When introducing changes in Canadian training programs, however, we have to recognize the
challenges faced by many teachers and programs in responding to the multiple requests they receive
for curricular changes, in medical education systems that are not always appropriately resourced.
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An extensive curriculum review regarding the postgraduate training of psychiatrists has
taken place, led by the Canadian Psychiatric Association. Psychiatry residents are now
required to spend a minimum of 8 weeks in collaborative projects. Programs need to work
with primary care partners to develop appropriate clinical placements.
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Family medicine residents in several programs have the opportunity to experience “Shared
Care”, or “Collaborative Mental Health” approaches during their training program. The
training of family medicine residents in behavioural science has improved tremendously
over the past several years. The Working Group recommends that a learning experience in
Collaborative Mental Health Care be more clearly spelled out in the accreditation criteria,
and specifically documented during accreditation visits.
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Working on defining core competencies in mental health, is important but is not enough. It
is essential that residents in family medicine and psychiatry be able to understand and
experience the process elements of good mental health care. Such process elements are
defined by reviewing the care experience of persons living with/suspecting they may suffer
from a mental illness. The Working Group would welcome the opportunity to meet with the
educator representatives of both Colleges to discuss innovative ways of doing this and of
measuring the outcomes of such interventions.
By The Research Community
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It is important for practices and groups involved in new projects/initiatives to to develop
common screening, monitoring and evaluation tools and measures in order to provide
comparative data.
It is also important to recognize the need for research projects, including multi-centre
studies, that will measure:
o Consumer and population outcomes of new initiatives
o Economic benefits
o The impact of standardized approaches to treatment
o Competencies required to work in these models
o The benefits to providers of participating in these models
o Which problems and populations are best served in primary care and which need
specialized mental health and addiction services
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