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Shared Care in Canada. Douglas Green MD TOH Shared Mental Health Team Ottawa, Ontario, Canada [email protected] Objectives. Learn about Canada and the Canadian health care system Review the problems in the provision of mental health services in Canada

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Shared care in canada
Shared Care in Canada

Douglas Green MD

TOH Shared Mental Health Team

Ottawa, Ontario, Canada

[email protected]


Objectives
Objectives

  • Learn about Canada and the Canadian health care system

  • Review the problems in the provision of mental health services in Canada

  • Review the history of the Shared Care movement in Canada

  • Briefly review the evidence for what works in Shared Care

  • Learn about the vision for Shared Care in Canada in the future

  • Learn about the Ottawa Shared Care model and innovations in care planned


The canadian context
The Canadian Context

  • Country of over 35 million people

  • Second largest country in the world in total area

  • 80% of the population live in urban areas with most living within 150 kms of the United States border

  • A demographic shift is occurring as the population is gradually aging

  • Canada has one of the highest per capita immigration rates in the world which is leading to an increasingly diverse population


Government and politics
Government and politics

  • Canada is a federal parliamentary democracy

  • It is comprised of 10 provinces and 3 territories


The canadian health care system
The Canadian Health Care System

  • Publicly funded health care system, which is mostly free at the point of use

  • Health care is administered separately by each of the 10 provinces

  • In most provinces dental and vision care and medications are not covered except for the indigent and the elderly

  • Of note psychological services are notcovered


The canadian health care system contd
The Canadian Health Care System (Contd.)

  • Family physicians are chosen by the individual patient

  • 85% of Canadians have a family physician

  • Specialists can only be seen upon referral from the patient’s family physician or by an emergency physician


The canadian health care system contd1
The Canadian Health Care System (Contd.)

  • Most physicians are paid on a fee-for-service basis although this is gradually changing

  • Hospital care is delivered by publicly funded hospitals

  • Rising debts have recently led to cuts in government funding to the health care system, which has placed the system under stress


Primary care reform
Primary care reform

  • Main objective is to improve patient access to primary care

  • Leading to changes in the remuneration of family physicians (capitation vs. fee for service), and increase in after hours services and the introduction of quality incentives for preventive care and chronic disease management

  • Often involves team-based care


Mental health treatment in canada
Mental Health Treatment in Canada

  • In the 19th century many asylums were built across the country to treat the mentally ill

  • After WW II psychiatric institutions became overcrowded

  • Beginning in the 1960s there began a trend to deinstitutionalization

  • Unfortunately adequate community resources to address the needs of the deinstitutionalized patients not put in place


Mental illness and primary care
Mental illness and primary care

  • Prevalence of mental illness in primary care is high

  • Up to 25% of patients have a diagnosable mental disorder

  • Family physician is usually the first and may be the only point of contact with a health care provider for individuals with a mental health disorder


Mental illness and primary care1
Mental illness and primary care

  • Unfortunately most family physicians lack adequate training and do not feel prepared to deal with much of the mental illness they see

  • Access to psychiatrists is often very difficult (may take months) and communication with specialist is often poor

  • Access to psychotherapy resources (especially for those without private insurance) is poor as not covered by public health system


Mental illness and primary care2
Mental illness and primary care

  • Psychiatric consultants report problems with poor communication and inadequate information from family physicians

  • Also report reluctance on part of family physician to take responsibility for continuing mental health care of patients once they are stabilized


Compounding factors
Compounding factors

  • Shortages of psychiatrists, especially in rural areas

  • Recently more acutely mentally ill patients found in primary care due to shorter hospital stays (due to health care cuts) and greater emphasis on community-based care (due to deinstitutionalization)


1997 cpa ccfp task force
1997 CPA/CCFP Task Force

  • In 1997 the College of Family Physicians of Canada (CCFP) and the Canadian Psychiatric Association (CPA) struck a task force which identified shared care as a possible solution to the need for increased collaboration between family physicians and psychiatrists


Shared care principles
Shared Care Principles

  • Family physicians and psychiatrists are part of a single health care delivery system

  • The family physician has an enduring relationship with the patient which the psychiatrist should aim to support and strengthen

  • No single provider can be expected to provide all the necessary care a patient may require


Shared care principles contd
Shared Care Principles (contd.)

  • Professional relationships must be based on mutual respect and trust

  • The patient must be an active participant in this process

  • Models of shared care must be sensitive to the context in which such care takes place


3 strategies
3 strategies

  • Improve communication in the working relationship between a psychiatrist or psychiatric service and local family physicians

  • Establish liaison relationships

  • Bring psychiatrists or other mental health providers into the family physician’s office


Since 1997
Since 1997

  • Now use term “collaborative mental health care” instead of “shared care”

  • Significant expansion in collaborative activities has occurred

  • Collaborative mental health is now seen as an integral component of provincial and regional planning

  • National conference established in 2004 and website introduced


Royal college requirement
Royal College requirement

  • Beginning in 2009 the Royal College of Physicians and Surgeons of Canada mandated that residents their PGY IV or V year must do a minimum rotation of no less than 2 months in collaborative/shared care with family physicians, specialist physicians and other mental health professionals


However
However…

  • Many of the mental health and addictions problems are still managed without the involvement of a psychiatrist or other mental health provider

  • Shared care/collaborative care continues to be provided in a somewhat haphazard and “patchwork quilt” type of way dependent upon local funding and hampered often by systemic factors


What is collaborative mental health care
What is Collaborative Mental Health Care?

  • “… care that is provided by providers from different specialties, disciplines, or sectors working together to offer complementary services and mutual support”


Models of collaboration
Models of collaboration

  • No single collaborative model or style of practice

  • Any activity that involve mental health professionals and primary care providers working together to more effectively deliver the care they deliver can be collaborative


Key components
Key components

  • Effective communication

  • Consultation (MHP>PCP or PCP>MHP)

  • Coordination of care

  • Co-location

  • Integration of MHP and PCP within a single service or team


Benefits of shared collaborative care
Benefits of shared/collaborative care

  • Symptom improvement

  • Functional improvement

  • Reduced disability days

  • Increased workplace tenure

  • Increased quality-adjusted life years

  • Increased compliance with medications


What we have learned so far contd
What we have learned so far (contd)

  • Benefits identified in youth, seniors, people with addictions and indigenous populations

  • Leads to reduction in health care costs

  • Most significant benefits seen in depression and anxiety

  • Less evidence for patients with severe and persistent mental illness


What does the research indicate are some of the ingredients of successful collaborative care models
What does the research indicate are some of the ingredients of successful collaborative care models?


Chronic care model
Chronic Care Model of successful collaborative care models?


Depression in primary care
Depression in Primary Care of successful collaborative care models?

  • Although depression is often a recurrent condition and the prevalence of depression in primary care is high, detection, treatment and referral rates are low

  • Moreover, even if treatment is initiated most patients do not receive adequate follow-up


Why is this the case
Why is this the case? of successful collaborative care models?

  • Models of care usually focus on acute treatment with short, often unprepared appointments

  • Rely on patient-initiated follow-up

  • Family physicians focus on those patients being seen, rather than an entire population of a practice, and often fail to provide appropriate follow-up and monitoring


The chronic disease model ccm
The Chronic Disease Model (CCM) of successful collaborative care models?

  • In the later part of the 20th century researchers began to develop care models for the assessment and treatment of the chronically ill

  • Edward H. Wagner, Director of the MacColl Institute for Healthcare Innovation and Director of the The Robert Wood Foundation national program “Improving Chronic Illness Care” developed the Chronic Care Model, or CCM


Elements of the ccm
Elements of the CCM of successful collaborative care models?

  • System Design

  • Self-management support

  • Decision support

  • Information systems

  • Organizational change

  • Links with community resources


Stepped care
Stepped Care of successful collaborative care models?


Having the right service in the right place at the right time delivered by the right person
“Having the right service in the right place, at the right time delivered by the right person.”


What does the research indicate are some of the ingredients of successful collaborative care models1
What does the research indicate are some of the ingredients of successful collaborative care models?


1 use of a care coordinator
1) Use of a care coordinator of successful collaborative care models?


Care coordinator
Care coordinator of successful collaborative care models?

  • Based in chronic care model

  • Provides psychoeducation

  • Encourages healthy life style changes

  • May focus on behavioural activation and other “low intensity” type therapy for depressed patient

  • Liaises with GP

  • Consults with psychiatrist when necessary


2 psychiatric consultation
2)Psychiatric Consultation of successful collaborative care models?


Psychiatric consultation
Psychiatric consultation of successful collaborative care models?

  • Can be either direct or indirect

  • Can be onsite, by telephone or using newer technologies such as videoconferencing or the internet (eConsult program in Ottawa)


3 self management and psychoeducation
3) Self management and psychoeducation of successful collaborative care models?


Web based self help resources cbt based
Web-based Self Help Resources (CBT based) of successful collaborative care models?

  • Get self help

    • http://www.getselfhelp.co.uk/

  • Living life to the full

    • http://www.llttf.com/

  • Positive Coping with Health Conditions

    • http://www.comh.ca/pchc/

  • Mood Gym

    • https://moodgym.anu.edu.au/welcome



Phq 2
PHQ-2 anxiety and depression


Using the phq 2
Using the PHQ-2 anxiety and depression

  • If score is 3 or above then proceed to do full PHQ-9


Phq 9
PHQ-9 anxiety and depression


Available at www phqscreeners com
Available at www.phqscreeners.com anxiety and depression


5 treatment algorithms
5) Treatment algorithms anxiety and depression


Treatment algorithms
Treatment algorithms anxiety and depression

  • Based on evidence based treatment guidelines

  • May employ standardized outcome measure (e.g. PHQ-9) to assess response to treatment

  • May involve standardized follow up

  • Should address when to refer for more specialized care


Using PHQ-9 Diagnosis and Score for Initial Treatment Selection**based on MacArthur Initiative on Depression and Primary Care


Using the PHQ-9 to Assess patient Response to Treatment Selection** Initial Response after Four - Six weeks of an Adequate Dose of an Antidepressant


Using the PHQ-9 to Assess patient Response to Treatment Selection** Initial Response to Psychological Counseling After Three Sessions over Four - Six Weeks



Brief psychological therapies
Brief psychological therapies Selection*

  • Most evidence for CBT either individually or in group format

  • Evidence also for interpersonal therapy (IPT) and problem-solving therapy (PST) for depression in primary care

  • Some collaborative models have therapy provided by care coordinator



Physician skill enhancement
Physician skill enhancement Selection*

  • Case-based discussion often well-received and helpful

  • Address gap in clinical care with respect to use of evidenced-based guidelines

  • Regular meetings between specialist and primary care physicians build trust and sense of collaboration in the learning process


Vision for primary care
Vision for primary care Selection*

  • First point of contact for people with mental health and addiction problems

  • Early detection

  • Early intervention for initial presentation and for emerging recurrence or relapse

  • Monitoring and follow up once stabilized

  • Crisis management

  • Integration of physical and mental health care

  • Coordination of care

  • Support of family and other caregivers


Vision for secondary and tertiary care system
Vision for secondary and tertiary care system Selection*

  • Provide rapid access to consultation and advice including telephone advice

  • Respond quickly to requests for assistance with urgent and emergent situations

  • Prioritize people who cannot be managed within the primary care system

  • Stabilize patient and then return care to primary care

  • Provide information on community resources


Achieving the vision
Achieving the vision Selection*

  • Requires changes in the training of family physicians to support the early detection and treatment of mental illness based on chronic management principles

  • Psychiatrists need to see consultation with family physicians as an integral part of their clinical activity

  • Funders and policy-makers must recognize and support the role that primary care can play in an integrated system

  • Academic departments of family medicine and psychiatry must prepare learners to work in this model of care

  • Evaluation and research projects must be undertaken to see what initiatives work best

  • CPA and CFPC must continue to promote this model


Shared care in mental illness a rapid review to inform implementation
Shared care in mental illness: A rapid review to inform implementation*

Core ingredients of effective shared care models include:

  • Engagement of primary and specialist services towards common goal of improved mental health care

  • A coherent treatment model relating to the target condition/s or patient population

  • An agreed clinical pathway and monitoring of patient outcomes with the provision of case review by specialist personnel when needed

  • *Kelly et al. International Journal of Mental Health Systems 2011, 5:31 pp1-12


Shared care in mental illness a rapid review to inform implementation contd
Shared care in mental illness: A rapid review to inform implementation (contd.)

  • Provision of clinical supervision to support skill development and maintenance of treatment model

  • A well-established clinical governance framework


Shared care in canada1
Shared Care in Canada implementation (contd.)


Shared care models in canada
Shared care models in Canada implementation (contd.)

  • No single model of shared care exists

  • A compendium of all existing shared arrangements in Canada was last done in 2006

  • Many different models exist which reflect the system of care, funding mechanisms and local resources. Examples include:

    • Individual psychiatrists meeting monthly with a group of family doctors and providing indirect consultation and teaching

    • Behavioural health consultant working with GP and psychiatrist (collaborative care model) as seen in Calgary

    • Shared mental health care team integrated into a family health team setting (Ottawa)


Shared care models in canada contd
Shared care models in Canada (contd.) implementation (contd.)

  • Tremendous variation between provinces

    • e.g. in BC much emphasis placed on training of GPs and providing self-management material vs. Ontario where there little resources are directed to shared care

  • Within a province significant there may be differences in amount of shared care activities undertaken e.g. in Ontario, Hamilton vs. Ottawa


Ottawa and shared care
Ottawa and Shared Care implementation (contd.)


Ottawa
Ottawa implementation (contd.)

  • Nation’s capital

  • Population of 870,000 but part of a larger urban area (Ottawa-Gatineau) of about 1.3 million people

  • Not clear the extent to which shared care/ collaborative care is being provided in the region

  • Long wait times exist for psychiatric outpatient care


Toh shared care program
TOH Shared Care Program implementation (contd.)

  • Introduced in 2007

  • Permanent funding provide through 2 academic family health teams

    • 4 family health team sites providing care for approximately 30,000 patients

  • Inter-professional Shared Care Team comprised of:

    • 4 part-time psychiatrists

    • Social worker

    • Psychologist

    • 2 nurses (one of whom is the team manager)

    • clerk


Toh shared care program1
TOH Shared Care Program implementation (contd.)

  • Provides direct and indirect psychiatric consultation

  • Short term follow-up is the goal but not always the outcome

  • Offer short term individual and group CBT-based psychotherapy primarily for anxiety and depression

  • Provides teaching to family health team staff and family medicine residents


Toh shared care initiatives
TOH Shared Care initiatives implementation (contd.)

  • Introduced several rating scales since 2010 to assist with management and communication:

    • PHQ-9 for depression

    • GAD-7 for anxiety

    • WSAS for functional assessment

  • Began education of family health teams about the Stepped Care Model of care


Phq 91
PHQ-9 implementation (contd.)


Available at www phqscreeners com1
Available at www.phqscreeners.com implementation (contd.)


Tipp toe transfer into primary practice the ottawa experience
TIPP-TOE: Transfer into Primary Practice – The Ottawa Experience

  • Study assessing the transfer of stable outpatient psychiatry patients to a multidisciplinary family health care team with access to TOH Shared Care team

  • Possible benefits include access to a family physician, access to allied health professionals (e.g. dietician, pharmacist), and improved coordination of medical and psychiatric care


Reflections on shared care
Reflections on shared care Experience

  • Joys of teamwork

  • Respect for family physician colleagues

  • Benefits of rating scales

  • Benefits of working in a non-fee for service arrangement

  • Appreciation for CBT


Reflections on shared care contd
Reflections on shared care Experience(contd.)

  • The “good, the bad and the ugly” of EMRs

  • Any change needs a “champion”

  • Benefit of technology in patient care and consultation with colleagues

  • Need to “share” patients with others

  • Appreciation for what a system of care is


In summary
In Summary Experience

  • In Canada there has been a gradual interest in, and development of shared care

  • No single model of shared care in exists

  • Research supports the benefits of shared care in terms of outcomes and money saved

  • The success of shared care is dependent upon the championing of its introduction and support from funding agencies


Websites of interest
Websites of interest Experience

  • www.sharedcare.ca

  • www.phqscreeners.com

  • http://www.comh.ca/antidepressant-skills/adult/

  • http://prevention.mt.gov/suicideprevention/13macarthurtoolkit.pdf


References
References Experience

  • Kates N, Craven M, Bishop J et al. Shared mental health care in Canada (position paper). Can J Psychiatry. 1997; 42(8 Insert): 1-12

  • Kates N et al. The Evolution of Collaborative Mental Health Care: A Shared Vision for the Future. The Canadian Journal of Psychiatry 2011; 56(5 Insert): 1-10

  • Kelly B et al. Shared care in mental illness: A rapid review to inform implementation. International Journal of Mental Health Systems 2011; 5:31: 1-12


Questions dogreen@toh on ca
Questions? [email protected]


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