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Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care

Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care. Nick Kates MB.BS, FRCP(C) Professor Dept. of Psychiatry, McMaster University Ontario, Canada Program Director, Hamilton Family Health Team. PLAN. The Canadian Context

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Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care

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  1. Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care Nick Kates MB.BS, FRCP(C) Professor Dept. of Psychiatry, McMaster University Ontario, Canada Program Director, Hamilton Family Health Team

  2. PLAN • The Canadian Context • The Hamilton Family Health Team Mental Health Program • Key Lessons learnt • Implications for Departments of Family Medicine • Lessons for patient-centred medical care

  3. Canada • 10 Provinces and 3 territories • Federal Government • Provinces responsible for Health Care (13 health care delivery systems) • Canada Health Act defined principles to guide the entire system (1964) • Universality • Portability • Publicly Administered • Comprehensive • Accessible • Almost all health services are publicly funded (9.2% of GDP) • 20:80 split – Was originally 50:50

  4. Ontario • Ontario spends $3,000.00 per capita per year on health care • 50 / 50 split – specialists / primary care • Strong base of primary care – 40% solo practitioners – first point of contact • 7.5% of the population have no family physician

  5. Ontario • Average practice size 2,200 patients • Most family physicians still funded by fee for service, but moving to capitation (33%) • Capitation pays approximately $130 per pt. / year (covers office expenses) • Average salary = $200,000 • Bonuses - For processes not outcomes : Can earn up to $75,000 - Usually closer to $25,000

  6. Ontario – Incentives(Examples) • Mammography • Flu shots • Immunization • Pap Smears • Colo-rectal cancer screening • Diabetes care • Managing 10 patients with severe mental illness • Taking on new patients without a family physician

  7. ROLE OF PRIMARY CARE • First point of contact with the health care system • Often cradle to grave • Family centred • 81% of population see their family physician annually • Initiates referrals to specialists – reinforced by billing tarriffs • Very few primary care internists / pediatricians / OBGYN • Co-ordinates information about a patients care • Increasingly provides a variety of specialized services • Seen by the patient as the place to turn first for care • Consistent with the concept of the medical home

  8. FAMILY HEALTH TEAMS • Next step in transformation of primary healthcare in Ontario • 150 FHTs funded in 3 waves in 2005 • 50 more approved for 2009 - 10 • Involve almost 25% of all comprehensive care family physicians in Ontario

  9. FAMILY HEALTH TEAMS • 2-25 family physicians (1 or 2 large networks) • Funded by capitation • Rostered populations (negations) • Supported by IT – still only 28% use EMR • Comprehensive care • Population-based care • 24 / 7 coverage

  10. FAMILY HEALTH TEAMS • Emphasize health promotion and illness prevention • Emphasise chronic disease management • Emphasize self-management • Care co-ordination / system navigation • Team based care • Family physician(s) • Nurse • Nurse practitioner • Social Worker / Mental Health Counsellor • Dietitian • Pharmacist • Health Educator • Linked with other community and health services

  11. HAMILTON City of 500,000 in S. Ontario Originally built upon heavy industry Home of McMaster University Tradition of innovation in health care / medical education (since 1967) Home of problem-based learning Home of evidence-based medicine McMaster Motto: “Melius est Urinam Facere quam Amovere!” It is more fun to make a mess Than to clean it up

  12. THE HAMILTON FHT (HSO) MENTAL HEALTH PROGRAM

  13. MENTAL HEALTH CARE IN PRIMARY CARE • Using as an example of ways in which the scope and role of primary care can be expanded • Prevalence is high, major challenge for primary care • Access to mental health services is often a problem • Addressing mental health problems is integral to the treatment of most health problems / chronic conditions • Key role primary care can play in early detection • Less stigmatising for the patient

  14. WHY THE PROGRAM CAME ABOUT (1994) • Family physicians already playing a key role in delivering mental health care • Low detection and treatment rates in primary care • Low detection and treatment rates with co-morbid chronic diseases • Family physicians saw this as a major area of need • Resource availability

  15. WHY THE PROGRAM CAME ABOUT • Family physicians already playing a key role in delivering mental health care • Low detection and treatment rates in primary care • Low detection and treatment rates with co-morbid chronic diseases • Family physicians saw this as a major area of need • Resource availability • Poor access to existing mental health services – FP frustration

  16. WHY THE PROGRAM CAME ABOUT • Family physicians already playing a key role • Low detection and treatment rates in primary care • Low detection and treatment rates with co-morbid chronic diseases • Family physicians saw this as a major area of need • Resource availability • Poor access to existing mental health services – FP frustration • Attempt to address problems in the relationship between mental health and primary care services

  17. OUR SOLUTION : TO INTEGRATE MENTAL HEALTH SERVICES INTO PRIMARY CARE

  18. 3 MAJOR INFLUENCES • Integrating teaching of family medicine residents into the clinical units • Rural mental health model • UK experience

  19. HAMILTON FHT (HSO)MENTAL HEALTH PROGRAM • 1994 MH Program started – 45 physicians • 1996 Expansion – 41 new physicians (86) • 2005 Became part of Hamilton Family Health Team - 73 new physicians (145)

  20. PRIMARY CARE REFORM IN CANADA • Began in 1995 • Accelerated by Federal funding in 1999 and 2002 • Emphasis on access • Emphasis on CDPM • Increasingly seen as foundation of the system / downloading • Introduction of learning collaboratives • Now emphasising quality more

  21. PRIMARY CARE REFORM IN CANADA • Mental health services increasingly integrated in primary care across the country • Planning is better co-ordinated • Strong national presence • CPA / CFPC have joint committee • Website / conference • New training guidelines for psychiatry residents • Changes to training guidelines for family medicine residents (slower)

  22. THE HAMILTON PROGRAM HAS BECOME THE NATIONAL PROTOTYPE FOR INTEGRATING MENTAL HEALTH SERVICES INTO FHTS

  23. HFHT MENTAL HEALTH PROGRAM - 2008 • 80 practices (57 solo practices) • 105 sites • 145 family physicians • 340,000 patients (68%)

  24. HOW DOES THE PROGRAM WORK

  25. STAFF RATIOS IN THE HFHT MHP Ratio FTEs FTEs 1996 2006 • Counsellors 1:7,200 22.9 50.5 • Psychiatrists 1:75,000 2.2 4.8 Co-ordinated by a central program team

  26. INCLUDES OTHER PILOT PROGRAMS • Children’s mental health • Addictions • Depression chronic disease management • Peer support for depression • Return to work project for injured workers • Groups

  27. CENTRAL STAFF • Manager • 2 Secretaries • Program assistant • 2 data entry clerks • 0.2 FTE Evaluation • 0.5 FTE Medical Director • Leads / facilitators for depression (0.5), addiction (0.2), child (0.2), peer support (0.1)

  28. HOW THE PROGRAM WORKS • See any case / any age (3-98) • Criterion is family physician is looking for help • Emphasis on short-term care • Specialists integrated within primary care • Indirect as well as direct service • Emphasis on education • Charting integrated • Stepped model of care • Shared care model

  29. CENTRAL PROGRAM TEAM • Coordination/management • Needs assessment • Direction • Guidelines • Evaluation • Trouble shooting • Liaison with practices • Liaison with Ontario MoHLTC (funder) • Recruitment • Staff preparation / continuing education • (Re)allocation of resources

  30. DOES IT MAKE A DIFFERENCE? Data from the programs evaluation.

  31. REFERRALS 2007 (145 FAMILY PHYSICIANS) • Total 7064 • Counsellors 6084 (87%) • 150 per Full Time Equivalent • Psychiatrists 1564 (21%) • 590 per Full Time Equivalent

  32. REFERRALS 2007 Total Referrals 7064 <12 5% <18 14% >65 8%

  33. MAJOR PRESENTING PROBLEMS Problem Primary (%) Any (%) Depression 35.7 68 Marital / family 16.0 37 Anxiety 12.1 45 Work problems 4.4 12 Child behaviour problem 2.4 20 Anger / temper control 2.9 8 Psychotic symptoms 2.8 4 Bereavement 2.0 10 Suicidal 1.4 7 Substance abuse 1.3 8

  34. REASON FOR REFERRAL TO HSO PSYCHIATRIST Reason for referral (%) Clarification of diagnosis 68 Advice regarding: Medications 84 Psychotherapy 32 Risk to self / others 6 Community resources 5 Family / Marital problem 8

  35. DIAGNOSIS: CASES SEEN BY PSYCHIATRIST Diagnosis (DSM IV) (%) Depression 31 Anxiety disorder 16 Dysthymia 10 No psychiatric diagnosis 8 Adjustment disorder 7 Personality disorder 6 Schizophrenia 5 Substance-related disorder 5 Bipolar disorder 4 Disorder of childhood / adolescence 4 Somatoform disorder 2 Other 2

  36. REFERRALS TO MENTAL HEALTH SERVICES (FIRST 13 PRACTICES - 45 PHYSICIANS) Service 92-93 94-95 2000 2003 Out-patient clinics 203 75 72 82 HSO Mental health - 2532 2180 2255 team Total Referrals 203 2607 2252 2337 Ref. / Phys / year 5 54 53 55

  37. Impact on use of mental health services Initial 13 sites began 1994 Additional 23 sites joined

  38. OUTCOME MEASURES : CES-D • Mean change = 21.2 • Improved > 1 SD = 68% • Score reduced > 50% = 79% All changes significant p<.05

  39. OUTCOME MEASURES : SF-8 • Mean change = 17.8 • Improved > 1 SD = 62% • Score reduced > 50% = 78% All changes significant p<.05

  40. SATISFACTION WITH SERVICES

  41. CONSUMER SATISFACTION • CSQ - 91% satisfaction • Ave score on V.S.Q. 4.5 out of 5 • Each item meets or exceeds AAGH Benchmarks

  42. PROVIDER SATISFACTION • Family Physicians • With Counsellors 92% • With Psychiatrists 92% • Counsellors 90% • Psychiatrists 90%

  43. HAMILTON FAMILY PHYSICIANS OVERALL SATISFACTION WITH MENTAL HEALTH SERVICES • Those with HSO Program 86% • Those without HSO Program 56%

  44. “ I think that knowing we have great back-up makes us less resistant to explore social issues during a busy clinic.” Family Physician in the Program

  45. “Over the 3 years of the program, I am convinced that my own knowledge and comfort with mental illness has increased to a highly significant degree. It is no longer an area of uncertainty and doubt, but a discipline which has begun to fall into place and gives great satisfaction and reward.” Family Physician in the Program

  46. EVOLUTION OF THE MODEL • Can’t be all things to all patients • Who is best seen in primary care / needs referral • Manage relationship with the mental health system • Physical proximity crucial for collaboration • Can still act in traditional ways (52 mins!) • Emphasise access • Standardisation • Strengthens links with community partners / agencies • Children’s mental health services critical • Opportunities for early detection

  47. LESSONS LEARNED

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