Future directions for primary mental health care

Rotorua July 2010

“Single system, personalised care”

“Patient-centred integration”

Stepped care model

STEP 5

Com-

plex

STEP 5

Com-

plex

STEP 44.7% severe disorders

STEP 44.7% severe disorders

STEP 39.4% moderate disorders

STEP 39.4% moderate disorders

STEP 26.6% mild disorders

STEP 26.6% mild disorders

STEP 1 Adjustment problems; distress; subthreshold symptoms

79.3% of population no disorder

STEP 1 Adjustment problems; distress; subthreshold symptoms

79.3% of population no disorder

Early identification of vulnerability

Integrated family health centres

Primary health care services

Specialist mental health and AOD services

PHQ=10-14Brief XmtExtended GP consultations; monitoring; green prescriptions; e-therapy; self-help books; education groups

Pathway to secondary care

First point of contact

Su

pp

ortive en

viron

men

t & h

ealth p

rom

otio

neg

, ND

I, Like M

ind

s, self-care, wh

ānau

ora,

ho

usin

g, em

plo

ymen

t, edu

cation

, social n

etwo

rkPHQ<10Ultra-brief Xmt Advice, support, psycho-education

PHQ=15-19Low intensity XmtHolistic assessment to determine patient needs; POC; guided self-help; SSRI

PHQ ≥ 20High intensity XmtA range of talking & drug therapies

Longer term Xmt (for complex and/or chronic disorders)

Four key objectives

1. Provide personalised, patient-centred care

2. Achieve seamless, integrated care

3. Build workforce capacity and capability

4. Improve performance and quality of services

1. Provide personalised, patient-centred care

Core functions for providing personalised care

• Prioritisation on the basis of need for mental health and AOD services more intensive than what primary care offers

• A targeted approach to meeting the needs of vulnerable population groups

• Active support for self-care or guided self-help• Connecting patients with appropriate services• Interventions which address patients’ needs• Care coordination• Active monitoring of service users• Review mechanism to determine patients’

progress• Feedback from service users

2. Achieve seamless, integrated care

Guidance for achieving integrated care

• Why integrate? - To improve the patient experience, wellbeing and health and social outcomes.

• What activities should be integrated? - Direct delivery of care

• How much co-location, collaboration, integration?

• Who should be involved? – General practice should serve as patients’ medical home. Both horizontal and vertical integration important.

10 strategies to achieve patient-centred integration

1. Designated liaison role 2. Consultation-liaison3. Shared care4. Co-location of services5. A new mental health and/or AOD

clinician in the primary care team6. Clinical networks7. Contracting for collaborative care8. Pooled budgets9. Clear service user pathways10.An effective IT platform which enables

sharing of electronic records & access to electronic decision support

6. Build workforce capacity and capability

Immediate workforce development priorities

• More GPs, nurses and other PC practitioners • More Māori, Pacific and Asian practitioners• More community support workers• Funders and providers of training to develop and

implement training programmes to increase essential knowledge, skills and attitudes required to work with people with mental health and AOD problems at primary care end of continuum.

• Develop and implement training on:o Psychoeducation o Increasing physical activityo Behavioural activationo Problem solving and/or solution focused counsellingo Simple anxiety managemento Simple motivational strategieso Parent management trainingo Skills training in anger management, social skills,

communication and stress management

Immediate workforce development priorities

• Increase PHC’s responsiveness to children and youth

• Increase PHC’s responsiveness to AOD problems• Ensure access to regular cultural and clinical

supervision• Further develop practice teams which include a

mental health/AOD clinician as part of the team• Further develop the role of peer support workers

and consumer advisors for services at the primary care end of the continuum

• Increase the level of consultation-liaison support between primary and specialist care

12. Improve performance & quality

Mechanisms for improving performance & quality

• An equitable funding mechanism that is based on need and supports single system, personalised care

• Clinical governance and leadership• Accountability and monitoring mechanisms• Ongoing collection of outcome data• Easy access to best practice guidelines and

other high quality, up-to-date information and resource materials relevant to primary mental health care

Recommended key performance indicators (MOH & RNZCGP)

• % of patients identified with common mental health disorders (CMHDs)

• % of patients identified with CMHDs who are followed up within 2 weeks of identification

• % of patients identified with CMHDs who are screened for alcohol problems (eg, using the AUDIT-C, 3 items).

• (Note: If too difficult to track CMHDs, substitute with depression)

• Prescription of SSRIs for the management of depression

• Referral to other primary care providers for the management of CMHDs.

Recommended screening/outcome measures for PC settings

Measure Population Problems

GHQ-12 Adults Common physical & psychological probs

PHQ-9 Adults Depression

PHQ-4 Adults Depression & anxiety

K10 Adults Depression & anxiety

GAD-7 Adults Anxiety

CHAT Adults Lifestyle issues

AUDIT & AUDIT-C Adults Alcohol

SACS Youth AOD misuse

SDQ Children, youth & parents

Behavioural & emotional probs

SMFQ Youth & parents Depression

RADS Youth Depression

Mind Screen Adults DSM-IV disorders

CDOI Children & adults Individual, interpersonal, social & overall wellbeing

Contact DetailsDr Sarah Dwyer Mental Health, Alcohol and Drug Policy Group Population Health DirectorateMinistry of HealthPh: 04 496 2326E-mail: sarah_dwyer@moh.govt.nz