Shared Care in Canada

Douglas Green MD

TOH Shared Mental Health Team

Ottawa, Ontario, Canada

dogreen@toh.on.ca

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• 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

• Canada is a federal parliamentary democracy

• It is comprised of 10 provinces and 3 territories

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 not covered

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 (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

• 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

• 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

• 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 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 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

• 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

• 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 PrinciplesFamily 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.)

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

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

2. Establish liaison relationships

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

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

• 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…

• 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?

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

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

• 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

Symptom improvementFunctional improvementReduced disability daysIncreased workplace tenureIncreased quality-adjusted life yearsIncreased compliance with medications

What we have learned so far (contd)Benefits identified in youth, seniors, people with addictions and indigenous populations

Leads to reduction in health care costsMost 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?

Chronic Care Model

Depression in Primary Care

• 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?

• 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)

• 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

• System Design• Self-management support• Decision support• Information systems• Organizational change• Links with community resources

Stepped Care

“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 models?

1) Use of a care coordinator

Care coordinator

• 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

Psychiatric consultation

• 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

Web-based Self Help Resources (CBT based)• 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

4) Screening for people with chronic medical illnesses for anxiety and depression

PHQ-2

Using the PHQ-2

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

PHQ-9

Available at www.phqscreeners.com

5) Treatment algorithms

Treatment algorithms

• 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

PHQ-9

ScoreProvisional Diagnosis

Treatment Recommendations

5-9 Minimal Symptoms Support Educate to call if worse; return in 1 month

10-14 Minor depression++ Support, watchful waiting

10-14 Dysthymia Antidepressant or psychotherapy

10-14 Major depression, mild Antidepressant or psychotherapy

15-19 Major depression, moderately severe

Antidepressant or Psychotherapy

≥20 Major Depression, severe Antidepressant and psychotherapy

(especially if not improved on monotherapy)

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

PHQ-9 Score Treatment Response Treatment Plan

Drop of ≥ 5 points from baseline Adequate No treatment change needed

Follow-up in four weeks.

Drop of 2-4 points from baseline Probably Inadequate Often warrants an increase in antidepressant dose.

Drop of 1 point or no change Inadequate Increase dose: Augmentation; Switch; Informal or formal psychiatric consultation; Add psychological counseling.

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

PHQ-9 Score Treatment Response Treatment Plan

Drop of ≥ 5 points from baseline Adequate No treatment change needed follow-up in 4 weeks

Drop of 2-4 points from baseline Probably adequate Possibly no treatment change needed.

Share PHQ-9 with psychological counselor

Drop of 1point or no change or increase

Inadequate If depression-specific psychological counseling (CBT,PST,IPT) discuss with therapist, consider adding antidepressant. For pt. satisfied with psychological counseling, consider starting antidepressant

For pts. Dissatisfied in other psychological counseling, review treatment options and preferences

6) Access to brief psychological therapies

Brief psychological therapies

• 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

7) Physician skill enhancement

Physician skill enhancement

• 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• 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• 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• 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*

Core ingredients of effective shared care models include:

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

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

3. 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.)

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

5. A well-established clinical governance framework

Shared Care in Canada

Shared care models in Canada

• 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.)

• 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

• 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• 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 Program

• 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

• 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-9

Available at www.phqscreeners.com

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

• 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.)

• 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 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

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

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

References

1. 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

2. 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

3. 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