Sharing care after nine years: Implications and impact on the

broader mental health system

Jack Haggarty M.D.Out-patients, SJHCAssoc. Prof Northern OntarioSchool of Medicine (NOSM)

haggartyj@tbh.net

September, 2010Valhalla Inn, Thunder Bay, Ontario

Disclosure:

This presentation/research has been funded by:

•NOSM: Res. Intern Pgm (05-08)

• MOHLTC/OMHF (08-09)

•MOH-AHSC Grant (’10-’11).

I sit on the board of directors for the following organizations:

•None…

•Advisory Board of NWLHIN MH Team; Chair Health Professional Committee (HPAC)

Objectives

Gain an appreciation of a model of collaborative care in Northwest Ontario;

Understand the implications of evolving and reforming mental health delivery for both primary care and a broader mental health delivery model.

AND opinions on • M Illness and treatment is expanding/creating greater need for Tx

(not less)• As decrease stigma and stigmatized settings, then resultant

increase in need/demand (are we ready?)• What we cannot afford to pay for• Essential components of care

Crossing the Quality Chasm: A New Health Systemfor the 21st CenturyCommittee on Quality of Health Care in America,Institute of Medicine (2001)

Crossing the Quality Chasm: A New Health System for the 21st Century (Free Executive Summary)http://www.nap.edu/catalog/10027.html

Establishing Aims for the 21st-Century Health Care SystemThe committee proposes six aims for improvement to address key dimensionsin which today’s health care system functions at far lower levels than it canand should. Health care should be:• Safe—avoiding injuries to patients from the care that is intended to helpthem.• Effective—providing services based on scientific knowledge to al whocould benefit and refraining from providing services to those not likely to benefit(avoiding underuse and overuse, respectively).• Patient-centered—providing care that is respectful of and responsive toindividual patient preferences, needs, and values and ensuring that patient valuesguide all clinical decisions.• Timely—reducing waits and sometimes harmful delays for both thosewho receive and those who give care.• Efficient—avoiding waste, including waste of equipment, supplies, ideas,and energy.• Equitable—providing care that does not vary in quality because of personalcharacteristics such as gender, ethnicity, geographic location, and socioeconomicstatus.

Bridging the Quality Chasm: US Report

Recommendation 4: Health careorganizations, clinicians, and patients should

work together to redesignhealth care processes in accordance with the

following rules:1. Care based on continuous healing relationships.

2. Customization based on patient needs and values.

3. The patient as the source of control.

4. Shared knowledge and the free flow of information. Patientsshould have unfettered access to their own medical

information 5. Evidence-based decision making.

6. Safety as a system property. Patients should be safe frominjury caused by the care system.

7. The need for transparency.

8. Anticipation of needs.

Mental Health Commission of Canada

This Framework proposes seven linked goals for a transformed mental health system:

People of all ages living with mental health problems and illnesses are actively engaged and supported in their journey of recovery and well-being.

Mental health is promoted, and mental health problems and illnesses are prevented wherever possible.

The mental health system responds to the diverse needs of all people living in Canada.

The role of families in promoting well-being and providing care is recognized, and their needs are supported.

MHCC Seven Priorities People have equitable and timely access to

appropriate and effective programs, treatments, services and supports that are seamlessly integrated around their needs.

Actions are informed by the best evidence based on multiple sources of knowledge, outcomes are measured, and research is advanced.

People living with mental health problems and illnesses are fully included as valued members of society.

NWLHIN 2009 Integrated Health Service Plan Priorities

Goldberg & Huxley’s Filters: Who moves up and down service Needs in MH system. Unmet need gaps at each. From: 2003 G Andrews.

Unmet need in psychiatry.

Goldberg & Huxley’s Filters: Who moves up and down service Needs in MH system. Unmet need gaps at each.

Goldberg & Huxley’s Filters:

M.H care And Psychiatry

Primary Care

MH. Psychia

Primary Care

Public Health, Schools, Informal providers

Public H.?Primary Care…see MHCC

An ideal collaborative care system.

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SMHC: A Working Definition1

(Tammy M)

Process of collaboration between family physician and mental health professional

Enables responsibilities for care to be appointed according to:(a) Treatment needs of the patient(b) Respective skills of mental health

professional and family physician

1. Collaborative Working Group on Shared Mental Health Care. Ottawa: Canadian Psychiatric Association and College of Family Physicians of Canada, 2000.

15

Consistent with Health System Reform

Primary-care is corner stone of the health system

Key piece of ‘shifting’ to community Improved links to specialty care Integrates specialty services in

Primary-care Improved links to other services

Nearly 10 years…we have learned a few things. (JH)

It works High clinical and evaluative participation patients AND

MD’s/ counsellors Part of continuity of primary care Communication can be continuous Sustained benefits Support evidence can effectively manage S.M.I. Lower wait times sustained Change to/with system over 5 yrs Primary care is very gratifying place in system to work Value of getting to ‘the table’ of decision sharing of MH

planning/believing in change (fight against apathy)

Part II : Our findings

21

Some burning questions we were asking…. What is it?....How does it work?... How good is this program really?

Do people get better…? Do they stay better? OK, what about the Serious Mentally ill? How much is agreement a part of SMHC? And the somatic frequent users helped? Impact on wait and other MH System? But can it be fun too?

And more

Findings From a Northern Ontario Shared Mental Health Care Program:

Changes in Patient Symptoms and Disability

John Haggarty M.D.Brian O’Connor Ph.DSacha Dubois MPH (Cand.)Janelle Jarva M.A.Andrew M. Blackadar M.D.Tammy McKinnon MSWDaniel Boudreau HSW

J. of Primary Care and Community Psychiatry, March 2008

Q: Does it work?

23

Canadian Institute for Health InformationHealth Indicators Framework

Acceptability

Accessibility

Appropriateness

Competence

Continuity Efficacy Effectiveness Safety

www.cihi.ca

24

Canadian Institute for Health InformationHealth Indicators Framework

Acceptability

Accessibility

Appropriateness

Competence

Continuity Efficacy Effectiveness Safety

www.cihi.ca

Survey Grid for SMHC Fort William Clinic. Version Fall 2001.

FORM OR SCALE

  Time of Referral

1st Visit

Follow-up Visit

Third Visit

PsychiatristVisit (each)

Last Visit

Symptom scale PHQTAG

X     X

Function Scale WHO-DAS   X     X

  GAF         X  

Satisfaction Scale

VSQ   X        

  

-CSQ-***each MD, CounsellorPsychiatrist

      X  

  X  

Referral Form

  X          

AssessmentPlan

    X        

CounsellorsContact Sheet *

    X X X   X

PsychiatricConsultation

    X (if requested)

       

Psychiatric Follow-Up

      X   X  

               

26

                                                                           

General Information                           Welcome to the Home Page for the World Health Organization Disability Assessment Schedule II (WHODAS II). This

site provides information relevant and useful to researchers, clinicians, and administrators who are interested in learning about and using this instrument for assessing levels of functioning. The WHODAS II has been under development by WHO for several years. Final versions are expected to be released in 2001. Currently, the WHODAS II is available in eleven versions and sixteen languages. Available versions include self-administered, interviewer-administered, and proxy-reported. The WHODAS II provides a profile of functioning across six activity domains, as well as a general disability score. This information can be used to

•Identify needs •Match patients to interventions •Track functioning over time •Measure clinical outcomes and treatment effectiveness

Return to this page often to receive the latest information and updates regarding the WHODAS II, including semi-structured versions of the instrument and publications.

Download WHODAS II

                                                       

Download I-Shell - WHODAS Manuals & Software*                          

Upload WHODAS data*                                                                     List of Centres                          

Translations                                                                     

Ongoing Field Trials                                                                     Scoring                              

Frequently Asked Questions                                                        Contact information                          

Related Links

                                                       WHO Home Page

Send your comments and feedback about this site to whodas@who.int

* Available only to WHODAS-II Centers and requires a user-id and password.

27

  

72.0%

40.5%

33.5%

18.4%16.2%

5.7% 5.1% 6.4%

0%

20%

40%

60%

80%

depressed anxiety sleep moodswings

panic somatic alcohol suicidal

Psychiatric symptoms identified by referring physicianJuly 2001 - April 2004

n = 945

28

29

30

31

AFTER SHARED CARE: PATIENTS’ SYMPTOMS AND FUNCTIONING

3 TO 6 MONTHS FOLLOWING CARE AT A RURAL SHARED MENTAL HEALTH

CARE CLINICJOHN HAGGARTY

Northern Ontario School of Medicine, and

Community Mental Health Services, St. Joseph’s Care Group, Thunder Bay, Ontario

RUPERT KLEIN

Department of Psychology, Lakehead University

Thunder Bay, Ontario

BOB CHAUDHURI

Northern Ontario School of Medicine, Thunder Bay

DANIEL BOUDREAU and TAMMY MCKINNON

Fort William Clinic, Thunder Bay, Ontario

Q: If it works, does its impact continue 3-6months after?

Community M.H. Journal March 2009. Suppl.

32

Figure 1.

WHO-DAS-II S scale demonstrating pre-treatment, post-treatment and 3-6 month follow up

N=25

33

Q: Effect on ‘Above threshold’ Somatization Disorder Patients?

Fam Med Resident Example of learner facilitated

research Second resident with paper

34

Shared Mental Health Care and Somatization: Changes in Patient Symptoms and Disability Mozzon JB; Haggarty JM; Jarva JA; and O’Connor BPSt Joseph’s Care Group, Northern Ontario School of Medicine (submitted)

Background/Objectives: Somatization is common in primary care, can lead to significant impairment, and poses a challenge for management. Psychotherapy, and in particular cognitive behavioural therapy, is one of the most effective treatment modalities for patients with severe somatic symptoms. However, the evidence supporting its use in a primary care shared mental health care (SMHC) setting is limited. The primary goal of this study is to describe the symptom improvement and change in function in patients with high levels of somatization referred to an outpatient SMHC service.

Results: For patients with high levels of somatization at entry, treatment with SMHC was associated with both a significant reduction in somatic symptom severity (41% reduction; P<0.001) and mental health related disability scores (44% reduction; P<0.001). Furthermore, levels of somatic symptom severity and disability approached community sample norms at the completion of their SMHC sessions.

Conclusion: Multidisciplinary, short term, counselling-based SMHC demonstrated significant improvement in patient symptoms and level of disability, and shows promise as an effective treatment option for patients with high levels of somatization.

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Pre-post Intervention PHQ-15 after course of care in SMHC setting.

36

Pre-post Intervention Functional Measure after course of care in SMHC setting.

37

Transition into Primary-care Psychiatry

TIPPDr. Jack Haggarty (Co-Principal Proponent)

St. Joseph’s Care Group, Lakehead Psychiatric Hospital, Community Mental Health Services, Thunder Bay

&Dr. David Haslam (Co-Principal Proponent)

Mental Health Consultation and Evaluation in Primary PracticeRegional Mental Health Care – London

Specialized Adult London ServiceDepartment of Psychiatry, University of Western Ontario

J Primary Care and Community psychiatry March 2009.

38

TIPPResearch

First randomized trial comparing ‘usual’ treatment to ‘supported repatriation’.

Transition into Primary-care Psychiatry (TIPP) based on Australian model (CLIPP)

http://www.health.vic.gov.au/mentalhealth/publications/clipp/

39

TIPP Project Broad Question

Can the TIPP model establish linkages that provide sustainable and effective mental health care in the primary care setting?

TIPP Findings

41

Psychiatric Symptoms at Endpoint

Brief Symptom Inventory – Outpatient Norms

Psychoticism

Paranoid Idation

Phobic Anxiety

Hostility

Anxiety

Depression

IP Sensitivity

Obsessive-Compulsive

Somatization

Mea

n R

epor

ted

Dis

tres

s (t

-sco

res) 60

50

40

TIPP

CAU

42

Psychiatric Symptom Distress Over Time

Time

12 Month6 MonthBaseline

Mea

n G

SI

(t-s

core

s)60

50

40

TIPP

CAU

* Significant at .05 level

*

43

Number of Symptoms Over TimeBSI Positive Symptom Total – Outpatient Norms

Time

12 Month6 MonthBaseline

Mea

n P

ST

(t-s

core

s)60

50

40

TIPP

CAU

*

* Significant at .05 level

44

Psychiatric Distress Over Time

BSI Positive Symptom Distress Index – Outpatient Norms

Time

12 Month6 MonthBaseline

Mea

n P

SD

I (t

-sco

res)

60

50

40

TIPP

CAU

45

Client Satisfaction

46

3 month 6 month 9 month 12 month

Time Period

1

2

3

4

Sat

isfa

ctio

n w

ith

Hel

p f

or

Ph

ysic

al H

ealt

h

TIPP

CAU

Shared Care Client Satisfaction Inventory

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Q: What is the impact of this model to wait times?

Wait shorter? Does it increase or decrease burden

on other providers? Cost-effective or increase service

need?

Symptom onset

Referral Sent

Accessing PCP

Help Seeking

Referral Received

Contacting Client

First Appointment

Start of Treatment

Start of Treatment Ψ

End of Care

Wait 1

Wait 3

Wait 2

50

Mental Health Service Provider

n Seen for

Treatment n (%)

Not Seen for

Treatment

n (%)

Existing Prior to 2001?

Staff #

F.T.E.

Shared Mental Health Care Service – Fort William Clinic

1685 1323 (78.5)

362 (21.5)

NoOpened Mid-

2001

2.2

Shared Mental Health Care Service – Port Arthur Clinic

219 144 (65.8)

75 (34.2)

NoOpened 2005

1.2

Community Mental Health Program - Thunder Bay Regional Health Sciences Centre

976 701 (71.8)

275 (28.2)

Yes 3.5

Personal Development Centre – St. Joseph’s Care Group

1142 879 (77.0)

263 (23.0)

Yes 4.0

Community Mental Health Services- St. Joseph’s Care Group

2028 1247 (61.5)

781 (38.5)

Yes 22.0

Total 6050 4294(70.98)

1756(29.02)

Thunder Bay Outpatient clinics Participating

51

Number of Referrals from the FWC to Other Mental Health Services

0

10

20

30

40

50

60

70

Year 2001 Year 2002 Year 2003 Year 2004 Year 2005

52

Number of Referrals from the FWC to Other Mental Health Services

0

10

20

30

40

50

60

70

Year 2001 Year 2002 Year 2003 Year 2004 Year 2005

53

Referrals from the FWC

0

50

100

150

200

250

300

350

400

450

500

Year 2001 Year 2002 Year 2003 Year 2004 Year 2005

Other Services

SMHCS FWC

54

Number of referrals from the PAC to Other Mental Health Services

0

50

100

150

200

250

Year 2001 Year 2002 Year 2003 Year 2004 Year 2005

55

Referrals from the PAC

0

50

100

150

200

250

Year 2001 Year 2002 Year 2003 Year 2004 Year 2005

Other Services

SMHCS PAC

56

The BIG Finding…. Mean wait times (days) and # of

referrals across ALL 5 sites (including SMHCS)

National Recommended Benchmarks for Wait Times (Weeks)

Site 1 Site 2 Site 3 Site 4 SMHC-1 SMHC-2

Wait Your Turn findings 2008 (Median) Canada

Ontario 7

7.9

Present Study Median 13 7 6 10 5 15

Met? N Y Y N Y N

Present Study Mean 14.14 7.95 9.71 11.63 5.63 15.37

CPA Benchmark Suggested Wait Time

4

Met? N N N N N N

SMHC : Present issues Stablized, decrease or expand role Be at table of evolving MH system, LHIN’s, FHT

development (QIIP) Impact on In-patient/ ED visits Further push integration of MH data bases ie

TBRH: Info. Service, H Records, ED data, AMH, Primary Care…..for use/access by others

Unmet need and Stigma based on non-attenders primary care sites

Child services Integrated Clinical model for learners. Academic

FHT. (Tammy McKinnon)

60

Where has this gotten us… Internationally recognized researchers

into a still fledgling model of care First goal of ‘Does this work’ has grown to

further important and critical contributions to the area.

We may be still 5+ years ahead to model implementation…early adopters

Still only pilot model of care…not supported by mainstream MH clinicians…’too much work…front line…’

Where has this gotten us? Change is possible.

• Helps if one can evaluate/demonstrate it

Change is infectious• Even when one is not aware• In ways one can’t always predict

Change is not always possible• Not for all locations• Not necessarily welcomed

62

Next considerations… What is stalling further dissemination of the

model? Is FHT the preferred or possibly only vehicle to

grow into? At FWC: Not using short time frame use of data,

slow to get data to clinician with ‘norms’ Further use of QIIP to build on success Child, Technology, Academic FHT, Regional expansion FHT Wait II study

65

Thankyou… haggartyj@tbh.net