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Shared Care in Canada

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Shared Care in Canada Douglas Green MD TOH Shared Mental Health Team Ottawa, Ontario, Canada dogreen_at_toh.on.ca Websites of interest www.sharedcare.ca www.phqscreeners ... – PowerPoint PPT presentation

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Title: Shared Care in Canada


1
Shared Care in Canada
  • Douglas Green MD
  • TOH Shared Mental Health Team
  • Ottawa, Ontario, Canada
  • dogreen_at_toh.on.ca

2
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

3
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4
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

5
Government and politics
  • Canada is a federal parliamentary democracy
  • It is comprised of 10 provinces and 3 territories

6
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7
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

8
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 patients family physician or by an emergency
    physician

9
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

10
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11
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

12
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

13
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

14
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

15
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

16
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 deinstitutionalizatio
    n)

17
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

18
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19
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

20
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

21
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 physicians office

22
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

23
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24
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

25
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

26
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27
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

28
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

29
Key components
  • Effective communication
  • Consultation (MHPgtPCP or PCPgtMHP)
  • Coordination of care
  • Co-location
  • Integration of MHP and PCP within a single
    service or team

30
Benefits of shared/collaborative care
  • Symptom improvement
  • Functional improvement
  • Reduced disability days
  • Increased workplace tenure
  • Increased quality-adjusted life years
  • Increased compliance with medications

31
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

32
What does the research indicate are some of the
ingredients of successful collaborative care
models?
33
Chronic Care Model
34
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

35
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

36
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

37
Elements of the CCM
  • System Design
  • Self-management support
  • Decision support
  • Information systems
  • Organizational change
  • Links with community resources

38
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39
Stepped Care
40
Having the right service in the right place, at
the right time delivered by the right person.
41
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42
What does the research indicate are some of the
ingredients of successful collaborative care
models?
43
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44
1) Use of a care coordinator
45
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

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48
2)Psychiatric Consultation
49
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)

50
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51
3) Self management and psychoeducation
52
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53
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54
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

55
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56
4) Screening for people with chronic medical
illnesses for anxiety and depression
57
PHQ-2
58
Using the PHQ-2
  • If score is 3 or above then proceed to do full
    PHQ-9

59
PHQ-9
60
Available at www.phqscreeners.com
61
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62
5) Treatment algorithms
63
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

64
Using PHQ-9 Diagnosis and Score for Initial
Treatment Selection based on MacArthur
Initiative on Depression and Primary Care
PHQ-9 Score Provisional 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)
65
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.
66
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
67
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68
6) Access to brief psychological therapies
69
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

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71
7) Physician skill enhancement
72
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

73
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

74
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

75
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

76
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, 531 pp1-12

77
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

78
Shared Care in Canada
79
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)

80
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

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82
Ottawa and Shared Care
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85
Ottawa
  • Nations 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

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87
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

88
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

89
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

90
PHQ-9
91
Available at www.phqscreeners.com
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94
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

95
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

96
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

97
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

98
Websites of interest
  • www.sharedcare.ca
  • www.phqscreeners.com
  • http//www.comh.ca/antidepressant-skills/adult/
  • http//prevention.mt.gov/suicideprevention/13macar
    thurtoolkit.pdf

99
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 531 1-12

100
Questions? dogreen_at_toh.on.ca
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