Models of Psychiatric Outreach for Northern Ontario

1. Models of Psychiatric Outreach for Northern Ontario Jill E. Sherman, MPH Raymond W. Pong, PhD Centre for Rural and Northern Health Research The authors have no affiliations, sponsorships, honoraria, monetary support or conflict of interest from any commercial source.

2. Presentation Objectives • Introduce the OPOP Research Project • Discuss findings from a review of international literature on the models of psychiatric outreach to rural and remote communities • Explore similarities and differences between the “OPOP Model” and other models

3. OPOP Research Project Collaboration between CRaNHR and OPOP to examine models of psychiatric outreach in smaller northern Ontario communities • What service delivery models exist to increase access to psychiatric services in Northern Ontario, and what factors influence the choice of these models? • How do the different approaches affect the organization and delivery of psychiatric services? • What are the differences between small communities served by OPOP vs. those not served by OPOP? • What innovations can be adopted in Northern Ontario to increase access to mental health services?

4. OPOP Research - Methods • Literature Review • Survey of OPOP-affiliated Consultants • Survey of Family Health Teams • Focus Group Interviews with Consultants • Community Case Studies

5. Literature Review • Database of 300+ references • International perspective (mainly Canada, UK, Australia, US) • Search strategy evolved over time • Rural, remote, frontier, Northern • Service delivery models • Specialist outreach, psychiatric outreach • Primary care • Mental health services • Shared care, collaborative care

6. Some “Early Classics” 1: Reviews & Theoretical Models • Williams & Clare (1981) “Changing patterns of psychiatric care” (UK) • Bachrach (1983) “Psychiatric services in rural areas: A sociological overview” (US A) • Strathdee & Williams (1983) “A survey of psychiatrists in primary care: The silent growth of a new service” (UK ) • Pincus (1987) Patient-oriented models for linking primary care and mental health care” General Hospital Psychiatry (USA) • Horder (1988) “Working with general practitioners” (UK) • Creed & Marks (1989) “Liaison psychiatry in general practice: A comparison of the liaison-attachment scheme and shifted outpatient clinic models” (UK, International)

7. “Early Classics” 2:Case Studies / Empirical Models • Miles (1980) “A psychiatric outreach project to a rural community” (Canada/British Columbia) • Tyrer (1984) “Psychiatric clinics in general practice. An extension of community care” (UK) • Carr & Donovan (1992) “Psychiatry in general practice: A pilot scheme using the liaison-attachment model” (Australia) • Kates, Craven, et al (1997) “Integrating mental health services within primary care: A Canadian program” (Urban Southern Ontario) • Weingarten & Granek (1998) “Psychiatric liaison with a primary care clinic – 14 years’ experience” (Israel)

8. Reviews Gruen, Weeramanthri, et. al. (2007) Specialist outreach clinics in primary care and rural hospital settings [Systematic Review]. Cochrane Database of Systematic Reviews 2007 (4):1-66, 2007. • Psychiatry – largest specialty represented • Outreach clinics associated with • Improved access • Improved quality of care, outcomes • More appropriate use of services • Fewer psychiatric hospitalizations • Higher “quality of evidence” from urban-high resource study areas w/limited potential to benefit from outreach • Little evidence for rural with greatest potential for benefit - most rural studies were descriptive

9. Gruen et al (2007) Conclusion: • “The evidence presented provides support for the hypothesis that specialist outreach can improve • access to specialist care on a range of patient-based measures, • health outcomes to a clinically important degree, • efficiency in the use of hospital-based services by reducing duplication and unnecessary referrals and investigations.” (p. 14)

10. Early Models • “Increased throughput” • Goal: Increase referrals to specialists, by: • Education of PCPs to “recognize and refer” • Establishment of specialist-PCP relationships • Shifted outpatient / visiting specialist clinic • Goal: Increase access to specialist services, by: • Bringing specialist into community / PCP clinic setting

11. “More Recent” Models • Liaison-Attachment (outreach version of “consultant-liaison”) – overlaps with shifted outpatient – more specific to psychiatry • Goal: Reduce “unnecessary” use of specialist services & increase access to “appropriate” care, by: • Educating and supporting primary care providers • Providing clinical care in PCP/community setting • Facilitating access to secondary, tertiary services where needed (strong emphasis on liaison function) • “Multifaceted” Outreach – complex interventions to increase access, quality, efficiency of care – more systems perspective, urban perspective • Shared care, collaborative care, multidisciplinary care • Integration of psychiatry, mental health, social services (bio-psycho-social) • Support services to patients (case manager/care coordinator) • Community-based care models (e.g. ACT)

12. “Intermittent model” • Owen, Tennant, et al (1999) “A model for clinical and educational psychiatric service delivery in remote communities,” Australian and New Zealand Journal of Psychiatry • Outreach by urban-based teams – psychiatrist + other mental health professionalBeyond clinical care - interventions included: • direct psychiatric care to clients in their own environment • peer support to lone mental health and generic health workers • skills development/education for general health staff, other professionals affiliated with health care (e.g. police and ambulance officers)

13. Variations in Outreach Models • Who does the outreach? • Individual vs. team? • Psychiatrist only • Psychiatrist + other clinical/MH Professional • MH professional + backstopping by Psychiatrist • Patterns of interaction ~ Types of collaboration • Patient consultation only (parallel model) • Patient & provider consultations, but separate • Joint consultations (=shared care?) • Team-based consultations (may include patient, family/caretakers) (= collaborative care?)

14. Variations, Part II • Frequency of outreach? • “Intermittent” vs. regular schedule • Weekly, monthly, or? • Outreach modes & setting? • Face-to-face: FP/GP office, Primary care clinic • Virtual: Telepsychiatry; dedicated space? • Linkages to other services? • Emphasis on “liaison” function? • Facilitate care at outreach providers’ “home base”

15. Variations, Part III • Inter-visit support services • Range – none to extensive (may depend on frequency, local provider capacity, ICT capacity) • Follow up (+ -) new cases/consultations? • Emergencies • Telephone, email support • Telepsychiatry • Prescription refills

16. Variations, Part IV • Education • Larger policy goals – who should provide what services? • Needs of local providers • Local capacity – the more local capacity, the more emphasis on education? • Relationships with local providers • Duration of outreach program (e.g. Israeli 14 year case report) • “Outreach geography” – Socio-spatial relationships between consultants’ “home base” and outreach community • Little attention – assumed in the literature • Related to liaison function • Nearest service center (implied) • “Hub-and-spoke” / Satellite services (intensive/dedicated outreach)

17. Variations, Part V Degree of Integration – at what level? • Organizational level – relies heavily on HIT – facilitates referrals, sharing of patient information, system navigation • “Satellite services model” (urban US) – integration through acquistion of PC clinics as “satellites” of hospital ambulatory care services (Nickels 1996) – Single system • Networked (e.g HMOs) • Interpersonal level – • Where services are not integrated at a formal organizational level, coordination of care relies on individuals, relationships (not systematic, but idiosyncratic)

18. Conclusion 1: Outreach models are embedded within larger models of health care organization • Goals & strategies of outreach models may vary depending on context, and dominant philosophies of the “right” or best way to deliver healthcare • Resource constraints, clout of professional groups are strong determinants of model components • Success of outreach strongly influenced by “upstream” systems factors (e.g. financing/payment arrangements)

19. Conclusion 2: Models vary on a number of dimensions • Who: Outreach Provider • Individual vs. team • Psychiatrist or other MH provider • What: Components of Outreach • Patient care • Provider consultations • Plus…? Support services, Education • When: Time (frequency, duration) • Where: Space (setting, spatial relations/linkages) • How: • Patterns & modes of interaction • Types of collaboration (continuum) • Degree of Integration • Why: Context; historical variations in goals of outreach

20. Conclusion 3: Evaluation is difficult but generally positive • Outreach – can be a “victim of success,” especially in Psychiatry • Outreach can tap a vein of unmet need • Can result in increases in revealed demand/need • Can be expected to change w/duration of outreach • “Usual” indicators of access are ambiguous • Waiting times • Change in number/percentage of referrals • Change in number/percentage of hospitalizations • Successful patient “outcome” measures – fuzzy & often difficult to attribute to outreach • “Cure” vs. management • Requires program-level indicators

21. What is the “OPOP Model” ? • Is there an “OPOP Model” ? • Multifaceted • Flexible - multiple models? • Individual specialist • Patterns of interaction/collaboration? • Linkages, service integration? • Support services? • Education? • Unique feature - outreach geography • providers from south to north – not from the nearest service centre (Exception-Queens program) • How does this geography affect service delivery? Effectiveness? Liaison & linkages?