Shared Care in Canada

1. Shared Care in Canada Douglas Green MD TOH Shared Mental Health Team Ottawa, Ontario, Canada dogreen@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

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

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 notcovered

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 patient’s 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

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 deinstitutionalization)

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

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 • Improve communication in the working relationship between a psychiatrist or psychiatric service and local family physicians • Establish liaison relationships • Bring psychiatrists or other mental health providers into the family physician’s 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

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

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 (MHP>PCP or PCP>MHP) • 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

39. Stepped Care

40. “Having the right service in the right place, at the right time delivered by the right person.”

42. What does the research indicate are some of the ingredients of successful collaborative care models?

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

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)