Bridging with primary care: A shared-care mental health pilot project

Introduction

Family physicians play an important role in assessing, treating, and caring for the mental health needs of patients in their practice. Studies show that the prevalence of patients seen in the primary care setting with psychosocial distress is as high as 40%,[1] and the prevalence of psychiatric disorder is 25%.[2,3] Yet fewer than 5% of patients with identified psychiatric illness are referred to psychiatry[4] and less than 1% to a community agency.[5] Family physicians have expressed frustration in accessing psychiatric consultations and mental health resources. The stigma attached to mental health problems by the patient is a barrier in accessing care.

The Fee-for-Service Psychiatry in BC 1995/1996 Report identified that 60% of people with schizophrenia and 83% of people with any mental illnesses in the Simon Fraser Area (SFA) of the Fraser Health Authority were treated by family physicians.[6] A 1998 survey[7] of family physicians in the SFA identified the following as barriers that might prevent their patients from receiving optimal mental health care:

• Lack of access to timely consultation (93%).
• Lack of psychiatric consultation and backup expertise (88%).
• Waitlist to community mental health services (71%).
• Waitlist to hospital mental health services (65%).
• Exclusion criteria for mental health services (60%).
• Limited or lack of mental health services (45%).

Poor communication between consulting psychiatrists and family physicians was also identified as a problem.

In October 1999, an opportunity arose to pilot a shared-care approach to mental health care delivery in the SFA. We wanted to develop a shared-care program to see if this model would fit as an adjunct to the existing mental health services structure already in place in the SFA. A recent needs assessment completed for the area identified the need to widen the mandate of the mental health program and improve accessibility to mental health services. The shared-care approach provided the opportunity to fill both these mandates.

The main goal of a shared-care model of service delivery is to have mental health staff (counselors and psychiatrists) work closely with family physicians to enhance the mental health care received by patients in these practices.[8] This shared-care project was modeled on the Hamilton-Wentworth HSO (Health Service Organization, a rostered primary care practice) Program, which was initiated in 1994 and funded by the Community Health Branch of the Ontario Ministry of Health.[9] In this program, mental health counselors and psychiatrists assessed and treated patients in the primary care setting, working collaboratively with family physicians.[10]

 The SFA Shared-care Pilot Project

In our project, the goals of the Hamilton-Wentworth Mental Health Program were adopted and adapted to strengthen the relationship between psychiatrists and family physicians. These goals were to:

• Enhance the range of mental health services available to the patients in the participating clinics.
• Increase the skills and comfort of the primary care physicians in identifying and managing mental health problems.
• Enhance the position of each primary care clinic in the mental health continuum of care by strengthening links with local mental health services.

The Hamilton-Wentworth program operates on the tenet that most mental health problems can be managed in the primary care setting with shared-care in place, and we adopted this tenet for our project. Two family practice clinics participated: a clinic in Coquitlam with four family physicians and a clinic in Port Coquitlam with five family physicians.

In each of the clinics, the family physician maintained his or her role as the most responsible physician. An experienced psychiatric nurse was assigned to each clinic and attended each clinic for one half-day a week to provide assessment, counseling, crisis management, and referral to other mental health resources. The nurse also supported the management plans of the family physicians and the visiting psychiatrist. The psychiatrist (Dr T. Isomura) visited each clinic for a half-day every 2 weeks to do consultations, brief follow-ups, and referral to other resources. She was actively involved in liaising with the nurse and the family physicians. Consultation notes and progress notes were handwritten into the mental health section of the patient’s chart, providing ready access to the family physician. The psychiatrist was available by telephone to the family physicians for advice when the psychiatrist was not at the clinic.

 Preliminary evaluation of the project

From October 1999 to March 2001, 129 patients were referred and assessed, and 561 visits were conducted by the nurse and psychiatrist. The shared-care mental health team was impressed with the range and severity of the mental disorders that the family physicians were treating, with little support, prior to the project. The shared-care team saw a range of patient diagnoses in the clinics, including depression (n = 80, 62%), bipolar disorder (n = 29, 22%), psychosis (n = 9, 7%), adjustment disorder (n = 7, 5%), and substance abuse (n = 2, 2%). Two first-episode psychotic patients were identified and treated. Patients with depression that were treated by the team had difficult, resistant depression or bipolar depression.

Patient satisfaction surveys conducted at each of the clinics showed that 84% of patients were satisfied with their care. Patients repeatedly reported that, without the program, they would not have sought help or would not have been compliant with a referral to mental health clinician or a psychiatrist. Some comments were: “If this service were not in the office I would not have made the effort to get the help I needed”; “I am glad the counselor is here. If not for him I’d not be seeing a therapist, and [I would] be in all kinds of trouble.”

The family physicians gave this project a 90% satisfaction rating. One physician commented, “I no longer feel so unable to intervene. The program has empowered me to help people earlier because I recognize the psychiatric component of their illness sooner…our clinic of 7000 to 8000 registered patients was well served by a psychiatrist for 1 half-day every 2 weeks.”

 Discussion

Family physicians are the contact and entry point for most Canadians into the medical system, so they are the ideal people to deliver basic psychiatric care. The shared-care model is a collaborative approach with family physicians, psychiatrists, and nurses to provide timely and accessible mental health care. In this pilot project, consultations were accessible within 3 to 4 weeks and notes were immediately written in the chart. The shared-care team was always available for advice and also provided mentoring and education to family physicians.

This pilot project was supported by the SFA, and the nursing staff was provided by Burnaby Mental Health Services. The psychiatrist was funded though sessional and fee-for-service billings. Since this was a pilot project, the family physicians were not reimbursed for services or for office overhead. The preliminary evaluation was limited since it included satisfaction ratings only and not patient outcomes or an assessment of service utilization cost.

In June 2001, the administration and senior managers of the SFA decided to undertake a more formal evaluation of this project by analyzing case profile outcome data, service utilization costs, patient satisfaction and benefits, and impact for the family physician. It is thought that this service could be incorporated into the existing mental health service structure.

In summary, this SFA shared-care pilot project increased the confidence and ability of family physicians to treat patients with psychiatric disorders. It improved accessibility to timely referrals and provided a continuum of care in a collaborative system. This project was restricted by limited funding, a limited evaluation process, and the inclusion of only two family practice clinics. As the project proceeded and patients were treated and improved, enthusiasm grew among the family practitioners, their staff, the mental health nurses, and the psychiatrist. The shared-care model seemed to greatly enhance the family physicians’ ability to deliver timely care to their community of patients with mental health problems.

 Competing interests

None declared

Theresa Isomura, MD, FRCPC, Jane Senay, RPN, RN, BSN, Carol Haldin, RPN, and John Edworthy, MD, CCFP, FCFP

Dr Isomura is a clinical instructor in the Department of Psychiatry at the University of British Columbia and head of the Department of Psychiatry at Royal Columbian Hospital, New Westminster. Ms Senay is the coordinator of the Adult Services/Programs, New Westminster Mental Health, New Westminster. Ms Haldin is the former manager of Burnaby Mental Health Services, Burnaby. Dr Edworthy is a clinical assistant professor in the Department of Family Practice, UBC, and staff physician at Royal Columbian Hospital.