Nick Kates MB.BS, FRCP(C)ProfessorDept. of Psychiatry, McMaster UniversityOntario, Canada

Program Director,Hamilton Family Health Team

PLANThe Canadian ContextThe Hamilton Family Health Team Mental Health

ProgramKey Lessons learntImplications for Departments of Family MedicineLessons for patient-centred medical care

Canada10 Provinces and 3 territories Federal GovernmentProvinces responsible for Health Care (13 health care delivery

systems)Canada Health Act defined principles to guide the entire system

(1964)UniversalityPortabilityPublicly AdministeredComprehensiveAccessible

Almost all health services are publicly funded (9.2% of GDP)20:80 split – Was originally 50:50

Ontario

Ontario spends $3,000.00 per capita per year on health care

50 / 50 split – specialists / primary care

Strong base of primary care – 40% solo practitioners – first point of contact

7.5% of the population have no family physician

Ontario

Average practice size 2,200 patients Most family physicians still funded by fee for service,

but moving to capitation (33%)Capitation pays approximately $130 per pt. / year

(covers office expenses)Average salary = $200,000 Bonuses - For processes not outcomes : Can earn up

to $75,000 - Usually closer to $25,000

Ontario – Incentives(Examples)

MammographyFlu shotsImmunizationPap SmearsColo-rectal cancer screeningDiabetes careManaging 10 patients with severe mental illnessTaking on new patients without a family physician

ROLE OF PRIMARY CARE • First point of contact with the health care system• Often cradle to grave• Family centred• 81% of population see their family physician annually• Initiates referrals to specialists – reinforced by billing tarriffs• Very few primary care internists / pediatricians / OBGYN • Co-ordinates information about a patients care• Increasingly provides a variety of specialized services• Seen by the patient as the place to turn first for care

• Consistent with the concept of the medical home

FAMILY HEALTH TEAMSNext step in transformation of primary healthcare in

Ontario

150 FHTs funded in 3 waves in 2005

50 more approved for 2009 - 10

Involve almost 25% of all comprehensive care family physicians in Ontario

FAMILY HEALTH TEAMS2-25 family physicians (1 or 2 large networks) Funded by capitationRostered populations (negations)Supported by IT – still only 28% use EMRComprehensive carePopulation-based care24 / 7 coverage

FAMILY HEALTH TEAMSEmphasize health promotion and illness preventionEmphasise chronic disease managementEmphasize self-managementCare co-ordination / system navigationTeam based care

Family physician(s) NurseNurse practitionerSocial Worker / Mental Health CounsellorDietitianPharmacistHealth Educator

Linked with other community and health services

HAMILTON• City of 500,000 in S. Ontario

• Originally built upon heavy industry

• Home of McMaster University

•Tradition of innovation in health care / medical education (since 1967)

• Home of problem-based learning

• Home of evidence-based medicine

McMaster Motto: “Melius est Urinam Facere quam Amovere!”

It is more fun to make a messThan to clean it up

THE HAMILTON FHT (HSO) MENTAL HEALTH PROGRAM

MENTAL HEALTH CARE IN PRIMARY CAREUsing as an example of ways in which the scope and role of

primary care can be expanded

Prevalence is high, major challenge for primary care

Access to mental health services is often a problem

Addressing mental health problems is integral to the treatment of most health problems / chronic conditions

Key role primary care can play in early detection

Less stigmatising for the patient

WHY THE PROGRAM CAME ABOUT (1994)

Family physicians already playing a key role in delivering mental health care

Low detection and treatment rates in primary care

Low detection and treatment rates with co-morbid chronic diseases

Family physicians saw this as a major area of need

Resource availability

WHY THE PROGRAM CAME ABOUTFamily physicians already playing a key role in delivering mental

health care

Low detection and treatment rates in primary care

Low detection and treatment rates with co-morbid chronic diseases

Family physicians saw this as a major area of need

Resource availability

Poor access to existing mental health services – FP frustration

WHY THE PROGRAM CAME ABOUTFamily physicians already playing a key role

Low detection and treatment rates in primary care

Low detection and treatment rates with co-morbid chronic diseases

Family physicians saw this as a major area of need

Resource availability

Poor access to existing mental health services – FP frustration

Attempt to address problems in the relationship between mental health and primary care services

OUR SOLUTION : TO INTEGRATE MENTAL HEALTH

SERVICES INTO PRIMARY CARE

3 MAJOR INFLUENCESIntegrating teaching of family medicine residents into the

clinical units

Rural mental health model

UK experience

HAMILTON FHT (HSO)MENTAL HEALTH PROGRAM

1994 MH Program started – 45 physicians

1996 Expansion – 41 new physicians (86)

2005 Became part of Hamilton Family Health Team - 73 new physicians (145)

PRIMARY CARE REFORM IN CANADABegan in 1995Accelerated by Federal funding in 1999 and 2002 Emphasis on accessEmphasis on CDPM Increasingly seen as foundation of the system / downloadingIntroduction of learning collaborativesNow emphasising quality more

PRIMARY CARE REFORM IN CANADAMental health services increasingly integrated in primary care across the countryPlanning is better co-ordinatedStrong national presence

CPA / CFPC have joint committeeWebsite / conferenceNew training guidelines for psychiatry residentsChanges to training guidelines for family medicine residents (slower)

THE HAMILTON PROGRAM HAS BECOME THE NATIONAL

PROTOTYPE FOR INTEGRATING MENTAL HEALTH SERVICES

INTO FHTS

HFHT MENTAL HEALTH PROGRAM - 2008

80 practices (57 solo practices)

105 sites

145 family physicians

340,000 patients (68%)

HOW DOES THE PROGRAM WORK

STAFF RATIOS IN THE HFHT MHP

Ratio FTEs FTEs

1996 2006

Counsellors 1:7,200 22.9 50.5

Psychiatrists 1:75,000 2.2 4.8

Co-ordinated by a central program team

INCLUDES OTHER PILOT PROGRAMS

Children’s mental healthAddictionsDepression chronic disease managementPeer support for depressionReturn to work project for injured workersGroups

CENTRAL STAFFManager2 SecretariesProgram assistant2 data entry clerks0.2 FTE Evaluation0.5 FTE Medical DirectorLeads / facilitators for depression (0.5), addiction

(0.2), child (0.2), peer support (0.1)

HOW THE PROGRAM WORKSSee any case / any age (3-98)Criterion is family physician is looking for helpEmphasis on short-term care Specialists integrated within primary careIndirect as well as direct serviceEmphasis on educationCharting integratedStepped model of careShared care model

CENTRAL PROGRAM TEAMCoordination / managementNeeds assessment Direction Guidelines EvaluationTrouble shootingLiaison with practicesLiaison with Ontario MoHLTC (funder) RecruitmentStaff preparation / continuing education(Re)allocation of resources

DOES IT MAKE A DIFFERENCE?

Data from the programs evaluation.

Total 7064

Counsellors 6084 (87%)150 per Full Time Equivalent

Psychiatrists 1564 (21%)590 per Full Time Equivalent

REFERRALS 2007

Total Referrals 7064

<12 5%

<18

14%

>65 8%

Problem Primary (%) Any (%)

Depression 35.7 68 Marital / family 16.0 37Anxiety 12.1 45 Work problems 4.4 12Child behaviour problem 2.4 20 Anger / temper control 2.9 8 Psychotic symptoms 2.8 4 Bereavement 2.0 10Suicidal 1.4 7Substance abuse 1.3 8

MAJOR PRESENTING PROBLEMS

REASON FOR REFERRAL TO HSO PSYCHIATRIST

Reason for referral (%)

Clarification of diagnosis68

Advice regarding:Medications 84Psychotherapy32 Risk to self / others 6Community resources 5Family / Marital problem 8

DIAGNOSIS: CASES SEEN BY PSYCHIATRISTDiagnosis (DSM IV) (%)Depression 31Anxiety disorder 16Dysthymia 10No psychiatric diagnosis 8Adjustment disorder 7Personality disorder 6Schizophrenia 5Substance-related disorder 5Bipolar disorder 4Disorder of childhood / adolescence 4 Somatoform disorder 2Other 2

REFERRALS TO MENTAL HEALTH SERVICES

(FIRST 13 PRACTICES - 45 PHYSICIANS)

Service 92-93 94-95 2000 2003

Out-patient clinics 203 75 72 82

HSO Mental health - 2532 2180 2255team

Total Referrals 203 2607 2252 2337

Ref. / Phys / year 5 54 53 55

Initial 13 sites began 1994

Additional 23 sites joined

Impact on use of mental health services

OUTCOME MEASURES : CES-D

Mean change = 21.2

Improved > 1 SD = 68%

Score reduced > 50% = 79%

All changes significant

p<.05

OUTCOME MEASURES : SF-8

Mean change = 17.8

Improved > 1 SD = 62%

Score reduced > 50% = 78%

All changes significant

p<.05

SATISFACTION WITH SERVICES

CONSUMER SATISFACTION• CSQ - 91% satisfaction

• Ave score on V.S.Q. 4.5 out of 5

• Each item meets or exceeds AAGH Benchmarks

PROVIDER SATISFACTION

• Family Physicians With Counsellors 92% With Psychiatrists 92%

• Counsellors 90%• Psychiatrists 90%

HAMILTON FAMILY PHYSICIANS OVERALL SATISFACTION WITH MENTAL HEALTH SERVICES

Those with HSO Program 86%

Those without HSO Program 56%

“ I think that knowing we have great back-up makes us less resistant to explore social issues during a busy clinic.”

Family Physician in the Program

“Over the 3 years of the program, I am convincedthat my own knowledge and comfort with mental illness has increased to a highly significant degree. It is no longer an area of uncertainty and doubt, but a discipline which has begun to fall into place and gives great satisfaction and reward.” Family Physician in the Program

EVOLUTION OF THE MODEL• Can’t be all things to all patients• Who is best seen in primary care / needs referral• Manage relationship with the mental health system• Physical proximity crucial for collaboration• Can still act in traditional ways (52 mins!)• Emphasise access• Standardisation• Strengthens links with community partners / agencies • Children’s mental health services critical• Opportunities for early detection

LESSONS LEARNED

SYSTEM PERSPECTIVE

BENEFITS

Increases capacity of primary careIncreases capacity of mental health

systemImproves access to mental health careImproves access for underserved

communities

BENEFITS

Improves communicationIncreases continuity of careCreates a continuum of careIncreases co-ordination of carePotential cost savings

COLLABORATION HAS IMPROVED Access

Waiting times

Communication

Relationships

MENTAL HEALTH CARE IS BETTER INTEGRATED WITH MEDICAL CARE

Primary care providers more aware of mental disordersDietitians screening for depressionEarly years – enhanced 18 month visitObesity groupsIntegrated with other chronic diseasesJoint educational eventsPharmacist part of mental health team

ROLE OF FAMILY PHYSICIAN Remains involved More likely to investigateShared care model Still sees the majority of mental health

problemsIncreased range of cases they can manage Prescribes

WHAT MAKES IT WORK

KEY COMPONENTS OF SUCCESS

Partnership with practices from the outset

Flexible model within program guidelines Tailored to needs of individual practices Sufficient space in the practices Well trained staff Family physician is available Care is shared Agree on goals and priorities

KEY COMPONENTS OF SUCCESS

Central co-ordinating teamRegular contact with practicesResponsive to individual practice needsAssists practices with governance /

managementAssists with problem solving

Facilitation

PATIENT’S PERSPECTIVE

PATIENT’S PERSPECTIVE• Easy access to care• More culturally acceptable• Co-ordinated through FPs office• Ease of negotiating systems• Familiar environment• Less stigma• Integrated with other care• Family physician entry to care• Counsellor can assist with community referrals

/ system navigation

CO-LOCATION ALONE IS NOT ENOUGH

WE ALSO NEED CHANGES IN OUR SYSTEMS OF CARE

TO SUPPORT THESE INTERVENTIONS / ROLES

“We have no money, therefore we must think”

Sign at Maudsley Institute in London, England

Focus on acute problemsEmphasis on triage and patient flowShort unprepared appointmentsBrief didactic consumer educationFollow-up is usually consumer initiated Treat only those people who reach usCan’t identify problems earlierNo prevention of episodes / recurrence

TRADITIONAL ORGANISATION AND CULTURE OF CARE

“The Tyranny of the Urgent”

Thomas Bodenheimer 2002

“Between the health care we have and the health care we could (should) have lies not just a gap, but a chasm”

US Institute of Medicine, 2001

U.S. Institute of Medicine

U.S. Institute of Medicine - “Chasm Report”

“These quality problems occur typically not because of failure of good will, knowledge, effort or resources directed to health care, but because of fundamental shortcomings in the way care is organized”

REDESIGNING SYSTEMS OF CAREBetter management and outcomes requires changes in the ways systems of care are organised

CHANGING THE PARADIGMFocus on populationsPatients as partners Pro-active careSystem takes responsibilityImprove accessFocus on longitudinal care / closing the loop (a system of

care)Co-ordination of careEmphasise quality as well as quantityRequires teamsRequires IM support

Informed,ActivatedConsumer

ProductiveInteractions

Prepared, ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformatio

nSystems

Self-Management

Support

Health System

Resources and Policies

Community Health Care Organization

(Chronic) Care Model

Improved Outcomes

Integrating counsellors in primary care

Access to psychiatric consultation

Opportunities for case discussions

Team-based care

Prepared visits

Organisational commitment / support

Links with community partners

SOME COMPONENTS ALREADY IN PLACE

Population focusRegistryScreeningTreatment algorithmPro-active follow-upSelf-management support

Goals Plan Information Education

Use of the phone Increase efficiency – Improve access / reduction of waste

, what doesn’t add value for the patients

OTHER CHANGES TO THE PROGRAM

IMPROVING ACCESS (OPEN ACCESS)Supply equals demandIncrease capacity (supply) – appointment slots not providersClear the backlogChange the way requests are handled (demand)

Use the phone moreTeamSelf managementPrepared visitsMorning huddle

IMPLICATIONS FOR DEPARTMENTS OF FAMILY

MEDICINE

EXPERIENCES FOR LEARNERSMental health problems in primary care

Training in mental health care delivery

Training in collaborative care

Training in Improvement methods

See collaboration modelled

Integrate teaching into the clinical units

OTHER OPPORTUNITIES FOR ACADEMIC DEPARTMENTS

Links with fellow Dept. of Psychiatry

Joint rounds

Involvement in resident training

Leadership

Student Health

Start with small pilots and build on learning

IMPLICATIONS OF THIS MODEL FOR PATIENT CENTRED

MEDICAL CARE

A patient-centered medical home integrates patients as active participants in their own

health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best

available evidence and appropriate technology. These relationships offer patients comfort,

convenience, and optimal health throughout their lifetimes. (May Board 2008)

IMPLICATIONS FOR THE PCMH: THE SERVICES

• Broader range of services available• Better co-ordinated• Increases system capacity• Patients more likely to receive the care they need• Patients less likely to be “lost” to follow-up• Better integrated• Better linked with community partners• More efficient• Facilitates the move to population-based care • Opportunities for early intervention

IMPLICATIONS FOR THE PCMH: THE TEAM

• New for many physicians• Team meetings / Morning huddles• Needs some space• Need to learn about the scope of all team members• Multidisciplinary or interdisciplinary• Parallel Referral Collaboration

• May need facilitation

IMPLICATIONS FOR THE PCMH: THE PATIENT

• Convenient• Less stigmatising• Culturally appropriate• They know who to contact to get into the system• More accessible • Life-long – for provider as well• Supports self-management• Family as well as patient-centred

“Some look at things that are, and ask why. I dream of things that never were and ask why not?”

George Bernard Shaw

10th. Canadian Collaborative Mental Health Care Conference

May 28th. – 30th. Hamilton, Ontario www.shared-care.ca

nkates@mcmaster.ca