Shared Care in Canada
Douglas Green MD
TOH Shared Mental Health Team
Ottawa, Ontario, Canada
dogreen@toh.on.ca
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
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
Government and politics
• Canada is a federal parliamentary
democracy
• It is comprised of 10 provinces and 3
territories
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
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
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
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
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
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
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
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
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)
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
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
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
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 physician’s
office
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
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
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
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”
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
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
Benefits of shared/collaborative care
Symptom improvement
Functional improvement
Reduced disability days
Increased workplace tenure
Increased quality-adjusted life years
Increased compliance with medications
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
What does the research indicate are
some of the ingredients of successful
collaborative care models?
Chronic Care Model
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
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
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
Elements of the CCM
• System Design
• Self-management support
• Decision support
• Information systems
• Organizational change
• Links with community resources
Stepped Care
“Having the right service in the right place,
at the right time delivered by the right
person.”
What does the research indicate are
some of the ingredients of successful
collaborative care models?
1) Use of a care coordinator
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
2)Psychiatric Consultation
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)
3) Self management and
psychoeducation
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
4) Screening for people with chronic
medical illnesses for anxiety and
depression
PHQ-2
Using the PHQ-2
• If score is 3 or above then proceed to do
full PHQ-9
PHQ-9
Available at www.phqscreeners.com
5) Treatment algorithms
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
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)
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.
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
6) Access to brief psychological therapies
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
7) Physician skill enhancement
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
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
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
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
Shared care in mental illness: A rapid review to inform
implementation*
Core ingredients of effective shared care models
include:
1. Engagement of primary and specialist
services towards common goal of improved
mental health care
2. A coherent treatment model relating to the
target condition/s or patient population
3. 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, 5:31 pp1-12
Shared care in mental illness: A rapid review to inform
implementation (contd.)
4. Provision of clinical supervision to
support skill development and
maintenance of treatment model
5. A well-established clinical governance
framework
Shared Care in Canada
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)
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
Ottawa and Shared Care
Ottawa
• Nation’s 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
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
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 CBTbased psychotherapy primarily for anxiety
and depression
• Provides teaching to family health team
staff and family medicine residents
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
PHQ-9
Available at www.phqscreeners.com
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
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
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
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
Websites of interest
• www.sharedcare.ca
• www.phqscreeners.com
• http://www.comh.ca/antidepressant-
skills/adult/
• http://prevention.mt.gov/suicideprevention/1
3macarthurtoolkit.pdf
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; 5:31: 1-12
Questions?
dogreen@toh.on.ca