The Evolution of Collaborative Mental Health Care in Canada: A Shared Vision for the Future

1. Session #D4 October 29, 201110:30 AM The Evolution of Collaborative Mental Health Care in Canada: A Shared Vision for the Future AjanthaJayabarathan, MD, FCFP Roger Bland, MB, FRCPC Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had relevant financial relationships during the past 12 months that could introduce commercial bias into our presentation

3. Need/Practice Gap & Supporting Resources The CPA-CFPC* conjoint working group has updated the 1997 Canadian Shared Mental Health Care position paper to promote & advance collaboration between mental health and primary care services. It proposes a shared agenda to improve care by building responsive, person-centred partnerships, enhancing primary mental health care, preparing future practitioners effectively and redesigning delivery systems. *Canadian Psychiatric Association-College of Family Physicians of Canada

4. Objectives •Explore aspects of the 2011 position paper that describe reorganisation of education, training & the system of health care delivery to implement collaborative, inter-professional delivery of mental health care •Identify key enablers that helped overcome barriers to implementation of Collaborative mental health care through Canadian examples. •List innovative, incremental steps integral to the successes in the landscape of Canadian Collaborative mental healthcare • Draw from knowledge of the Canadian experience and explore solutions to personal, local and regional barriers to collaborative care.

5. Learning Assessment Please pose questions linked to the objectives of our presentation, for which you want answers.

6. Canada’s Health Care System Canada area 9.9m km² population 34.1 million GDP PP $39,000 US area 9.8m km² population 313.2 million GDP PP $47,000 Healthcare expenditure as a percentage of GDP Canada 11.4% US 17.4% • Health is a provincial responsibility • Publicly administered and funded healthcare system • Guarantees universal access to medically necessary hospital and medical services • Coverage provided through provincial healthcare insurance plans • All physicians bill through this plan • All residents are covered • There are minimal charges at the point of service (non-insured services)

7. Our Home Provinces Nova Scotia area 53,300 km² population 940,000 density 17.6 per km² GDP PP $35,000 Alberta area 642,000 km² population 3.7 million, density 5.8 per Km2 GDP PP $59,000

8. Alberta Primary Care Networks (PCNs) • Alberta has 40 Primary Care Networks (PCNs) & more than 80% of all family physicians in the province are part of PCNs. • Other Each PCN is unique • developed locally to meet the needs of the local patient population. • a PCN is a “network” of physicians and other health care providers working together to provide primary care • Most PCNs are made up of physicians operating out of existing clinics, and are geographically dispersed. • Some services are accessed in the physicians home clinic, others through a central location for the PCN

9. Physician management of mental illness in Alberta • 95% of all patients seen and diagnosed as having a mental disorder were seen by a family physician • 78% were seen only by family physicians & General practitioners. • Psychiatrists managed 14% of all persons presenting with mental illness • Psychiatrists had a higher mean number of visits per person than did family physicians. • Psychiatrists managed • 5.2% of people with anxiety disorders • 13.9% of depressive disorders • 49.4% of those with schizophrenia or other psychoses

10. In Canada we Recognized… • The high prevalence of mental health problems in primary care • The key role primary care plays in delivering mental heath care within the individual’s community • These problems often presented concurrently with issues of addiction, co-morbid chronic disease and affected the social determinants of health of the individual and their families Despite this… • Detection, referral and treatment rates were low • Concurrent addictions were not integrated into management of illness • Co-morbid medical illness and physical care of mentally ill populations was poorly managed • Individuals often didn’t receive guideline based care • Family physicians felt unsupported by mental health services and there was general dissatisfaction with the relationship

11. Some major influences Declaration of Alma-Ata in 1978. Emphasis on primary health care as the means to “Health for All by 2000”. World Bank. World development report 1993: investing in health. New York: Oxford University Press, 1993. Emphasized concentrating on economic benefits of “single item” interventions. World Health Report 2008 − Primary health care: now more than ever. WHO.

12. We saw the need for better collaboration between sectors…. • CFPC and CPA had joint meetings and in 1997 produced a groundbreaking position paper • New evidence about effective “shared care” practices emerged • Collaborative care became an integral part of provincial and national medical service planning

13. Collaborative MH Care is now… • Being accepted as an integral part of practice • Being included in provincial / RHA planning • Producing increasing Canadian models and evidence • Expected by consumers So why revise the paper….. • Present a new conceptual framework that reflects the evolution of this field - emerging knowledge, integrating new partners, preparing practitioners for new methods of practice • Understand trends and changes in the health care environment & respond to health system challenges by utilizing CMHC-produce better outcomes, meet population needs more effectively

14. Key contextual changes • People with lived experience of mental illness and family members as partners • Emphasis on quality and system redesign – using existing resources differently (the Triple Aim) • Primary Care transformation-Medical home model, office redesign • Increasing expectation of collaborative approach across the system • Increasing expectations from collaborative mental health programs • Changing economic climate

15. Key enablers & developments.. • Champions- individuals & groups,peoplewith lived experience, families, employers & practitioners, institutional & community based, local, regional, provincial & national • Establishment of the CPA – CFPC Conjoint Working Group (Canadian Psychiatric association-College of Family Physicians of Canada) • Literature Review of Shared care/ Collaborative care,Bland & Craven • Provincially held annual Collaborative Mental Health Care Conference • Federal PHCT Funds (Primary Health Care Transition) • CCMHI, Charter &Tool Kits(Canadian Collaborative Mental Health Initiative, 12 National organizations involved in mental health (http://ccmhi.ca/en/products/series_of_papers.html) • Provincial funding-incentives promoting collaborative networks of practice and learning • RX 2000-Canadian Armed Forces initiative (http://www.forces.gc.ca/health-sante/proj/rx2000/default-eng.asp) • CMPAacknowledging collaborative models of medical practice(Canadian Medical Protective Association) • RCPSC adoption of Training Guidelines for psychiatry residents in Collaborative care(Royal College of Physicians & Surgeons of Canada) • MHCC – CHEER (Mental Health Commission of Canada – Collaborative Healthcare exchange, evaluation & research)

16. The Evolution of Collaborative Mental Health Care in Canada: A Shared Vision for the Future N Kates, G Mazowita, F Lamire, A Jayabarathan, R Bland, P Selby, T Isomura, M Craven, M Gervais, D Audet A position paper developed by the Canadian Psychiatric Association and the College of Family Physicians of Canada Collaborative Working Group on Shared Mental Health Care and approved by their respective Boards in August 2010

17. What is collaborative mental health care? Mental Health, addiction and primary care practitioners working together, with the person and family members, to ensure an individual reaches the services they need when they need them, with a minimum of inconvenience. • Built on personal contacts • Based on mutual respect and trust • Based on effective practices • Responsive to changing needs, openness to new ideas • Shaped by context, culture and local resources-shared goals & local solutions • Contain five key components – Effective communication, Consultation, Coordination, Co-location, Integration

18. What we have learned so far… • Convincing evidence of the benefits of collaborative partnerships in both shorter and longer terms • Measured by symptom improvement • Functional improvement • Reduced disability days • Increased workplace tenure • Increased quality-adjusted life years • Increased adherence with medication • Benefits have been identified for • Youth, seniors, people with addictions, indigenous populations and practitioners of primary care, mental health & addictions care

19. Common components of successful programs • Introduction of evidence-based treatment guidelines • Use of a care coordinator or case manager • Skill enhancement programs for primary care providers • Ready access to psychiatric consultation • Screening people with chronic medical conditions for depression or anxiety • Enhanced patient education • Enhanced access to resources (community based, peer support , online resources, integration & linkage to primary care)

20. Challenges • Lack of experience or training in collaborative work • Provider time constraints • Poor access to family physicians in some regions • Funding levels and models • For programs • For clinicians • Organizational culture • Medico-legal issues • Geographic disparities in access to resources

21. Vision for integration of primary care, mental health & addiction services A coordinated & sustainable health care system • that optimizes the utilization of primary care services embedded with mental health & addiction services • and is supported by ready access to secondary and tertiary mental health and addiction services

22. Achieving this vision: Primary Care • Mental health & anti-stigma promotion to preserve wellness • Addiction and mental illness prevention • Early detection of mental health & addiction problems across the lifespan, with attention to those at high risk, medical conditions & chronic disease. • Early recognition, intervention and treatment of new problems and relapses • Proactive crisis management and planned follow-up with community & institution based interventions.

23. Achieving this Vision: Primary Care • Managed follow-up of patients with chronic & severe mental illness and addictions • Integration of recovery, risk reduction and proactive relapse management in mental health care services • Integration of physical and mental health care • Coordinated care linked with community services and the social determinants of health (e.g. home care, housing, income support, employment and recreation) • Support and involvement of families and other caregivers

24. Achieving this vision: primary care providers Primary care providers should possess core competences in mental health and addiction care. This may include: • Routine screening for anxiety and depression in those with chronic medical illnesses • Supporting self-management • Including those with lived experience and families in new projects and services • Use of motivational approaches for health behaviors and lifestyle change

25. Achieving this vision: primary care providers Apply chronic disease management, risk reduction techniques where applicable • Guideline-based care and treatment algorithms • Registry of patients with specific problems to assist in planning care, relapse prevention, crisis management and follow-up • Review of population & individual outcome measures within practice • Improve quality of care through feedback

26. Achieving this Vision: Secondary and tertiary mental health and addiction services • Provide rapid access (e.g. phone, tele-health) • Rapid response to requests for assistance • Provide direct care to people who cannot be managed within a primary care setting • Stabilize patients and return to primary care providers with a joint care plan • Ongoing availability to the primary care team • Assist with access to other resources

27. Achieving this vision: Psychiatrists • Recognize role of primary care in MH&A • Provide support to primary care practitioners as an integral part of their clinical activity: • Team meetings • Telephone consultation • Case conferences • Joint CPD • Integrate psychiatric with medical care in those with medical problems

28. Achieving this vision: Training new practitioners • Promote and develop core competencies in mental health and addictions across all sectors of health practitioner and medical disciplines • Promote inter-professional knowledge transfer, learning & training opportunities at all levels (undergraduate, postgraduate and professional development) • Integrate people with lived experience of mental illness/ addictions and family members into training curricula as teachers and in models of person centered care. • Support integration of trainees into community based models of collaborative care and collaborative care networks • Advocate to include training in collaborative care models in Family medicine and other primary care based health professions.

29. Achieving this vision: Mental Health Services • Make access easy and user-friendly • Provide telephone backup to family physicians • Offer rapid consultation • Involve family physicians in discharge planning and follow-up • Routine telephone follow-up after discharge • Timely reports • Strengthen links between crisis and urgent services and family physicians

30. Achieving this vision: System-wide changes • Guide people with lived experience and families to develop their own care plans • Reduce stigma (internal & external) • Promote mental wellness and recovery across all sectors of clinical practice & medical disciplines • Focus on access, quality improvement, efficiency & sustainability • Define & promote competencies in mental health & addictions for all practitioners

31. Achieving this vision: System-wide changes • Build collaborative networks of health care • Ensure practitioner roles and responsibilities are clearly defined and understood within networks of collaborative care • Develop sustainable funding models to support collaborative care at practitioner and system levels • Strengthen personal connection within collaborative groups • Apply new technologies to enhance care , collaboration and clinical flow (clinic/institutions/systems) • Develop a strong culture of improvement and innovation, recognize and support champions and learn through continuous use of evaluation and feedback

32. Changes that can be introduced… • Proactive and systematic approaches (utilizing electronic health management ,information and communications technologies) • Education and Support for self-management • Understand & improve the pathway of care through feedback and involvement of the person & family members using the service • Develop efficient care pathways that avoid duplication and meet needs of diverse patient populations • Improve access by removing obstacles, building in flexibility and assistance to find the most appropriate service • Within networks of care, develop clarity of roles, effective communication, enable knowledge transfer and clear understanding of the care pathway • Aim to simultaneously achieve sustainable & cost efficient care that leads to better health for populations, while providing a better experience of seeking, receiving & providing care.(triple aim)

33. Tackling inertia & resistance to change…. • Start where you are, use what you got, do what you can, share what you learn • Use a person centered, family inclusive lens to view your practice and system of care • Collect and use knowledge about the journey of care through the consumer and family member’s perspective as the basis for understanding how you are doing and where you need to improve • Recognise that we work in complex systems. Start with things that are small and do-able. Pick key tasks for the initial focus. Spread what works.

34. Tackling inertia and resistance to change…. • Create cultures of improvement and innovation- • Help everyone feel they can contribute • guide everyone to be committed to improvement • think differently • continuously look for new ideas to test • be open to learn from things that don’t work • share and learn from each other • Partnerships are still evolving. Identify and support champions. • Big Changes in Small Steps

35. Expected Outcomes of our presentation…. • Reflect on the similarities and differences in the evolution of collaborative mental health care in Canada & the USA. • Consider opportunities to redesign education, training and systems of care to implement collaborative, inter-professional delivery of mental health care in your practice • Consider the incremental innovative steps taken locally , provincially and nationally in Canada to reach the tipping point for collaborative mental health care in your jurisdiction

36. Let’s return to your questions… Discussion Thank you!

37. Postgraduate Education in Psychiatry in Canada • Residency training is 5 years post-M.D. • All residency programs are run by University Departments of Psychiatry • All programs must meet Royal College Physicians and Surgeons of Canada training requirements and be accredited • PGY 1 year is basic medical training but includes blocks in the family medicine or collaborative psychiatric care

38. Postgraduate Education in Psychiatry in Canada • Residency training is 5 years post-M.D. • All residency programs are run by University Departments of Psychiatry • All programs must meet Royal College Physicians and Surgeons of Canada training requirements and be accredited • PGY 1 year is basic medical training but includes blocks in the family medicine or collaborative psychiatric care