Sharing care after nine years: Implications and impact on the broader mental health system Jack Haggarty M.D. Out-patients, SJHC Assoc. Prof Northern Ontario School of Medicine (NOSM) [email protected]September, 2010 Valhalla Inn, Thunder Bay, Ontario
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Sharing care after nine years: Implications and impact on the broader mental health system Jack Haggarty M.D. Out-patients, SJHC Assoc. Prof Northern Ontario.
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Sharing care after nine years: Implications and impact on the
broader mental health system
Jack Haggarty M.D.Out-patients, SJHCAssoc. Prof Northern OntarioSchool of Medicine (NOSM)
I sit on the board of directors for the following organizations:
•None…
•Advisory Board of NWLHIN MH Team; Chair Health Professional Committee (HPAC)
Objectives
Gain an appreciation of a model of collaborative care in Northwest Ontario;
Understand the implications of evolving and reforming mental health delivery for both primary care and a broader mental health delivery model.
AND opinions on • M Illness and treatment is expanding/creating greater need for Tx
(not less)• As decrease stigma and stigmatized settings, then resultant
increase in need/demand (are we ready?)• What we cannot afford to pay for• Essential components of care
Crossing the Quality Chasm: A New Health Systemfor the 21st CenturyCommittee on Quality of Health Care in America,Institute of Medicine (2001)
Crossing the Quality Chasm: A New Health System for the 21st Century (Free Executive Summary)http://www.nap.edu/catalog/10027.html
Establishing Aims for the 21st-Century Health Care SystemThe committee proposes six aims for improvement to address key dimensionsin which today’s health care system functions at far lower levels than it canand should. Health care should be:• Safe—avoiding injuries to patients from the care that is intended to helpthem.• Effective—providing services based on scientific knowledge to al whocould benefit and refraining from providing services to those not likely to benefit(avoiding underuse and overuse, respectively).• Patient-centered—providing care that is respectful of and responsive toindividual patient preferences, needs, and values and ensuring that patient valuesguide all clinical decisions.• Timely—reducing waits and sometimes harmful delays for both thosewho receive and those who give care.• Efficient—avoiding waste, including waste of equipment, supplies, ideas,and energy.• Equitable—providing care that does not vary in quality because of personalcharacteristics such as gender, ethnicity, geographic location, and socioeconomicstatus.
Bridging the Quality Chasm: US Report
Recommendation 4: Health careorganizations, clinicians, and patients should
work together to redesignhealth care processes in accordance with the
following rules:1. Care based on continuous healing relationships.
2. Customization based on patient needs and values.
3. The patient as the source of control.
4. Shared knowledge and the free flow of information. Patientsshould have unfettered access to their own medical
information 5. Evidence-based decision making.
6. Safety as a system property. Patients should be safe frominjury caused by the care system.
7. The need for transparency.
8. Anticipation of needs.
Mental Health Commission of Canada
This Framework proposes seven linked goals for a transformed mental health system:
People of all ages living with mental health problems and illnesses are actively engaged and supported in their journey of recovery and well-being.
Mental health is promoted, and mental health problems and illnesses are prevented wherever possible.
The mental health system responds to the diverse needs of all people living in Canada.
The role of families in promoting well-being and providing care is recognized, and their needs are supported.
MHCC Seven Priorities People have equitable and timely access to
appropriate and effective programs, treatments, services and supports that are seamlessly integrated around their needs.
Actions are informed by the best evidence based on multiple sources of knowledge, outcomes are measured, and research is advanced.
People living with mental health problems and illnesses are fully included as valued members of society.
NWLHIN 2009 Integrated Health Service Plan Priorities
Goldberg & Huxley’s Filters: Who moves up and down service Needs in MH system. Unmet need gaps at each. From: 2003 G Andrews.
Unmet need in psychiatry.
Goldberg & Huxley’s Filters: Who moves up and down service Needs in MH system. Unmet need gaps at each.
Goldberg & Huxley’s Filters:
M.H care And Psychiatry
Primary Care
MH. Psychia
Primary Care
Public Health, Schools, Informal providers
Public H.?Primary Care…see MHCC
An ideal collaborative care system.
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SMHC: A Working Definition1
(Tammy M)
Process of collaboration between family physician and mental health professional
Enables responsibilities for care to be appointed according to:(a) Treatment needs of the patient(b) Respective skills of mental health
professional and family physician
1. Collaborative Working Group on Shared Mental Health Care. Ottawa: Canadian Psychiatric Association and College of Family Physicians of Canada, 2000.
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Consistent with Health System Reform
Primary-care is corner stone of the health system
Key piece of ‘shifting’ to community Improved links to specialty care Integrates specialty services in
Primary-care Improved links to other services
Nearly 10 years…we have learned a few things. (JH)
It works High clinical and evaluative participation patients AND
MD’s/ counsellors Part of continuity of primary care Communication can be continuous Sustained benefits Support evidence can effectively manage S.M.I. Lower wait times sustained Change to/with system over 5 yrs Primary care is very gratifying place in system to work Value of getting to ‘the table’ of decision sharing of MH
planning/believing in change (fight against apathy)
Part II : Our findings
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Some burning questions we were asking…. What is it?....How does it work?... How good is this program really?
Do people get better…? Do they stay better? OK, what about the Serious Mentally ill? How much is agreement a part of SMHC? And the somatic frequent users helped? Impact on wait and other MH System? But can it be fun too?
And more
Findings From a Northern Ontario Shared Mental Health Care Program:
Changes in Patient Symptoms and Disability
John Haggarty M.D.Brian O’Connor Ph.DSacha Dubois MPH (Cand.)Janelle Jarva M.A.Andrew M. Blackadar M.D.Tammy McKinnon MSWDaniel Boudreau HSW
J. of Primary Care and Community Psychiatry, March 2008
Q: Does it work?
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Canadian Institute for Health InformationHealth Indicators Framework
Acceptability
Accessibility
Appropriateness
Competence
Continuity Efficacy Effectiveness Safety
www.cihi.ca
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Canadian Institute for Health InformationHealth Indicators Framework
Acceptability
Accessibility
Appropriateness
Competence
Continuity Efficacy Effectiveness Safety
www.cihi.ca
Survey Grid for SMHC Fort William Clinic. Version Fall 2001.
FORM OR SCALE
Time of Referral
1st Visit
Follow-up Visit
Third Visit
PsychiatristVisit (each)
Last Visit
Symptom scale PHQTAG
X X
Function Scale WHO-DAS X X
GAF X
Satisfaction Scale
VSQ X
-CSQ-***each MD, CounsellorPsychiatrist
X
X
Referral Form
X
AssessmentPlan
X
CounsellorsContact Sheet *
X X X X
PsychiatricConsultation
X (if requested)
Psychiatric Follow-Up
X X
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General Information Welcome to the Home Page for the World Health Organization Disability Assessment Schedule II (WHODAS II). This
site provides information relevant and useful to researchers, clinicians, and administrators who are interested in learning about and using this instrument for assessing levels of functioning. The WHODAS II has been under development by WHO for several years. Final versions are expected to be released in 2001. Currently, the WHODAS II is available in eleven versions and sixteen languages. Available versions include self-administered, interviewer-administered, and proxy-reported. The WHODAS II provides a profile of functioning across six activity domains, as well as a general disability score. This information can be used to
•Identify needs •Match patients to interventions •Track functioning over time •Measure clinical outcomes and treatment effectiveness
Return to this page often to receive the latest information and updates regarding the WHODAS II, including semi-structured versions of the instrument and publications.
Download WHODAS II
Download I-Shell - WHODAS Manuals & Software*
Upload WHODAS data* List of Centres
Translations
Ongoing Field Trials Scoring
Frequently Asked Questions Contact information
Related Links
WHO Home Page
Send your comments and feedback about this site to [email protected]
* Available only to WHODAS-II Centers and requires a user-id and password.
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72.0%
40.5%
33.5%
18.4%16.2%
5.7% 5.1% 6.4%
0%
20%
40%
60%
80%
depressed anxiety sleep moodswings
panic somatic alcohol suicidal
Psychiatric symptoms identified by referring physicianJuly 2001 - April 2004
n = 945
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29
30
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AFTER SHARED CARE: PATIENTS’ SYMPTOMS AND FUNCTIONING
3 TO 6 MONTHS FOLLOWING CARE AT A RURAL SHARED MENTAL HEALTH
CARE CLINICJOHN HAGGARTY
Northern Ontario School of Medicine, and
Community Mental Health Services, St. Joseph’s Care Group, Thunder Bay, Ontario
RUPERT KLEIN
Department of Psychology, Lakehead University
Thunder Bay, Ontario
BOB CHAUDHURI
Northern Ontario School of Medicine, Thunder Bay
DANIEL BOUDREAU and TAMMY MCKINNON
Fort William Clinic, Thunder Bay, Ontario
Q: If it works, does its impact continue 3-6months after?
Community M.H. Journal March 2009. Suppl.
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Figure 1.
WHO-DAS-II S scale demonstrating pre-treatment, post-treatment and 3-6 month follow up
N=25
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Q: Effect on ‘Above threshold’ Somatization Disorder Patients?
Fam Med Resident Example of learner facilitated
research Second resident with paper
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Shared Mental Health Care and Somatization: Changes in Patient Symptoms and Disability Mozzon JB; Haggarty JM; Jarva JA; and O’Connor BPSt Joseph’s Care Group, Northern Ontario School of Medicine (submitted)
Background/Objectives: Somatization is common in primary care, can lead to significant impairment, and poses a challenge for management. Psychotherapy, and in particular cognitive behavioural therapy, is one of the most effective treatment modalities for patients with severe somatic symptoms. However, the evidence supporting its use in a primary care shared mental health care (SMHC) setting is limited. The primary goal of this study is to describe the symptom improvement and change in function in patients with high levels of somatization referred to an outpatient SMHC service.
Results: For patients with high levels of somatization at entry, treatment with SMHC was associated with both a significant reduction in somatic symptom severity (41% reduction; P<0.001) and mental health related disability scores (44% reduction; P<0.001). Furthermore, levels of somatic symptom severity and disability approached community sample norms at the completion of their SMHC sessions.
Conclusion: Multidisciplinary, short term, counselling-based SMHC demonstrated significant improvement in patient symptoms and level of disability, and shows promise as an effective treatment option for patients with high levels of somatization.
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Pre-post Intervention PHQ-15 after course of care in SMHC setting.
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Pre-post Intervention Functional Measure after course of care in SMHC setting.
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Transition into Primary-care Psychiatry
TIPPDr. Jack Haggarty (Co-Principal Proponent)
St. Joseph’s Care Group, Lakehead Psychiatric Hospital, Community Mental Health Services, Thunder Bay
&Dr. David Haslam (Co-Principal Proponent)
Mental Health Consultation and Evaluation in Primary PracticeRegional Mental Health Care – London
Specialized Adult London ServiceDepartment of Psychiatry, University of Western Ontario
J Primary Care and Community psychiatry March 2009.
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TIPPResearch
First randomized trial comparing ‘usual’ treatment to ‘supported repatriation’.
Transition into Primary-care Psychiatry (TIPP) based on Australian model (CLIPP)
Can the TIPP model establish linkages that provide sustainable and effective mental health care in the primary care setting?
TIPP Findings
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Psychiatric Symptoms at Endpoint
Brief Symptom Inventory – Outpatient Norms
Psychoticism
Paranoid Idation
Phobic Anxiety
Hostility
Anxiety
Depression
IP Sensitivity
Obsessive-Compulsive
Somatization
Mea
n R
epor
ted
Dis
tres
s (t
-sco
res) 60
50
40
TIPP
CAU
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Psychiatric Symptom Distress Over Time
Time
12 Month6 MonthBaseline
Mea
n G
SI
(t-s
core
s)60
50
40
TIPP
CAU
* Significant at .05 level
*
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Number of Symptoms Over TimeBSI Positive Symptom Total – Outpatient Norms
Time
12 Month6 MonthBaseline
Mea
n P
ST
(t-s
core
s)60
50
40
TIPP
CAU
*
* Significant at .05 level
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Psychiatric Distress Over Time
BSI Positive Symptom Distress Index – Outpatient Norms
Time
12 Month6 MonthBaseline
Mea
n P
SD
I (t
-sco
res)
60
50
40
TIPP
CAU
45
Client Satisfaction
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3 month 6 month 9 month 12 month
Time Period
1
2
3
4
Sat
isfa
ctio
n w
ith
Hel
p f
or
Ph
ysic
al H
ealt
h
TIPP
CAU
Shared Care Client Satisfaction Inventory
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Q: What is the impact of this model to wait times?
Wait shorter? Does it increase or decrease burden
on other providers? Cost-effective or increase service
need?
Symptom onset
Referral Sent
Accessing PCP
Help Seeking
Referral Received
Contacting Client
First Appointment
Start of Treatment
Start of Treatment Ψ
End of Care
Wait 1
Wait 3
Wait 2
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Mental Health Service Provider
n Seen for
Treatment n (%)
Not Seen for
Treatment
n (%)
Existing Prior to 2001?
Staff #
F.T.E.
Shared Mental Health Care Service – Fort William Clinic
1685 1323 (78.5)
362 (21.5)
NoOpened Mid-
2001
2.2
Shared Mental Health Care Service – Port Arthur Clinic
219 144 (65.8)
75 (34.2)
NoOpened 2005
1.2
Community Mental Health Program - Thunder Bay Regional Health Sciences Centre
976 701 (71.8)
275 (28.2)
Yes 3.5
Personal Development Centre – St. Joseph’s Care Group
1142 879 (77.0)
263 (23.0)
Yes 4.0
Community Mental Health Services- St. Joseph’s Care Group
2028 1247 (61.5)
781 (38.5)
Yes 22.0
Total 6050 4294(70.98)
1756(29.02)
Thunder Bay Outpatient clinics Participating
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Number of Referrals from the FWC to Other Mental Health Services
0
10
20
30
40
50
60
70
Year 2001 Year 2002 Year 2003 Year 2004 Year 2005
52
Number of Referrals from the FWC to Other Mental Health Services
0
10
20
30
40
50
60
70
Year 2001 Year 2002 Year 2003 Year 2004 Year 2005
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Referrals from the FWC
0
50
100
150
200
250
300
350
400
450
500
Year 2001 Year 2002 Year 2003 Year 2004 Year 2005
Other Services
SMHCS FWC
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Number of referrals from the PAC to Other Mental Health Services
0
50
100
150
200
250
Year 2001 Year 2002 Year 2003 Year 2004 Year 2005
55
Referrals from the PAC
0
50
100
150
200
250
Year 2001 Year 2002 Year 2003 Year 2004 Year 2005
Other Services
SMHCS PAC
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The BIG Finding…. Mean wait times (days) and # of
referrals across ALL 5 sites (including SMHCS)
National Recommended Benchmarks for Wait Times (Weeks)
Site 1 Site 2 Site 3 Site 4 SMHC-1 SMHC-2
Wait Your Turn findings 2008 (Median) Canada
Ontario 7
7.9
Present Study Median 13 7 6 10 5 15
Met? N Y Y N Y N
Present Study Mean 14.14 7.95 9.71 11.63 5.63 15.37
CPA Benchmark Suggested Wait Time
4
Met? N N N N N N
SMHC : Present issues Stablized, decrease or expand role Be at table of evolving MH system, LHIN’s, FHT
development (QIIP) Impact on In-patient/ ED visits Further push integration of MH data bases ie
TBRH: Info. Service, H Records, ED data, AMH, Primary Care…..for use/access by others
Unmet need and Stigma based on non-attenders primary care sites
Child services Integrated Clinical model for learners. Academic
FHT. (Tammy McKinnon)
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Where has this gotten us… Internationally recognized researchers
into a still fledgling model of care First goal of ‘Does this work’ has grown to
further important and critical contributions to the area.
We may be still 5+ years ahead to model implementation…early adopters
Still only pilot model of care…not supported by mainstream MH clinicians…’too much work…front line…’
Where has this gotten us? Change is possible.
• Helps if one can evaluate/demonstrate it
Change is infectious• Even when one is not aware• In ways one can’t always predict
Change is not always possible• Not for all locations• Not necessarily welcomed
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Next considerations… What is stalling further dissemination of the
model? Is FHT the preferred or possibly only vehicle to
grow into? At FWC: Not using short time frame use of data,
slow to get data to clinician with ‘norms’ Further use of QIIP to build on success Child, Technology, Academic FHT, Regional expansion FHT Wait II study