Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care
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Nick Kates MB.BS, FRCP(C) Professor Dept. of Psychiatry, McMaster University Ontario, Canada Program Director, Hamilton Family Health Team
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Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care. Nick Kates MB.BS, FRCP(C) Professor Dept. of Psychiatry, McMaster University Ontario, Canada Program Director, Hamilton Family Health Team. PLAN. The Canadian Context - PowerPoint PPT Presentation
Transcript of Towards the Patient Centred Medical Home: Integrating Mental Health Services into Primary Care
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
