improving access and the quality of care through better ......improving access and the quality of...

Improving access and the quality of care through better collaboration

between mental health and primary care : A global perspective

Nick Kates, ChairDept. of Psychiatry & Behavioural

NeurosciencesMcMaster University

Hamilton Family Health Team

“Improving Access and the Quality of Care by Better Collaboration Between Mental Health and Primary Care Providers: A Global Perspective”

Nick Kates MB.BS FRCPC MCFPCChair, Dept. of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamilton, ON

Session # D7A

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

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Plan for today• Why we need to collaborate

• A Framework for Collaborative Care

• Enhancing PMHC through Collaboration

– All mental health services

– Within primary care (Integrated care)

• Keys to success

• Evaluation

• Future Opportunities

Thought for the day

“”Here is Edward Bear, comingdownstairs now, bump, bump, bump,on the back of his head, behindChristopher Robin. It is, as far ashe knows, the only way of comingdownstairs, but sometimes he feelsthat there really is another way, if onlyhe could stop bumping for a momentand think of it”

Why do we need to collaborate better?

Because of the key role primary care is already playing, often without support

There are challenges in addressing mental health issues in primary care

Problems in the relationships with mental health services

What prevents us from collaborating• Physician remuneration models

• Service funding models

• Attitudes

• Cultures of care

• Power and control

• Comfort / convenience

• Training

• How our systems are designed

Primary Mental Health CareDelivery of mental health care within primary care settings

Not dependent on the presence of a mental health professional

Framework for Collaborative Care

4 Components to PMHC

Recognition, Assessment and

Initiation of Therapy

Care Management and Relapse Prevention

Education and Support for Self-

Management

Protection of Human Rights /

Equity

Primary Mental Health Care

Delivery of mental health care within primary care settings


Enhancing PMHC through Collaboration

By any service

Bringing mental health services into primary care






By any service


External Supports

Policy Framework

Funding Strategy

Training Strategy


Collaboration• Delivery of service by two or more stakeholders

(including consumers)

• Working together in a partnership characterised by – Common goals or purpose– Recognition and respect for

strengths and differences– Equitable and effective decision

making– Clear and regular communication

• To improve access to a comprehensive range of services delivered by the right person, in the right place at the right time

Integration

The realignment of resources, and of the delivery, management and organisation of services to develop a comprehensive continuum of services to improve access, quality, user satisfaction and efficiency

Primary Mental Health CareDelivery of mental health care within primary care settings



It draws upon

Informed,ActivatedConsumer

ProductiveInteractions

Prepared,Proactive

Practice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-Management

Support

Health System

Resources and Policies

Community Health Care Organization

(Chronic) Care Model

Improved Outcomes

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Our premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec;20(6):64-78.

- Effective- Safe

- Timely (accessible)- Equitable- Efficient- Consumer & Family-centred

- Integrated and collaborative- Focused on population health

Quality Care is care that is:

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Failures to collaborate are often system failures

Redesigning Systems of Care

Better management, obtaining better outcomes and delivering better quality

care require changes in the way systems of care are organized, both within and

between systems.

Changes in Delivery Systems to Support Collaborative Care

• Treatment protocols, guidelines or pathways• Case registries• Pro-active outreach and recall (planned care)• Clarity regarding roles and expectations• Person to person handovers of care • Incentives to promote collaborative practice, • Shared record keeping and charting• Task-sharing• Measurement• Preparation for working in primary care

Changes in Delivery Systems to Support Collaborative Care (Whitebird, Unutzer)

• Treatment protocols, guidelines or pathways• Case registries• Pro-active outreach and recall (planned care)• Clarity regarding roles and expectations• Person to person handovers of care • Support by leadership in both organisations• Incentives to promote collaborative practice, • Shared record keeping and charting• Task-sharing• Measurement

The triple (quadruple) aim (IHI)

PopulationHealth

Experienceof Care

Per CapitaCost

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Presentation Notes

At the individual level this translates to good or better health , good experience and good value

GOALS OF COLLABORATIVE CARE PROGRAMS

Improve quality & outcomes

Increase capacity

Enhance the provider’sexperience

Improve access

Enhance the person’s experience

POSSIBLEGOALS

mhGAP• WHO Program 2008

• 14% of the Global Burden

• 75% have no access to care

• Integration of mental health services into generalmedical settings

• Produced a series of guides

Without mental healththere is no health

mhGAP – 4 roles for Primary Care• Assessment and Treatment

• Care Management and monitoring

• Education and Supportfor Self-Management

• Protecting human rights /(Equity)

Collaborative Care Model (Katon et al)

Primary Care Practice

• Primary Care Provider• Patient (informed activated)

+ • Mental Health Care Manager• Psychiatric Consultant

Outcome Measures

Treatment Protocols

PopulationRegistry

Psychiatric Consultation

Core Principles of Effective Collaborative Care

Patient-Centered Care Teams• Team-based care: effective collaboration between PCPs and Behavioral Health

Providers.• Nurses, social workers, psychologists, psychiatrists, licensed counselors, pharmacists,

and medical assistants can all play an important role.

Population-Based Care• Behavioral health patients tracked in a registry: no one ‘falls through the cracks’.

Population-based screening

Measurement-Based Treatment to Target• Measurable treatment goals clearly defined and tracked for each patient• Treatments are actively changed until the clinical goals are achieved

Evidence-Based Care• Treatments used are ‘evidence-based’, having credible research evidence

AIMS Center 2011, http://aims.uw.edu/

http://aims.uw.edu/

Stepped Care Approach

1o Care

Psychiatric consult

(Face-to-face)

PsychiatricInpatient tx

Self-Management

1° Care + MHP

BH specialty long term tx

1° Care + Health Educ.

Primary Care

Stepped Care Approach

1o Care

Psychiatric consult

(Face-to-face)

PsychiatricInpatient tx

Self-Management

1° Care + MHP

BH specialty long term tx

Psychiatric Consultant

1° Care + Health Educ.

Primary Care





By any service



Strengthening PMHC through better collaboration

statement

Changes that any mental health service can make

statement

Bringing mental health services with primary care


statement


Communication

Improving Access

Co-ordinating Care

Capacity Building

TelepsychiatryThings that any mental health service can do

CAPACITY BUILDING• Case Discussion• Relevant / Case based / Brief• Not one-offs• Family physicians involved in design

Educational sessions with Primary Care

Providers

• Information with discharge summaries• Other resources• Links to on-line resources

Provision of Information

• Practice Support Program Modules in BC• Adults• Children and Youth• Different conditions• Processes of care

Training Programs

Physical Health Care for the Mentally Ill


statement


statement

Bringing mental health services with primary care

Mental Health Services in Primary Care

Co-LocationEducational sessions / joint rounds – opportunities to meetVisits to primary care for consultation / follow-up / case reviewsOffices in the same building

Visiting MH Professionals• Individual clinician• Team• Hub and spoke

Integrated Team

The keys to success

Making it work

Principles

To get the best outcomes

Evaluation

Preparation of staff

Setting up a project

Principles

Principles – The Entire System

• Collaboration and integration is a process, not a single event • Better collaboration is a means to an end• Mutual respect and support• Recognition of each other’s strengths and limitations• Individually tailored – one size fits one• Personal contacts and direct communication• All partners need to be willing to make adjustments• Language is relevant, jargon-free and easy to understand• Physical proximity is essential.• Approaches need to be adapted according to resources, local

cultural and geography and problem severity

Entire System

Principles – Between Providers

• Common goals• Primary care tasks must be realistic and relevant to the

skills, interests and resources of the providers.• Care should be person and family centred (to ensure

treatment is effective) and responsive to their changing needs.

• There should be a regular and unimpeded flow of information between providers

• There needs to be effective co-ordination of care and shared care plans

• Personal contacts – Getting to know each other

Between Providers

Integrative Care needs to

be

Team-Based Person

and family

centred

Populationfocused

Co-ordinated Emphasise

Communic-ation

Evidence-informed

Proactive &

Planned

Stepped


How can integrated care reinforce Primary Mental Health Care

4 Components to PMHC

Recognition, Assessment and

Initiation of Therapy

Care Management and Relapse Prevention

Education and Support for Self-

Management

Protection of Human Rights /

Equity

Assessment and Initiation of Treatment

• Diagnosis• Consultations • Referral• Advice about treatment • Educational sessions for primary care

providers • Introducing clinical guidelines

Evidence-based Brief Interventions

Motivational Interviewing

Support for Self-Management

Behavioral Activation

Problem Solving Therapy

Distress Tolerance

Care Management and Monitoring

• Delivering psychological therapies• Care co-ordination and case management.• Telephone back-up when not in the practice• Intermittent care• Case reviews• Systematic and proactive follow-up• Leading groups or shared medical

appointments• Monitoring of progress and treating to target.• Providing educational resources

•Follow evidence informed guidelines

•Outcomes

•Percentage who reach treatment targets.

Effective

• Waiting time

• Type of services delivered

Timely

• The extent and type of integration and coordination

• Team functioning

• Utilization of other services

• Amount of service delivered

Efficient

• Patients involved in developing their plans and goals

• Patient has a copy of their plan

• Patient satisfaction

• Provider satisfaction

Patient-Centred

Quality Measures

• The elimination of barriers to access

• Equity in outcomes

Equitable

• Medication reconciliation

• Elimination of preventable adverse events

• Always / Never events

Safe

• Follow-up after treatment

• Subpopulations being seen

Population-focused

Quality Measures

Education and Support for Self-Management

• Support for self-management,• Providing resources• Education about relapse

prevention• Engaging a family or support

system• Support for primary care teams

Protecting Human Rights/Equity• Decreasing stigma amongst

primary care staff• Decreasing stigma amongst

family and community members

• Participating in advocacy efforts

• Increasing equity in access and outcomes





By any service


External Supports

Policy Framework

Funding Strategy

Training Strategy


Other Supports Required

• Integrated Funding• Integrated Governance• Physical integration of staff• Support from Leadership• Common Charting / EMR• Standardisation of interventions• Commitment to Performance Management,

Quality Improvement and Evaluation

Preparing people to work in primary care

Skills Required

• Competencies– Understand primary care– Able to work in a team– Flexible and open– Communications

• Prepared

• Opportunities to share experiences

Planning and Implementing a project

Implementing a project

• Collaborative• Recognise the past and move on• Common goals (shared)• Small steps and build• Lead / ambassador / liaison• Monitoring / oversight group• Measurement• Review process

Other opportunities

CMHC can assist with other health system challenges

• Access and waiting times • Fragmentation of services • Avoidable ED visits

• Improving transitions• Improving quality of care

• Aging population – Complex conditions• Rural and isolated communities • Inequities

• Earlier detection – especially children

20th. Canadian Collaborative Mental Health Care Conference

May 10-11th. 2019

Vancouver British Columbia

www.shared-care.ca

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