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Recognizing the key role that family physicians play in delivering mental health care, mental health and primary care services are exploring new models of collaboration that support and strengthen this role (1). One way to achieve this is to integrate mental health services within primary care settings. Still relatively unusual in North America, this integration is more common in other countries. In the UK, for example, it has been estimated that one-third of general practices employ a counsellor, with more than 14 000 counsellors working in primary care, a number that continues to increase (2). Two broad models of activity have been described: the replacement model, in which a counsellor sees cases referred by family physicians, and the consultation-liaison model, whereby the counsellor is more closely involved with the family physician on a daily basis (3). Mental health counsellors working in primary care come from various professional backgrounds. Some are community psychiatric nurses, often seconded from mental health clinics (4,5), Others may be psychologists (6–9) or social workers (10). Some have particular skills; namely, family therapy (11) or behavioural therapy (12), while others primarily assist individuals with solving instrumental problems (10). Generally, counsellors tend to work with different populations according to their training and comfort (13). Further, there is a wide range in the amount of time counsellors spend in practices, in the degree to which these services are integrated with the work of the family physician, and in the treatment approaches used (13). Studies that focused on the impact of counsellors in primary care have identified benefits such as improved communication with a family physician, more efficient use of resources, increased access to mental health care, and reduced stigma (13–17). However, some drawbacks that were identified included variability in the expertise and experience of counsellors and in the treatment approaches they choose, a lack of accountability on the part of counsellors, a lack of standardization of treatment approaches, and on occasion, limited communication between counsellors and family physicians, even though they work in the same setting (13–17). Even so, consistent evidence exists that there are high satisfaction levels with this approach on the part of family physicians, as well as an improvement in certain populations exposed to specific treatments (13–15,17). Further, an increasing body of evidence supports the effectiveness of counselling, compared either with regular care by the family physician or with outpatient care (18). More recently, studies have focused on identifying specific populations that could benefit from specific treatments, attempting to define what these treatments are and differentiating the patients who would be best served in which sectors (14,15,18). MethodsProgram Description The program includes the following 4 goals: 1) to increase accessibility to mental health care for primary care patients, 2) to increase the range of mental health interventions available in primary care, 3) to strengthen links between mental health and primary care services, and 4) to enhance the role of the family physician as a provider of mental health care. To achieve these, each practice has a mental health counsellor who is permanently attached to that practice. The amount of time spent in the practice depends upon practice size and clinical needs. One full-time counsellor will serve approximately 8000 patients. For instance, family physicians in single-person practice may have a counsellor in their office for 3 one-half days weekly, while a larger (for example, 6-partner practice) may have as many as 2 full-time equivalent counsellors. There are currently 23 full-time positions occupied by 41 counsellors. Of the counsellors, 60% work part-time in the program. Some counsellors work in 2 or 3 smaller practices, usually in close geographic proximity. The professional discipline of the counsellors includes registered nurses (25%), social workers with a masters degree (50%) or a bachelors degree (15%), PhD psychologists (2%), or another degree (8%). Counsellors are expected to handle a broad range of mental health problems, including individuals with severe mental illness. The community workers who have less formal mental health training have expertise in working with particular populations; specifically, the elderly or ethnocultural groups. Each practice has a consulting psychiatrist who visits for one-half day every 1 to 4 weeks, again depending upon need and practice size. The psychiatrist sees new cases in consultation (often with the counsellor present) as well as selected cases in follow-up, reviews cases with the family physician and counsellor, provides educational input, and provides availability by telephone between visits to offer advice or support. The activities of individual practices are integrated into a single program administered by a central management team. This team is responsible for allocating resources, for recruiting and orientating counsellors and psychiatrists, for setting, monitoring, and evaluating program standards, and for linking with the funding source and advocating for the program. Counsellor recruitment, a 2-step process, includes the screening of potential candidates by the program coordinator to ensure that they possess the necessary skills to work with individuals who have serious mental illnesses and to ensure that they have the flexibility to handle the demands of working in primary care. From this pool, each practice selects the counsellor who best meets its needs. Likewise, the practice hires the counsellor directly. Counsellors will see any individual whom the family physician refers. The only intake criterion is a desire on the part of a family physician for assistance with the management of a case. Consequently, counsellors see a broad spectrum of patients, though priority is given to individuals with a serious mental illness. Every effort is made to ensure that family physicians remain informed and involved in the care of cases they have referred (shared care), because they will continue with the counsellor for care after treatment has been completed. In addition to individual treatment, counsellors see couples and families and provide group leadership, which usually has a psychoeducational focus. The 2 most frequently organized groups have been stress management for women and depression education. Other groups have included a parenting group, a couples communication group, a group for adolescents, a support group for single mothers, and pain management groups. Being in primary care enables the counsellor to discuss cases with the family physician. These discussions include reviews of cases seen by the counsellor, advice about cases that may not need referral, and information on community resources. This occupies about 1 hour of the counsellor’s time weekly and has become an important activity in all practices. Psychiatrists support counsellors and meet with them during their one-half day visit to review cases or to assess individuals together. The program organizes regular counsellor meetings to enable the exchange of ideas on activities in individual practices, to learn about recent developments in the local mental health system, and to provide each other with mutual support. In addition, counsellors have organized their own professional development groups, for which they can receive continuing education credits. Nevertheless, a few problems have been encountered. Some counsellors who have moved from working in a large mental health team to working on their own in a small practice occasionally feel isolated. This can be reduced through participation in monthly counsellors’ meetings and professional development groups. Practical issues have arisen, such as finding adequate space in primary care and gaining access to filing or dictation. These have been resolved with the assistance of the central program on a practice-by-practice basis. Evaluation Design
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