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Models of Sharing Mental Health Care
This section reviews descriptions of shared mental health care initiatives that have been implemented in various different countries and health care systems.
Several different models have been described, many originating in the UK. They can be conceptualized as existing along a spectrum of linkage between mental health care providers and family physicians. The shifted outpatient clinic, for example, is essentially an arrangement whereby a psychiatrist provides traditional outpatient care in the primary care setting instead of within a hospital site. In this model, there are few if any enhanced links between the psychiatrist and the primary care physician, and the primary benefits to patients appear to be reduced stigma and increased geographical convenience.
The consultation-liaison model, in contrast, involves regular visits by the psychiatrist to the primary care physicians office, with direct care to patients and opportunities for liaison activities such as case discussions, advice about nonreferred patients, and educational interventions. In some models, the psychiatrist and the family physician may assess the patient together. The main advantages of the consultation-liaison model are greatly enhanced opportunities for face-to-face communication, skill transfer, collaborative treatment planning, integrated medical and mental health care, support for the family physician with difficult cases, and increased continuity of care. This model may also have the stated goal of reducing referrals in cases of less severe illness and selectively encouraging referral of more serious disorders to psychiatry (Gask and others 1997).
In the liaison-attachment scheme, one or more mental health professionals are assigned to a primary care setting, and provide various services. This model may build on the consultation-liaison model and may consist of a team that includes a psychiatrist who provides consultation-liaison services, or it may be limited to nonpsychiatric mental health workers. The more complex, multidisciplinary teams appear very similar to full-service outpatient programs, with the added benefits of improved convenience for the patient, decreased stigma, increased ease of referral, increased communication, better continuity of care, and more integrated care. Liaison-attachment schemes may require considerable structural and organizational support.
Another way of classifying these collaborative care models is by the type and duration of service provided. Some models offer case discussions only, others provide consultation only, others provide consultation and short-term treatment, and still others provide ongoing follow-up and maintenance care.
Examples of programs that offer family physicians regular opportunities for case discussion can be found in Kates and others (1992) and Midgley and others (1996). In the former study, psychiatrists attached to a Hamilton, Ontario, mental health clinic visited the offices of area family physicians once monthly to discuss patients and provide informal advice and recommendations, educational sessions, and assistance in negotiating the local mental health system. In a similar UK program (Midgley and others 1996), a community mental health team visited 2 general practices once monthly to discuss patients who might or might not have been referred to the team. Each report describes a simple method of increasing collaboration between family physicians and other mental health providers, often without the psychiatrist providing direct care.
An example of a program at the other end of the collaborative care spectrum is an intensive, multifaceted US initiative designed to improve implementation of consensus guidelines for the treatment of depression (Katon and others 1995). This program involved targeted family physician education, patient education, longer patient visits, close monitoring of medication compliance, and an arrangement whereby patients were seen alternately by the psychiatrist and the family physician over the course of their illness. It offers some unique insights into the value of targeted or disorder-specific programs.
Deserving of special note are 2 Australian programs. The first of these (Meadows 1998) established a consultation-liaison model with a difference: in addition to providing regular on-site consultation and backup to family physicians, the organizers addressed the need for a better system of discharging patients from the formal mental health system back to primary care. They developed a method for identifying patients who were being treated in the hospital outpatient clinics but were stable enough for transfer to the primary care setting. Specially trained psychiatric nurses reviewed each patients file, prepared a detailed summary and treatment plan, and then arranged for a bridging meeting between the patient, the family physician, and the psychiatrist who would provide backup. Patients were then followed by the family physician, with backup and review by the consult-liaison psychiatrist every 6 to 12 months. The advantages of this model are that it is well integrated into the larger mental health system, works actively to promote flow through the system, and helps to prevent the primary care service from becoming clogged with episodic or less severely ill patients.
The second Australian program (Davies and others 1997) established its collaborative service in a 2-step process: the organizers took a year to do preparation work with GPs who would be participating in a shared care project. They provided the GPs with an extensive educational intervention that comprised monthly didactic sessions, demonstrations of real patient interviews to teach interviewing skills, and case conferencing around the case demonstrated. In light of how disappointing the literature to date has been on skill transfer in collaborative programs, this approach offers important potential advantages. It establishes expectations that the family physician will continue to play an important and enhanced role as a mental health care provider (and may thereby discourage de-skilling), and it provides family physicians with a good knowledge base to do so. It also sets the stage for ongoing educational interventions tailored to the needs of the individual physicians.
Less costly programs requiring fewer resources also exist. A Hamilton, Ontario, program (Hobbs 1999) combines traditional outpatient clinic services with an enhanced relationship with the family physician. This hospital-based outpatient clinic provides assessment and intensive treatment for patients with psychotic disorders and then discharges them back to the family physician once they are stable. The innovative aspect of this program is that it also provides regular, planned return visits to the clinic while the patient is being followed by the family physician. If a crisis occurs between clinic visits, the patient and family physician have rapid access to the clinic team, who will reassume care and restabilize the patient. An important advantage of this model is that it can be adapted to any existing outpatient program.
Another simple, low-cost intervention was implemented in the UK. Two reports (Warner and others 2000; Essex and others 1990) describe the introduction of patient-held shared care records for patients with serious, chronic mental illness. The cards include details of current care, such as clinician names, diagnosis, current medications, brief clinical notes, and dates of follow-up visits. The cards are designed to increase continuity of care and ensure that all caregivers are aware of changes in the patients condition or treatment plan.
Collaborative care models have been designed specifically for pediatric (Subotsky and Brown 1990) and geriatric (Joseph and others 1995; Oxman 1996) populations, as well as for rural settings (Kaufmann 1993), but these appear to be rare.
Only a few articles describe programs developed specifically to deal with those having serious mental illness (SMI). In addition to the initiatives of Warners and others (2000) and Essex and others (1990) described above, these include an innovative multidisciplinary program in Britain (Wilkinson and others 1995) that, like the Meadows (1998) Australian program, was able to transfer stable SMI patients to the primary care setting, with the GP as the main care provider, based on a model of frequent systematic assessments. An interesting twist of this model is that it proved to be successful in a semirural setting.
In contrast, a US mental health service chose to reverse this trend and developed a medical clinic to serve chronically mentally ill patients whom they identified as having high medical comorbidity. This move to widen the responsibilities of psychiatrists to include the physical health of their patients is supported in a discussion paper by Shore (1996a) who advocates for psychiatrists providing primary care services to such populations.
Evaluation data are available for many of the programs described in this section. They can be found in the section Evaluation and Research in Shared Mental Health Care.
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