Results
Referrals
In 2000, the counsellors received 3550 referrals, or 161 cases per full-time
equivalent counsellor yearly (Table 1). Of referrals, 13% were under age
18 years, while 8% were over age 65 years. The number of individuals referred
yearly for a mental health assessment by each family physician in the program
has increased from 5 (prior to the establishment of the program) to 58,
since the program’s inception. Of cases seen by the counsellor, 5% are
referred by the psychiatrist after an initial consultation. The most common
referral problems are depression, marital problems, anxiety, and family
problems.
Counsellor Activities
To maintain an accessible service, the emphasis is on short-term care.
Of the individual visits, 50% are seen just once, while the average number
of visits per referral is 5.7. The average duration of a visit is 48 minutes.
Counsellors will also provide longer-term care if needed; however, this
is kept to a minimum. As of January 2001, 10.9% of open cases had been
seen for more than 12 months, 2.4% for more than 24 months, and 1.6% for
more than 36 months.
A total of 62% of a counsellor’s time is spent in face-to-face clinical
contact, 5% in discussing or reviewing cases with physicians, 9% in charting,
and 6% in other patient-related activities. Similarly, counsellors spend
88% of clinical time in individual treatment, 10% in couple or family treatment,
and 1% in leading group sessions. The remaining time is spent in administrative
activities and education. Table 2 illustrates counsellor activities during
the year 2000.
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Table 1 Presenting problem for referrals to the program in 2000 (total
referrals = 3550)
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Primary Problem
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%
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Depression
Marital or separation
Anxiety
Family or parent–child problem
Bereavement
Other stressful events
Child behaviour problem
Psychotic symptoms
Suicidal attempt or ideation
Anger or temper control
Substance abuse
Work problems
Mood swings
Chronic pain
Sexual abuse (past)
Other
Total
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35
14
12
8
3
3
3
2
2
2
2
2
1
1
1
9
100
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Table 2 Counsellor activities in 2000 (total hours = 40 643)
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Activity
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% of time spent
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Individual treatment
Couple and family treatment
Group treatment
Case discussions (family physician)
Case discussion (psychiatrist)
Case discussion or referral other services
Other clinical or telephone
Charting
Education
Completing program evaluation materials
Other administration
Total
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55
5
2
3
2
2
4
9
3
3
12
100
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Outcomes
Clinical Outcomes
Evidence from the first 900 completed cases shows that individuals treated
in the program improve substantially. The average change in score was 17.6
for the CESD (29.8 at admission and 12.2 at discharge) and 5.7 for the
GHQ (7.4 at admission and 1.7 at discharge). At admission, 720 individuals
were defined as a case using the CESD (cut-off point of 21) and 765 using
the GHQ (cut-off point of 3). At discharge, the number of individuals exceeding
this threshold had been reduced by 73% (using the CESD) and 82% (using
the GHQ). All of these changes are statistically significant (P < 0.005).
Utilization of Mental Health Services
Since the program started, there has been a 65% reduction in referrals
to psychiatry outpatient services by participating family physicians. There
has also been a nonsignificant reduction of 10% in inpatient admissions
(patients from participating practices). Once admitted, these patients
have a length of stay that is about 8% shorter than that of patients from
family physicians who are not in the program.
Consumer Satisfaction
Using the CSQ, consumers had an overall satisfaction rating of 92%. On
the VSQ, counsellors met or exceeded the Association of America Group Health
benchmark criteria for all 9 items. The item consistently receiving the
highest scores was “being seen in your family physician’s office.”
Provider Satisfaction
Every 2 years, family physicians and counsellors complete a satisfaction
questionnaire that covers different aspects of counsellors’ roles and that
includes their fit with the practice. Family physicians have consistently
been highly satisfied with the program, with the way that counsellors are
integrated within their practices, and with the assistance that they provide.
Counsellors have also been satisfied with their work in primary care and
would strongly recommend this style of practice to their colleagues (20).
Discussion
The integration of counsellors in primary care practices appears to have
made mental health care more accessible, with good outcomes for individuals
using the service and a high level of satisfaction on the part of providers
and consumers.
Numerous factors have contributed to this success. From the outset, the
program has been a partnership. Family physicians have been actively involved
in all aspects of establishing, leading, and evaluating the program—which
ensured that the program remained relevant to their needs. Second, the
presence of a central coordinating team has provided ongoing support to
individual practices and counsellors, assisting in solving problems that
have arisen in individual practices and in reallocating resources when
needed. Next, supports built in for the counsellors are carefully screened
to ensure that they are able and willing to handle the demands of the job.
Counsellors participate in a preparatory workshop before starting, meet
as a group for ongoing support and mutual problem solving, and have access
to regular psychiatric consultation in the office and by telephone. Finally,
the program encourages personal contacts between counsellors and family
physicians.
Other Important Lessons Learned
First, the style of practice differs from traditional outpatient care.
The mental health counsellors work more in the manner of primary care providers
than do mental health outpatient clinicians. Like family physicians, counsellors
will see whoever is referred, irrespective of age or the nature of the
problem. This contrasts with outpatient psychiatric clinics, wherein services
are often subdivided according to the patient’s age, the nature of the
problem (for example, anxiety or depression), or the services to be offered
(that is, psychotherapy clinics and rehabilitation programs). These divisions
do not exist in primary care—which allows a better integration of treatment
modalities and a more holistic view of the individual.
Not unlike the family physician, a counsellor will see an individual during
an episode of illness or time of stress but may not need to see that person
again for months, or sometimes even years, until a problem recurs or a
new problem arises. Individuals who contact the counsellor again will be
seen without any formal intake or referral process. Although an episode
of care may be completed, the case always remains open.
The relationship and communication between referral source (the family
physician) and counsellor also differs from traditional outpatient clinics.
The daily contact eases the referral or the discussion of a case and enhances
continuity of care after treatment with the counsellor is completed.
The second lesson learned is that primary mental health care complements
but does not replace traditional outpatient clinics or programs. We should
view outpatient care and primary mental health care as part of a continuum.
While a broad range of problems can be managed successfully in primary
care, a counsellor may not have the skills or expertise to assess every
problem or to implement certain treatment approaches. These individuals
may still require the services of outpatient clinics or programs that offer
specialized assessment and treatment or rehabilitation programs. The presence
of counsellors in primary care also enables outpatient clinics to discharge
individuals back to the care of their family physician at an earlier stage
of an episode of care.
Third, this approach offers opportunities for increasing detection of mental
health problems and initiating treatment at an earlier stage of an episode.
Many individuals with mental health problems receive no mental health treatment
over the course of a year, but most will visit their family physician during
this period. Having ready access to mental health services (in-office counsellors)
appears to increase the likelihood that family physicians will identify
these problems and initiate treatment at an earlier stage.
Summary
The Hamilton Program has demonstrated the effectiveness of integrating
counsellors who are willing to see a broad range of problems in primary
care. This makes mental health care more accessible, improves the outcomes
of individuals with mental health problems—many of whom may not otherwise
receive mental health care—and increases the skills and comfort of primary
care providers in handling mental health problems. Counsellors enjoy this
style of practice, particularly because the presence of a central coordinating
team able to assist in resolving problems that arise in individual practices
and to provide additional supports enhances their work. This has created
a unique service, linking the primary and secondary sectors.
Funding and Support
The Hamilton Health Service Organizations (HSO) Mental Health and Nutrition
Program is funded by the Alternate Payments Branch of the Ontario Ministry
of Health and Long-Term Care.
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Authors
Manuscript received December 2001, revised, and accepted August 2002.
1. Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster
University, Hamilton, Ontario.
2. Clinical Lecturer, School of Nursing, McMaster University, Hamilton,
Ontario.
3. Clinical Lecturer, School of Nursing, McMaster University, Hamilton,
Ontario.
4. Hamilton Health Service Organizations Mental Health and Nutrition Program,
Hamilton, Ontario.
Address for correspondence: Dr N Kates, Hamilton HSO Mental Health and
Nutrition Program, 40 Forest Avenue, Hamilton, ON L8N 1X1
e-mail: nkates@mcmaster.ca
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