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Letters to the Editor Using Financial Incentives to Promote Shared Mental Health Care Dear Editor: We agree with Dewa and others that lack of financial mechanisms to reimburse physicians is a major obstacle to promoting shared care between psychiatrists and family physicians (1). As they point out, without reimbursement for treatment coordination, communication often becomes poor between family physician and psychiatrist, with little information shared by the psychiatrist after an initial consultation report. Family physicians may be reluctant to provide follow-up psychiatric treatment unless they can easily access advice from a psychiatrist or other mental health professional. Consistent with mental health reform, our academic general hospital has in recent years become the major provider of emergency and acute psychiatric care for the region. With limited numbers of outpatient psychiatrists, our outpatient department (OPD) soon had difficulty providing access for patients who had been seen in the emergency room and discharged, but who required urgent follow-up. Our OPD also has traditionally accepted referrals from family physicians, many of whom reported difficulty securing consultation from community psychiatrists within 2 or 3 weeks for patients with urgent and severe psychiatric problems. The outpatient psychiatrists had previously provided all diagnostic assessments and almost all individual psychiatric follow-up, with psychiatric nurses or social workers providing medication injections, telephoning prescriptions, triaging referrals, leading psychotherapy groups, and following a few relatively stable patients with chronic psychiatric conditions, on a long-term basis. With lengthening waiting lists, we reorganized our OPD to focus on providing urgent psychiatric consultation and short-term treatment to the most patients. We gave priority to patients discharged from the emergency room or inpatient unit who required urgent follow-up. We asked our psychiatrists to work with psychiatric nurses or social workers to conjointly assess all referrals to our urgent consultation clinics. The initial psychiatric history is now taken by a nurse or social worker, according to a standard format, with a subsequent immediate but abbreviated interview with the psychiatrist. A key role for the psychiatric nurse or social worker is liaison with a family physician or arranging referral to a family physician if the patient is without one. A short, standardized, handwritten consultation note signed by both the nurse or social worker and the psychiatrist is immediately sent to the family physician. This note outlines a psychiatric diagnosis, mental status examination, and management plan. In most cases, the nurses and social workers are involved in individual short-term follow-up, with backup by the psychiatrist. They provide individual supportive psychotherapy, monitor the patient’s mental status and response to psychotropic medication if prescribed, and arrange appropriate referrals for ongoing care. We can now see most patients referred for urgent consultation within
days of referral, but they are only followed for a maximum of 6 to 8 weeks
by a nurse or social worker and psychiatrist. Communication with the family
physician is facilitated by follow-up telephone calls or letters from
the nurse or social worker, which lightens the load on the psychiatrist.
All psychiatrists are largely funded by fee-for-service and receive less
than 2% of their income from sessional fees. In their paper, Dewa and
others mention that some funding options for shared care may lead to family
physicians’ hiring the least expensive mental health clinicians,
who presumably have also the least amount of training (1). We believe
that if mental health professionals lack the training and credentials
of psychiatrists and clinical psychologists to diagnose and treat, they
will not have the necessary expertise to manage moderate or severe mental
illness in a shared care model. However, our urgent consultation service
operates on a multidisciplinary model wherein psychiatric nurses and social
workers assume a major role in the assessment and short-term treatment
of acute psychiatric illness, with psychiatrist involvement and backup.
In the absence of dedicated funding for shared care, we think this hospital-based
model has facilitated rapid access to psychiatric treatment and improved
communication with family physicians, while expanding the role and responsibilities
of our department’s psychiatric nurses and social workers. As Dewa
and others point out, however, funding by some mechanism is necessary
to involve community psychiatrists and other community-based mental health
professionals in shared care and to remunerate family physicians for taking
the time to communicate and coordinate care with hospital or community-based
mental health professionals (1). References 1. Dewa CS, Hoch JS, Goering P. Using financial incentives
to promote shared mental health care. Can J Psychiatry 2001;46;488–95.
J Robert Swenson, MD, FRCPC
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