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Barriers to Physical Care

Network, Winter 2006

Access to mental health care through general practitioners and other primary health care providers is becoming more and more of a reality. But what about access to physical care for people who are already in treatment and recovery from serious mental illnesses? Is there a role for collaborative care to make a difference in people’s physical health as well?

Being able to access physical health care is as pressing an issue for people with significant mental health problems as it is for all Canadians. Perhaps even more so. People with serious mental illness have higher rates of a variety of significant physical health problems such as heart disease and diabetes. They also have high rates of cigarette smoking and obesity, both of which significantly contribute to ill health.

According to the Canadian Collaborative Mental Health Initiative (CCMHI), people with serious mental illness have a mortality rate that is four times higher than the general public. CCMHI is a national project whose goal is to inspire collaboration among providers to increase access to mental health care in primary care settings. Recognizing that a wide variety of people are affected by mental health problems, the initiative has developed a series of toolkits about establishing collaborative initiatives to serve specific populations, including children and adolescents, seniors, Aboriginal and ethnocultural groups, people with serious mental illnesses, and the “urban marginalized,” among others.

Pat Larson, a nurse practitioner at the Sherbourne Health Centre in downtown Toronto, has experience working with people who fit the initiative’s definition of the urban marginalized — people with mental illness and mental health problems, but also, more broadly, people who experience homelessness or unstable housing, people who have substance abuse problems, street youth, individuals with disabilities, and others who share lives of social exclusion and poverty.

Without the proper supports, the lives of some people with serious mental health issues can become chaotic, and this often leads to a multitude of problems. “When people’s lives are in chaos, that chaos can lead to other things — homelessness, being in and out of shelters, in and out of rooming houses or other substandard housing,” observes Larson. “That, in turn, leads to further chaos and lack of stability, which has an impact not only on mental health but also physical health” — problems related to exposure from living outside, and injuries from substance use and experiencing violence.

Not all people with mental illness end up homeless, of course. In fact, despite some common assumptions, only 20 to 40 percent of people who are homeless have a mental illness. But navigating through the mental and physical health care systems can be particularly difficult for many people because of the cyclical nature of their mental health problems, where periods of recovery are interrupted by periods of ill health.

“We have a physical health system and a mental health system, and we really haven’t figured out how to mesh these two particularly well,” says Larson. As a result of this divide between mental and physical health, people confront “lots and lots of issues when accessing physical health care, some of which are more concrete, some more esoteric.”

Sadly enough, physical health problems can be related to the treatment of mental health problems. “We do know,” Larson says, “that long-term use of certain antipsychotic agents seems to be associated with increased risk of diabetes, significant weight gain, and possibly with risks to the liver and kidneys, depending on the medication.”

“And then, of course, there’s the regular sort of health conditions like high blood pressure,” and for women, preventative measures “like mammograms, pelvic and breast exams” that easily get overlooked when people are struggling to achieve basic needs like having a place to live.

Larson works with people who have extensive involvement with the psychiatric system, who may be homeless, and who have become marginalized in our communities. “They’re at more risk for being ‘rolled,’” she says. “They’re subject to violence, to having things lost, or when their lives get more chaotic, just not knowing — things go missing, people end up in very chaotic situations.”

Some people face concrete challenges getting health care, involving the things that most of us take for granted — having an OHIP card, or making an appointment to see a nurse or doctor. Larson says that the government of Ontario “made a choice” back in the mid-1990s to make applying for a health card more restrictive, requiring more paperwork and supplementary identification. Having no ID and no health card is definitely a barrier to health care. “Even having an appointment-based system” is a barrier, observes Larson. “Having to serve very regulated systems [is a problem] when people’s lives are at a point when they’re not as regulated.”

The way health care is funded can also be a problem. “If you’re an OHIP-billing person, you may want to get people out of your office in 7.5 minutes,” Larson explains. But this type of funding “doesn’t reflect the time intensity that it takes to work with people whose lives are more chaotic — where the person doesn’t have an OHIP card, or other ID, where their housing is in jeopardy, they’ve been using different substances, they’ve got bed bugs, they’ve got scabies, they haven’t been on their medications for weeks, it can just go on and on. This isn’t a 7.5-minute visit.”

Beyond the concrete challenges, there are subtle barriers. The people Larson works with “will often have experienced trauma and significant abuse, deprivation or neglect in their lives.” Building trust with people is key. She finds that nurses, among other health care providers, often have the skills to “just live with people where they are, not preaching” at people to change.

“The attitudes of health care providers make a very big difference in the lives of people who may be very mistrustful, or who have had extremely difficult experiences with the health care system. It takes a long time to build trust with people. It takes a long time to sustain that trust,” says Larson.

Services need to accommodate the lives of people with serious mental illness who face multiple barriers. This could involve a range of activities, beginning with education for health care providers. “It takes a lot of skill to build and sustain people’s trust, but we really haven’t built a lot of that into our educational programs, as health care providers.”

And it takes collaboration among health care providers. “This is a group [of clients] where teamwork may be the way to go” in order to overcome the division between physical and mental health care. “I think some of the most promising work that is being done is bringing the two pieces back together.”

Larson believes that she and other nurse practitioners have an important role to play in collaborative care. There are nurse practitioners connected with some community mental health agencies, including a few CMHA branches in Ontario, and with psychiatric hospitals. “We have a bridging role. Others can do it too, but what’s unique is that we can actually do both mental and physical health care.”

Larson also feels that health care providers need training, and need to make the effort, to bridge both systems and to understand the roles played by different providers within those systems. To do her job effectively, says Larson, “I need to know how mental health care is organized and how physical health care is organized. I also need to know who my colleagues are — social workers, case managers, harm reduction workers, outreach workers — and how they fit together.”

Psychiatrists who are willing to work in collaboration with health care providers beyond general practitioners are also needed to effectively serve this group of people with serious mental illness. “There are some psychiatrists who are willing to work with outreach workers, with family workers, nurses, and social workers in order to provide really good mental health consultation. There are some very good possibilities happening in the system, just not as many as we actually need.”

Heather McKee is a community mental health analyst for CMHA, Ontario.


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