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In Principle and in Practice

Network, Winter 2006

Everyone knew that collaboration was the key. Family doctors, dietitians, social workers, occupational therapists, nurses, pharmacists, psychologists, psychiatrists, consumers, families and caregivers — they all knew that collaboration was the key to improving mental health care in primary care. So they got together and did something about it.

They — or rather, colleges or associations that represent these professions — formed the Canadian Collaborative Mental Health Initiative (CCMHI), jumping at $3.8 million in funding from the federal government’s Primary Health Care Transition Fund, which the first ministers set up in 2000 to support new approaches to primary health care. Together, they are finalizing a two-year effort to set out some principles and practices for improving integration. In fact, visitors to their website enter it by clicking on the words “Collaboration is the key.”

The idea, says the initiative’s executive director, Scott Dudgeon, was to create a group that “would identify what the barriers were to collaborative mental health care, that would research what’s actually going on across the country and internationally, that would put in place some strategies, and that would create a charter to be signed off by all of the member associations so that this work on integration could take place continuously.”

The Canadian Mental Health Association has been involved from the start. Penny Marrett, the CEO of CMHA National, says, “We’re seen to be the organization that can bring the community voice to the table.”

There are 12 organizations at the table, to be precise, amongst them the family doctors and social workers and psychologists. As of mid-January 2006, ten of the member organizations, including CMHA, had signed off on the CCMHI charter, one of the initiative’s key deliverables. Dudgeon expects the rest to sign off before the initiative officially ends on March 31, 2006.

“The charter came out of a recognition that the funding was for two years,” Dudgeon says, “and that we weren’t going to solve all the problems in the space of two years but we were going to get some momentum going, and the charter was intended to be the vehicle by which that momentum could be continued beyond the life of the project.”

The charter presents principles of effective collaborative mental health care, such as the right of Canadians who need mental health services to be full partners in their own plan for recovery, as well as commitments from the member organizations such as providing leadership, eliminating stigma, respecting diversity and being consumer-driven.

Dudgeon invited federal Minister of Health Ujjal Dosanjh to sign the charter on behalf of the Canadian people at the annual conference on shared care in May 2006. But with an election in January, says Dudgeon, “I can appreciate that this invitation isn’t foremost in his mind at the moment.”

If the charter is the guide to collaboration, and a series of 12 research papers the initiative produced are the evidence base, then the other major outcome of the CCMHI — a series of toolkits for service providers, consumers and educators — may have the most practical influence on how collaboration occurs.

Dr. Marie-Anik Gagné, the CCMHI project manager, was involved in the development of all 12 toolkits, including the “implementation” toolkits for service providers. “They’re really for people who are on the ground and who want to either enhance their collaborative initiatives or create a new one,” says Gagné. Dudgeon says the general toolkit “deals with the generic questions [such as], ‘Having understood that collaboration will help me improve my practice, how do I go about planning this, who do I need to include in the planning, what are the potential partners I might have in this collaboration, how do we evaluate process, how do we document this,’ things of that sort. It’s not clinically oriented; it won’t tell you how to treat depression. But it will tell you what professionals you might want to work with and how you can get them to function as a team. So I regard that as the substrate, that’s the basis of it.”

To accompany the general implementation toolkit, the initiative developed eight “companion” toolkits about establishing collaborative initiatives to serve special populations, including rural and isolated populations, children and adolescents, seniors, ethnocultural populations, Aboriginal peoples, urban marginalized populations and individuals with substance use disorders or serious mental illness. The development of these toolkits was led by Dr. Martha Donnelly, who teaches psychiatry and family medicine at the University of British Columbia.

“If the general toolkit is ‘how to,’ the specialized toolkits are ‘what about,’” Donnelly says. If service providers want to focus on a population, or they want to ensure they didn’t leave a population out of their planning, then the toolkits provide information about how to work collaboratively to serve that special population. For example, the doctors, dietitians, social workers and psychiatrist who work at a clinic in the downtown core of a city may want to consult the toolkit on urban marginalized populations.

While the eight expert groups worked independently, Donnelly adds, some issues came up in almost every group: the need to work as a team, for example, and the need for more research.

Consumers, families and caregivers have their own toolkit, which features information on how to access services, what type of professionals can help them in their recovery, and information on self-care and the needs and contributions of caregivers. There’s also a toolkit for Aboriginal consumers, families and caregivers, which discusses how historical, social, political and economic conditions may affect the mental health of Aboriginal peoples.

Lastly, there’s a toolkit for educators that includes a sample lesson plan, case studies, and best practices in inter-professional education. In order to make change happen, Gagné says, “we need to make sure that the new professionals are trained to think in a collaborative fashion, and trained in an inter-professional way.” Gagné expects the toolkits to be published in February 2006.

Dudgeon chuckles when he’s asked if producing all these toolkits and the charter at the same time was a challenge. Since the project only had a two-year timeframe, he says, they had to do analytical work — research on best practices and barriers to collaborative care — and produce the toolkits and charter at the same time.

“It was a big challenge,” he says. “One of the things we did very early on was establish a framework that allows us to look at the features of effective collaborative mental health care, and that framework speaks of quadrants that would include patient centredness, structures of collaboration, richness of collaboration, and accessibility.… That was helpful, that was a reasonable way to offset the fact that we were doing all of these things concurrently.”

Marrett thinks contributing to the framework was one of CMHA’s biggest contributions to the initiative. Some of the principles of CMHA’sFramework for Support, a policy paper that calls for the full involvement of consumers and their families in recovering from mental illness, are now part of the initiative’s framework, particularly the focus on the consumer.

Donnelly says that the expert groups that developed the special population toolkits used the initiative’s framework as a guide. For example, since accessibility is one of the fundamentals of the framework, the seniors toolkit group she co-led looked at accessibility issues for seniors. Since seniors may have trouble getting to a doctor’s office, the toolkit suggests that service providers may need to go into seniors’ homes or into long-term care facilities to offer care.

And how do 12 groups collaborate when teaching others how to collaborate? Keeping that focus on the person who needs mental health care was a means of keeping things running smoothly, Marrett says.

“I think there are always challenges when 12 organizations sit down and start to figure out what exactly does all this mean and what are we going to do? How are we going to do it and how are we going to work together in order to be able to achieve what we want to achieve? The challenge has been for all of us to be able to put our biases aside about any and every health professional or community organization, to be able to achieve what we’re there for. We’re really there for the individual who needs the service.”

For more information about the Canadian Collaborative Mental Health Initiative, visit www.ccmhi.ca.

Jeff Kraemer is the e-content developer for CMHA Ontario.


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