Partners and Peers
Network, Winter 2006
For people in Ontario, the family physician will most likely be the medical professional who handles their mental health and addiction issues. Not a psychiatrist or an addiction counsellor, but their local general practitioner, who in the course of a day may have delivered a baby, diagnosed chicken pox, managed the complex treatment of an elderly patient with heart disease, counselled an adolescent patient about birth control, and treated everyday coughs, colds and sore throats.
The nature of primary care allows the physician to treat patients at all stages of life, creating the opportunity for continuous, trust-based relationships. This is the up-side. The down-side is that family doctors may feel a lack of expertise and comfort in addressing complex treatment areas, such as serious mental illness and addiction.
Family doctors in Ontario reflected their unease in a survey published in 2000 by the Ontario College of Family Physicians (OCFP). Sixty-five percent of family doctors reported that they felt it was “often to always difficult” to diagnose and treat patients with addiction issues, and 63 percent reported that it was “often to always difficult” to help patients with a severe mental illness such as schizophrenia (see table).
|In a recent survey, the Ontario College of Family Physicians asked their members, “How easy or difficult do you find it to treat each of the following mental health conditions?”|
|Often to Always Difficult|
|Drugs and Alcohol Addictions||65%|
|Obsessive Compulsive Disorder||19%|
|Bipolar Affective Disorder||50%|
|Post-Traumatic Stress Disorder||52%|
|Source: Ontario Mental Health CME Main Questionnaire, OCFP, 2000|
Considering that patients with severe mental illness and addiction issues will be treated initially in the primary care setting, and for some only by their family doctors, this could mean unnecessary and prolonged suffering due the physician’s challenge of diagnosing and treating these complicated conditions. And when psychosis occurs, the need is even more pressing: evidence shows that there is a critical window for early intervention, and if left untreated, psychosis can lead to neurological damage. The burden of early intervention lies most often with the family doctor, who may have had as little as four weeks of psychiatry training in two years of family residency.
The OCFP offers continuing education for family doctors, with basic courses in addiction and mental health, but until recently, it had not addressed the relatively new field of early intervention in psychosis or a critical addictions issue, withdrawal management. Lena Salach, director of research and professional development for the OCFP, says, “At the college we’re obviously very interested in education for family doctors. Early psychosis intervention and withdrawal management are two areas we have identified in the Collaborative Mental Health Care Network as needing education.”
In November 2003, for the first time in its educational programming, the OCFP turned to leading service organizations in the field to collaborate on new educational modules for its peer presenter program. The peer presenter program delivers Continuing Medical Education (CME) credits to physicians who attend educational sessions delivered by specially trained peers. Historically, the OCFP had only collaborated with other medical specialties to develop curriculum for these modules.
The two co-principals on the new project, called “Interdisciplinary Mental Health and Addiction Education Project for Primary Care Providers,” are Addictions Ontario (formerly Alcohol and Drug Recovery Association of Ontario) and the Canadian Mental Health Association, Ontario (CMHA). These two organizations, together with the OCFP, have taken on the task of developing and delivering a train-the-trainer module on two focused topics, “Early Intervention in Psychosis” and “Withdrawal Management.” The Canadian Society of Addiction Medicine and the Ontario Federation of Community Mental Health and Addiction Programs are on board as supporting partners.
Project manager Janis Cramp, from Addictions Ontario, reports that the new module will be rolled out at the OCFP’s February 2006 Collaborative Mental Health Care Network conference, where up to 20 physicians will be trained to deliver the new content to their peers. “An e-learning component will follow later in 2006,” says Cramp, “and will be geared to a wider spectrum of health care professionals, including physicians, community care access workers, front-line workers, nurse practitioners and social workers.”
Even before the training has been delivered, Cramp identifies two early successes. “First, the collaboration on this major project demonstrates that addictions groups and mental health groups can and do work together — we do work together! Secondly, the existence of a solid working relationship with OCFP is a significant marker.” Many people have shown enthusiasm and amazing commitment, says Cramp, including the members of two content development groups and the physicians who provided peer reviews for the course content.
The main focus of the content is building physicians’ capacity to understand and apply treatment protocols for both early psychosis and addiction withdrawal. Michael Dean, manager of addiction services at St. Joseph’s Hospital in Toronto and a member of the content development group, says that addiction treatment is challenging for physicians because they are used to responding to physical elements and test results in deciding on courses of treatment. “Addictions treatment is about talking, helping patients discover their strengths,” explains Dean. “Our program helps physicians do this in their offices. It bolsters their confidence to develop effective treatment plans for patients, rather than use a hit-and-miss approach.”
Both the early psychosis and withdrawal management programs use an interactive format, with videos of dramatized case studies giving participants realistic situations for discussion. For the early psychosis program, the videos also address the participation of family members in treatment and recovery — so common with early psychosis, which usually appears first in the teen years — to help health care providers understand how to manage this complex relationship.
A unique adjunct that grew out of the project was the collaboration between the OCFP and CMHA Cochrane-Timiskaming, a local branch serving the northern Ontario area of Timmins and vicinity. Jonathan Zinck, evaluation and service coordinator at CMHA Cochrane-Timiskaming, had been trying to address the problems of a severe physician shortage and lack of psychiatric services in the area through the development of a project called “Sharing and Caring.”
“Sharing and Caring has two components,” explains Zinck. “One involves bringing mental health perspectives into the physician’s office, right into primary care delivery, and the second involves bringing a nurse right into the CMHA office to bring primary health care into the mental health setting.”
“In the North, there is quite a shortage of both primary care physicians and mental health care, including psychiatry, in all of our districts. When I worked with the case management team at CMHA in Timmins, I found that we would be involved in shared care all the time. We would be the person trying to present the system to our client as seamless, so if someone had to go to a doctor’s appointment or up to emergency and a client was intimidated by this (which was often the case), we would accompany them or help them understand what to expect. The Sharing and Caring project formalizes this approach.”
In speaking with doctors, Zinck found that it’s not that family physicians don’t want to treat mental illness-related issues in their practices, it’s that they don’t feel they have enough tools to treat them effectively. Zinck continues, “For many people with their first experience of mental illness, they will go see their family physician. We wanted to enhance the capacity for family physicians to treat their patients effectively.”
Zinck was in the early stages of developing his own educational modules when he heard about the OCFP’s programs from Janis Cramp. Zinck says that the work of developing and accrediting courses is an arduous job, so to find high-quality, CME-accredited courses for family physicians ready-made was a perfect partnership. He and the OCFP have since collaborated on a multidisciplinary educational module that was rolled out this fall to family physicians in the North. The module was structured to include participation from not only a physician peer presenter, but also a nurse practitioner, a social worker and a consumer/survivor.
Participant satisfaction was high. “Very practical, take-home information. I learned more in a few hours than in weeks of residency,” said one physician participant. Zinck credits the quality of the course content and the peer presenter model, because the unique challenges facing a busy family physician are completely understood by the instructor. Salach says that colleague-to-colleague education is effective for physicians because it creates a more comfortable learning environment where they feel less inhibited than when they have a specialist instructor.
The other half of Sharing and Caring is also showing success. A mental health nurse has been a part of the CMHA Cochrane-Timiskaming team since September 2004, serving CMHA clients with medical care, education and health promotion. In the next five months, says Zinck, the program will evaluate the nurse’s impact on client health outcomes by tracking the number of emergency-room visits, conducting health-satisfaction surveys among CMHA clients, and holding focus groups of CMHA staff and clients.
As the common partner, the OCFP meets its own needs by adding a new educational module about early psychosis and withdrawal management to its successful peer presenter program. Through the Sharing and Caring project, the OCFP will be able to reach family doctors in an underserved area. Salach says that the collaboration with a local CMHA branch has been great because more than likely the college would not otherwise have been able to reach such an in-depth target. She adds, “We’ve been able to help because we already had the modules and facilitators available. Developing partnerships and linkages will hopefully eliminate reinvention of the wheel.”
Addictions Ontario, CMHA, and the OCFP all report that the partnerships have been highly successful, not just in the delivery of new training, but also in the creation of strong relationships that will undoubtedly lead to future collaboration and ultimately enrich the primary health care of Ontarians.
Donna Hardaker is a community mental health analyst for CMHA, Ontario.
The Ontario College of Family Physicians’ Collaborative Mental Health Care Network is a mentorship program that connects family physicians to psychiatrists, GP-psychotherapists, and social workers. This clinical component, combined with small-group case-based sessions and the annual CME conference, creates a strong backbone of education and support for family doctors registered in the program. The program currently has 44 mentors linked to over 370 family physicians. The network has received funding to 2009 from the Ministry of Health and Long-Term Care and is currently piloting a residency program that matches psychiatry and family medicine faculty with psychiatrist residents and family physician residents so that connections have already been made before the family physician even begins independent practice.
Evaluation after one year indicates success, with all of the family physician participants reporting increased knowledge and skills and greater confidence in their ability to care for patients with complex mental illnesses, especially among physicians who were rated as heavy users of the mentoring service. Those physicians were able to decrease their reliance on face-to-face contact with specialists and instead found support through the more cost-effective means of e-mail and telephone contact.
“The network is always looking to expand and meet people’s needs, with the goal of having all family physicians eventually able to participate in the program,” says Lena Salach, director of research and professional development for the OCFP. Family physicians or psychiatrists who are interested in joining the mentorship program should contact Salach at firstname.lastname@example.org.
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