Network, Fall 2005
Let’s say you’re a 19-year-old woman sitting in your family doctor’s office. You’ve been on medication for anxiety for a few years but lately your panic attacks have been much more frequent. You find your symptoms embarrassing, so you don’t want to talk about them with your friends or family. You’re not eating well, and you’re feeling pretty isolated.
Besides adjusting your meds, your doctor wants you to talk to a dietician. And she has another suggestion: talk to a mental health worker about trying some cognitive behavioural therapy, which can help reduce anxiety symptoms. The mental health worker should also have information about joining a peer support group in the area, where you can meet some people who are going through what you’re going through.
Now… let’s say the mental health agency and the dietician are just down the hall.
That’s the idea behind family health teams, a key part of the transformation agenda in Ontario. And CMHA, Windsor-Essex County Branch is one of the agencies putting that idea into practice in Leamington, a small community in Essex County near Windsor.
The CMHA branch and its partners — Leamington District Memorial Hospital, Hospice of Windsor and a community health centre named Teen Health Centre — had been talking about creating a “basket of services,” which would involve collocating services from each of the partners at one site. They had been considering whether to propose a community health centre to the Ministry of Health and Long-Term Care when it announced in late 2004 that it was no longer going to create community health centres and would instead focus on creating family health teams.
Family health teams aren’t a radical departure from other models of collaborative care, but they are a departure from how most family doctors in Ontario now work. The concept is simple enough: health professionals will work in a team environment, collaborating on patient care. Doctors, nurses, nurse practitioners, social workers, dieticians, therapists, and so on — all under the same roof. While every family health team will have a core medical staff of doctors, nurses and nurse practitioners, the specialties of other health professionals on staff will vary depending on community needs. The point is more effective and efficient care.
Let’s say you’re a mental health worker at a satellite office of a CMHA branch located in the office of a family health team. You’re in the office kitchen heating up your lunch when one of the doctors on staff, who’s waiting for the microwave, asks about your work. You mention the supportive housing program, the court diversion program that steers clients with mental illness away from the criminal justice system, and the cognitive behavioural therapy program. And you mention the anxiety disorder support group you facilitate.
That’s interesting, the doctor says. She didn’t know there was an anxiety disorder support group in town.
From a doctor’s point of view, referring patients to a community mental health agency that’s part of a family health team means “someone in the next office,” says Dr. Robert Page, the chief of medical staff at Leamington District Memorial Hospital. Working together closely and talking about one another’s capabilities in providing care is one of the advantages of the family health team model.
Dr. Nick Kates, a McMaster University professor of psychiatry and expert on collaborative care, says that the interdisciplinary approach is the heart of the family health team model. Delivering optimum care, he says, means “being able to work together, to share responsibilities, to support each other, to deliver treatments that are complementary…. All of that really demands collaboration.” Kates says family health teams are also focusing on helping patients manage chronic diseases and on promoting health.
When Kates and colleagues studied the effectiveness of collaborations between mental health care providers and health service organizations — which offer similar but somewhat less comprehensive care than family health teams — they found that the model “increases access to services, is highly rated by people using the service, and reduces a lot of the stigma. It’s much easier to be seen in a family physician’s office,” Kates says, “particularly when mental health services are less available in the community.”
Once the ministry called for proposals for family health teams, the four partners, including CMHA, Windsor-Essex County Branch, submitted a proposal for Leamington. Earlier this year, the ministry announced that the Leamington and Area Family Health Team will be one of the first in the province to open its doors. That should happen in 2006.
The partners have identified certain population groups that need specific attention. The Leamington area has significant numbers of migrant workers and Low German-speaking Mennonites, says Pam Hines, the executive director of CMHA, Windsor-Essex County Branch. In fact, the branch created a position just to work with the Low German-speaking population.
The third group that the family health team will focus on is people with mental illness. Not because there is a particularly high rate of mental illness in the area, but because people with mental illness suffer what Hines calls “adverse selection.”
“Any new doctors who are taking on clients avoid our client population” — people with serious mental illness — “because they’re more complicated,” Hines says.
Hines says Leamington is one of the most underserved communities in Canada. Page estimates that the area is short 20 to 30 family doctors, and has no practicing psychiatrist. One retired doctor moved to the area, Page says, and “just let it be known that he’d be willing to see the odd person to help out.” Soon he had a full practice.
In fact, it was the lack of primary care for people with mental illness in the community that prompted CMHA, Windsor-Essex County Branch to launch primary care initiatives of its own over four years ago. The branch now has a nurse practitioner delivering on-site primary care to clients.
Joining a family health team didn’t require a big shift in how the branch approaches client care. It already partners with Windsor Regional Hospital to offer a mental health program for older adults, and will soon host a satellite office of a community health centre at the branch’s main location in Windsor.
These collaborations help maintain the essential link between mental health care and primary care. Hines says it’s difficult to support clients’ mental health needs when their basic medical needs are neglected. What appear to be flare-ups of mental health problems are often related to physical ailments, she notes. A kidney infection, for example, could make a client’s psychiatric medication less effective. What seems to a mental health worker to be voice hearing, says Hines, may be a very bad ear infection.
Still, it’s not yet clear exactly how the CMHA branch’s day-to-day involvement in the Leamington family health team will take shape. The partners are working on a business plan, and have proposed hiring a social worker, a cognitive behavioural therapist and an addictions therapist. The CMHA branch will have a satellite office on the family health team’s premises, and will focus on clients with serious mental illness, linking newly diagnosed or undiagnosed clients to early intervention services.
Some people have expressed concern, says Hines, that primary care settings that directly provide mental health services will act as “competition” with mental health agencies. But from her point of view, most mental health agencies focus on clients with serious mental illness, while people with more moderate mental illness have few options outside their family doctor’s office. Also, she thinks primary care is an ideal setting for identifying early psychosis.
“I think every community should have one primary care setting that specializes in mental health,” Hines adds. The doctors wouldn’t work exclusively in mental health care, she suggests, but could lend their knowledge to other primary care providers and help patients find their way to mental health agencies in the community.
She also suggests more support for doctors who are caring for people with a serious mental illness. And she wants the health system to deal with the whole person, “not silos of physical and mental health.”
There’s been progress lately on collaborative health care, she says, but “more work needs to be done.”
Let’s say you’re a health professional working in a private practice. Why change the way you work?
Collaboration, in Page’s view, is more than most doctors can manage, given their workloads. “I actually think physicians are running so hard and so fast in most cases to try and manage the workload that they have, in our area anyhow, [that] they don’t have time to think about what they’re doing.”
While there may be ways to make more money as a doctor than working in a family health team, Page says there are other reasons doctors would want to join a collaborative practice. One of the main attractions for doctors is getting off what Page calls the “treadmill.”
“If it takes you half an hour to see a particular individual and work through their problem, then that’s fine. You’re not worrying about the fact that you’re only being paid so much to see this patient and in order to generate an income and pay all your expenses you’ve got to keep on that treadmill.”
Kates has seen many collaborations between mental health care providers and family doctors. The key, he says, is to plan collaboratively and work as partners. The partners must be willing to learn from one another, to understand each other’s limitations, and develop shared and realistic goals based on local needs and resources.
“It’s not a question of saying, ‘Let’s take a program that was developed in Hamilton or Ottawa or Toronto and try that in our community.’ It’s a question of saying, ‘What do we want to achieve? What are the principles that we want to make sure we follow in developing this program? And how then can we put it in place?’”
Page has observed that younger doctors feel more comfortable working in a collaborative environment, but Kates thinks age is not a factor. The actual experience of working in a new way, he says, makes the difference.
“My experience has been that when you talk to physicians of any age who have been involved in collaborative partnerships that work, they’ll say, ‘I can’t understand how I functioned before this was set up.’ And some of these collaborations involve a big shift — sharing office space or having other people working in the office. But if there is a willingness to make that kind of leap, I think almost everybody who’s gone into that kind of relationship has found not only does it improve patient outcomes but it makes practicing that much more enjoyable and supportive.”
Jeff Kraemer is the e-content developer for CMHA, Ontario.
For More Information
Family Health Teams
CMHA, Windsor-Essex County Branch
Ontario Centre for Collaborative Primary Health Care
Canadian Collaborative Mental Health Initiative
Shared Mental Health Care in Canada
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