The Gold Standard: Placing Consumers at the Centre
Network, Winter 2006
This issue of Network focuses on the benefits of collaborative care for persons with mental health problems or mental illness. Much of the impetus behind collaborative care arises from the fact that the majority of persons with mental health problems first discuss their concerns with their family doctor. Patients with mental health problems account for a significant portion of family doctors’ time, and family doctors are often uncomfortable or unsure how to manage the mental health concerns that patients bring to them. As a result, collaborative care strategies have been developed that emphasize improving communication between family doctors and psychiatrists, and developing new models of sharing care and information to support family doctors in their practice.
Situating other health professionals in family doctors’ offices is a well-recognized approach that expands the vision from family medicine to “primary health care.” As early as 1978, the World Health Organization convened an international conference on primary health care, culminating in the landmark Alma-Ata Declaration, which identified a vision for primary health care emphasizing health professionals working in teams to promote well-being as well as treat the physical, mental and social needs in a community. The benefit of multidisciplinary health providers working in collaboration was further endorsed in Ontario’s “PCCCAR” report, presented to the Minister of Health in 1996.1 These are two of the early direction-setting documents generating momentum for change in primary health care, although the Ministry of Health began funding multidisciplinary health care providers to work in teams in some Ontario communities through “alternate funding” beginning in the late 1980s, with the development of Health Service Organizations (HSOs) and through Community Health Centres (CHCs). We are now seeing the Ministry of Health and Long-Term Care fund family health teams across Ontario. I suggest we think of this as continuing progress towards collaborative care.
But what of individuals with serious mental illness? Oftentimes, persons with serious mental illness have no access to primary care, despite the fact that many suffer from serious physical health-related problems and chronic conditions. One solution is to embed primary health care in mental health programs. In one review, providers expressed satisfaction with this type of collaborative care model, identifying increased identification and treatment of physical health needs for persons with serious mental illness. As a result, individuals in embedded programs were less likely to use emergency rooms. Consumers expressed comfort receiving primary health care services in their usual program setting.2 This is the thinking behind the primary care services provided at the Windsor-Essex County Branch of the Canadian Mental Health Association. In 2004, two full-time nurse practitioners and two part-time physicians provided primary health care to 1,280 clients with serious mental illness at this CMHA branch. The hospitalization of these clients was substantially reduced.
Many mental health consumers have complex, long-term needs that require services from a broad array of health care providers as well as community-based services. This includes specialized community mental health services, vocational support, housing, and social/recreational programs. Additional strategies need to be designed for the health system to effectively link primary health care services, wherever they may be located, with community-based services.
One of the most promising approaches is the Chronic Care Model, which identifies six strategies to improve outcomes for persons with chronic conditions, such as serious mental illness.3 The model emphasizes that consumers need to be “informed and activated” in their relationship with health care providers. This can include self-care and/or participating in one’s own care as a collaborating “partner.” The chronic care model extends the vision beyond shared care models that merely prescribe what the health care provider should do for the patient. The government of British Columbia has adopted a version of the Chronic Care Model to guide its approach to managing depression. I would urge primary health care policy-makers to next give their attention to incorporating chronic care approaches into primary health care reform to initiate true collaborative care.
The Canadian Collaborative Mental Health Initiative (CCMHI) also places the consumer at the centre of its collaborative care framework and uses the language of partnerships, roles and responsibilities to reflect the collaboration envisioned between health care providers and mental health consumers. CCMHI promises to provide consumers and families with tools in 2006 to describe what consumers can do to assist themselves to take an active role in their own care. Readers should watch the CCMHI website (www.ccmhi.ca) and take advantage of these new materials as they become available online.
Michelle Gold, MSW, MSc, is senior director of policy and programs at CMHA Ontario.
1. Provincial Coordinating Committee on Community and Academic Health Science Centres Relations (PCCCAR), Subcommittee on Primary Health Care. New Directions in Primary Health Care. Toronto: Ontario Ministry of Health, 1996.
2. Bazelon Center for Mental Health Law. Get It Together: How to Integrate Physical and Mental Health Care for People with Serious Mental Disorders. Washington, D.C., 2005. www.bazelon.org.
3. MacColl Institute for Healthcare Innovation. Overview of the Chronic Care Model. www.improvingchroniccare.org.
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