Success comes to Ontario's
FP/psychiatrist teams

Now almost three-years-old, the mentoring program is
showing results. More phone calls, less face time

By Marvin Ross

An innovative collaboration between Ontario family doctors and psychiatrists is proving to be so successful that the model is being extended beyond mental illness into other therapeutic areas. The Collaborative Mental Health Care Network was launched in 2001 by the Ontario College of Family Physicians (OCFP), with funding from the Ontario Ministry of Health, as the result of a 1999 needs assessment that outlined numerous problems in care.

The OCFP found that family doctors struggled with a number of aspects of psychiatric clinical care - schizophrenia and addictions, to name two. Just as serious, they had difficulty either making referrals or gaining consults with psychiatrists. Over 80% of mental health services are provided by family doctors rather than psychiatrists and they felt that they could effectively manage fully 90% of the mental health problems in the community. The FPs reported that 50% of visits to them are for mental health problems.

The family doctors indicated that what they needed to improve their services was a mentoring program with psychiatrists that included telephone, face-to-face and email advice along with a mentor-delivered CME program.

The practice that existed before the new program was implemented was called the split-care model. Under it, family doctors spent a great deal of their time trying to find a psychiatrist who would take their patient on. Once a patient was referred, treatment took place between the psychiatrist and the patient with the family doctor locked out. This effectively eliminated the likelihood that the patient would receive coordinated care.

The new shared-care model allows the FP and the psychiatrist to collaborate with the patient and his or her family to develop a treatment plan and define the appropriate role for each of the providers. In the case of seriously compromised patients, the psychiatrist assumes the lead role and the family doctor's involvement ensures that continuity of care is maintained. Family doctors have primary responsibility for stable patients with the psychiatrist providing backup when and if needed.

With this model, the skills of the psychiatrist are more effectively used while backup is provided to the family doctor so that he/she can provide more mental health service. Dr Pat Rockman, a Toronto GP/psychotherapist, former mentee and now chair of the program says, "the model decreases the burden on the doctors and improves care for the patient."

SELECT GROUPS
Launched at the start of fiscal 2001, the program is based on groups of 20 family doctors (mentees) who work with one psychiatrist mentor. The groups are mainly based on geography and there are currently 20 of them with 275 family doctors and 30 mentors. The doctors have access to their mentor either by phone, fax or email. But, according to Lesa Salach, the OCFP director of research and professional development, the program began to evolve beyond that.

She says that some people felt that direct contact between the family doctors and their mentors would be even more helpful, particularly to foster group cohesion. Some of the groups, therefore, began to meet face-to-face twice a year while others met via teleconference and others did so by webcam. Groups either discussed specific topics or simply reviewed cases. Once a year all groups get together for a two-day CME session.

An evaluation completed after the second year of operation found that the program is very successful, if not perfect. Before the program began 58% of the FPs reported difficulty getting telephone advice; the figure has since dropped to 13%. Only 14% of doctors were satisfied with the results of their psychiatric consultations before the program; it's now up to 51%. Telephone consults increased from 27% to 41% while person-to-person consults dropped from 24% to 3%.

Even better, 88% of the family doctors reported that their ability to provide quality mental health care had improved, 75% reported their knowledge-base had improved significantly, 75% reported higher job satisfaction, 68% reported time to optimal treatment had decreased, and 64% reported that the amelioration of their patients' symptoms had increased.

Ms Salach said that an additional evaluation will be done at the end of year three, which is coming up. The college is still looking to the Ministry of Health for funding and is opening up the program and actively recruiting more doctors. There are big plans for the future - the program is expanding into the treatment of Alzheimer's disease and hysterectomies. There's even a new one for family practitioners to mentor nurse practitioners.