Establishing a collaborative service model for primary mental health care A collaborative project between general practitioners and mental health services, which links a consultation-liaison model with shared care, was piloted with success. This article provides a broad overview of the service model and the stages in its development. Graham N Meadows
MJA 1998; 168: 162-165 → Other articles have cited this article
Introduction -
History of the CLIPP service -
Activity of the service -
Benefits and costs -
Summary and prospects -
Acknowledgements -
References -
Authors' details
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| Introduction |
Improving collaboration between mental health services and general
practitioners in caring for people with serious mental illness is an
aim of Commonwealth Government policy.1,2 Recent documents
examining the psychiatry workforce have also recommended stronger
links between specialist and generalist services in this
area.3-5 Mental health care needs
may often be more appropriately met by general practitioners than by
long term specialist care. This will be true for many patients with
anxiety disorders and depression, but also for selected patients
with psychotic disorders. General practitioner involvement with
people with continuing mental illness may also provide an
opportunity to address unmet physical health needs,6 and may
ultimately have an impact on the high rates of physical morbidity and
mortality associated with major mental disorder.7
Various models of consultation-liaison links between psychiatric services and GPs have been described in reports from the United Kingdom.8-11 Although this area of activity in Britain was described as "the silent growth of a new service" in 1984,12 a more recent review noted that many such schemes had not proceeded beyond pilot phase. This review stressed the need for further evaluations, including cost-benefit evaluation, in response to this situation.13 In Australia, a pilot scheme in Newcastle, New South Wales, providing consultation-liaison attachments to GPs was initially reported positively,14 but a later viewpoint paper alluded to less encouraging aspects, and the project did not move beyond pilot phase.15 A recent survey of psychiatrists in South Australia suggests considerable enthusiasm for collaboration in consultation-liaison models,16 but revealed little actual activity in this area. The Consultation Liaison in Primary Care Psychiatry (CLIPP) service model developed in the Northwest Melbourne Area Mental Health Service promotes collaboration between GPs and public mental health services in managing psychiatric problems. CLIPP is now established, with recurrent funding from State public mental health services, and is being extended into another area mental health service. This article describes the CLIPP model and the activity involved in ensuring its continuation beyond the pilot phase. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
History of the CLIPP service | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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In 1993, Health and Community Services Victoria received Federal
Government National Mental Health Initiative funding expressly for
promoting shared care initiatives in mental health. Early in 1994,
staff of the Northwest Melbourne Area Mental Health Service and local
GPs (represented by the Division of General Practice) proposed a
pilot project, for which they were granted $97 000 over two years.
These funds supported a half-time psychiatric nurse case manager for
18 months and most of the cost of a half-time psychologist project
officer for two years. The area mental health service contributed
about four half-day sessions per week of psychiatrist time.
Consultation-liaison attachments, although they are well liked and help to improve GP confidence, have been criticised as doing little to enhance GPs' involvement with the care of the seriously mentally ill.15 Shared care arrangements for specific patients with serious mental disorder may result in GPs feeling that public mental health services are not helping them with the types of problems they see most frequently. We aimed to counter these problems by combining the two approaches. Consultation-liaison attachments were set up first. General practitioners were recruited by mail through the Division. Interested GPs were followed up with personal visits by project staff, then with fortnightly visits by a psychiatrist to each practice (similar to the British "liaison-attachment" model9). Details of the consultation-liaison attachment system are shown in Box 1. Three months after setting up these attachments, shared care was initiated by asking participating GPs to accept patients referred from the area mental health service. At this point, the number of psychiatrist consultation appointments for patients referred by GPs was generally reduced to two each session to allow time for discussion of the shared care patients referred from the area health service. Operation of the shared care system is described in Box 2. During 1995, consultation-liaison attachments were set up with seven group practices of between two and 12 GPs. By late 1995, all of these practices were accepting patients transferred from the area mental heath service. The CLIPP service was recognised by a National Mental Health Achievement Award in 1996, in the category of prevention and health promotion. The project was reported to Health and Community Services Victoria, with an account of the development, and a cost-benefit analysis supported by work carried out in the area mental health service.17 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Activity of the service | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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During its first two years, CLIPP provided care to over 220 patients
through the clinical consultation-liaison service, patients
having been referred by 31 of the 40 GPs from the seven participating
group practices. It has facilitated the transfer of over 90 clients
from the area mental health service into shared care with 28 GPs,
including GPs from each participating practice. Box 3 lists the
clinical diagnoses of the patients in these two groups.
The most common single impediment to the transfer of care to GPs -- affecting about 15 patients -- is drug costs. Some regimens are free to patients under area mental health service care, but prohibitively expensive (under the Pharmaceutical Benefits Scheme) for others. A change to a rebated alternative drug may sometimes remove this impediment, but is not always clinically appropriate. One partial solution would be for a GP to see patients every two to four weeks for clinical monitoring, while the psychiatrist sees them around six-monthly, prescribing through the area mental health service pharmacy. Among patients transferred to GPs, telephone follow-up by area mental health service staff has found that 90% report being satisfied with their management. One year after transfer to GP care, 60% felt their physical health care had improved with the increased GP input. In some 20% of cases, review of GP case notes showed that newly identified physical health problems had been treated. Two patients whose care was transferred to GPs died of natural causes. No other cases have so far been lost to follow-up. An unexpected referral route developed during the pilot phase of the service, with public community mental health services making one or two referrals a month to GPs working with CLIPP. This is appropriate for patients who present directly to these specialist services, but whose needs could be as well, or better, met in this augmented primary care model. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Benefits and costs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The pilot project was reported to Human Services Victoria in June
1996. While the clinical service had been running for little over a
year, and was hardly ready for summative evaluation, the following
benefits could be claimed on the basis of a combination of qualitative
and quantitative data.
The model:
A detailed cost-effectiveness report of the project is in press.18 Costing analyses included projecting estimates of the activity of the service forward up to two years, and examining the projected cost effectiveness that could be reasonably expected from the service over that time. A simplified version of this analysis can be rendered as follows. The total cost of the CLIPP service was compared with the cost of providing care through area mental health services for the 110 patients in CLIPP who would otherwise have been cared for in the area mental health service. This group comprised 90 patients transferred from the area mental health service to GPs, 10 patients seen in the consultation-liaison attachments who would otherwise have had their care transferred to the area mental health service, and 10 patients diverted from triage at the area mental health service to GPs. Two patterns of area mental health service care that would otherwise have been required for the patients transferred into shared care through CLIPP were identified. These were 1-25 community service contacts per year, and 25-50 such contacts per year. The median cost per case for area mental health service care was estimated to be $623 and $2261 per annum, respectively.17 The 110 patients transferred to the CLIPP service were estimated to have originated from these two groups in a ratio of 4:1 (88 patients at $623 and 22 patients at $2261 per annum). From these estimates, the annual costs of mental health service care for the 110 patients transferred to GPs within CLIPP is $104 566. By comparison, the total cost of the CLIPP program (including the cost of staff initally funded through the Commonwealth Government grant, and psychiatrists whose time was committed from area mental health service budgets) was estimated at within $1000 of this sum. Hence, the model can be argued to be cost neutral for the area mental health service, but with the advantages to patients described earlier. The evaluation report was positively received by Human Services Victoria. In late 1996, commitment was made to continue funding for the project through the Western Region of Human Services Victoria, and extended to developing another project along similar lines in a nearby area of metropolitan Melbourne. Further development of the service is now an active process of participation between Western Region as purchasers and the Western Health Care Network as providers, with the support of academic staff from the University of Melbourne. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Summary and prospects | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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It has been previously shown that GP consultation-liaison services
can be implemented in Australia.14 In the CLIPP model, the
strengths of the relationships established through
consultation-liaison links have been harnessed in support of
effective shared care. Combining these two activities means that a
cost-effectiveness case can be presented which is more convincing
than that for a consultation-liaison service alone. Experience of
this development suggests that, if such schemes are to continue, they
need to meet the needs and expectations of all stakeholders with
purchaser and provider roles -- GPs, patients, case managers,
psychiatrists, and mental health service managers.
Current plans for further development of the CLIPP model include use of computer-based reminder systems to support GPs in managing transferred patients, and providing periodic group education sessions for participating GPs. Over the next three years, CLIPP will provide the setting for a Commonwealth Department of Health and Family Services examination of process and outcome in shared care (General Practice Evaluation Program Grant 518). The new study uses a quasi-experimental design to compare processes and outcomes of care in the shared care setting with those in a community mental health service. Further systematic analysis of the consultation-liaison service is under way. This will include description of GP referral patterns, management suggestions from psychiatrists, determinants of outcomes, and a further cost-benefit analysis. I believe CLIPP to be a very useful model for improving collaboration between GPs and psychiatric services. It has allowed a diverse group of practitioners to work together in ways that transcend funding and organisational barriers in the interests of sensible arrangements for the delivery of health care. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Acknowledgements | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Human Services Victoria for funding through Western Metropolitan Region budgets, particularly Mr John Hedditch for support in expansion of the service. The Commonwealth Government for funding through Mental Health Initiative funding and General Practice Divisional resources; also, Dr Philip Hegerty of the Northwest Division, Dr Bob Long, and the many other GPs involved. The project team from the Northwest Area mental health services: Dr Lynette Joubert, Mr Guy Dobson, Dr Carol Harvey, Dr Rajeev Kumar, Dr Philip Price, and Dr Michael Wong. Western Health Care Network management staff, particularly Mr George Shaw, for support. Mr Paul Mcrone, health economist at the Institute of Psychiatry, London, for assistance with cost-benefit analyses. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| References |
Received 1 Sep, accepted 22 Dec, 1997 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Authors' details |
Department of Psychiatry, University of Melbourne, Royal Park
Hospital, Melbourne, VIC.
Graham N Meadows, MRCP(UK), FRANZCP, Senior Lecturer.
Reprints: Dr G N Meadows, Department of Psychiatry,
University of Melbourne, Royal Park Hospital, Private Bag 3, PO
Parkville, VIC 3052. ©MJA 1999 Other articles have cited this article:
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Graham N Meadows. Overcoming barriers to reintegration of patients with schizophrenia: developing a best-practice model for discharge from Med J Aust 2003; 178 (9 Suppl): S53-S56. [Schizophrenia]