Info Centre Home | Contents | Search | eMJA Home
|
Info Centre Home | Contents | Search | eMJA Home |
|
2 Collaboration between general practice and community psychiatric
services for people with chronic mental illness
Nicholas A Keks, B Malcolm Altson, Tobie L Sacks, Harry H Hustig and Amgad Tanaghow |
| General practitioners are often the patient's preferred source of
psychiatric care; they can also play a role as coordinators of the care
team for patients with complex needs
Synopsis - The general practice context - The psychiatric service context - Needs of patients with chronic mental illness - Case management - Ways of collaboration - Essential aspects of collaboration - Difficulties in establishing shared care - Rural settings - Educational and service development needs - References - Authors' details - Box 1: Interventions available from many community psychiatric services - Box 2: Treating the whole problem - targets and interventions for patients with chronic psychiatric illness - Box 3: Patterns of collaboration between psychiatric service providers and general practitioners - Box 4: Components of coordinated care agreement - Case history 1: Improving care through collaboration - Case history 2: Return to the community - Short course - Contents list | ||
Synopsis | |||
| |||
The general practice context | |||
|
Case history 1:
|
General practitioners manage 75% to 90% of patients with mental
illness in the community.1 They provide 30% of services
to people with severe mental illness, particularly the
psychoses.2 The number of patients seen
with long-term mental illnesses varies considerably between
different general practices depending on the prevalence of chronic
illness in the area and the nature of the practice,1 but about 25% of
patients with chronic psychoses see only their general
practitioner.3
There are major advantages to conducting psychiatric care in general practice rather than a specialist or hospital setting. General practitioners are able to offer rapid and affordable access to comprehensive health care for patients and their families without the stigma that is often associated with attending specialist psychiatric services. Surveys indicate that patients prefer to attend general practitioners for psychiatric treatment.3 The consequent enhanced patient-doctor relationship fosters unparalleled continuity of care, compliance with medication and the opportunity for early intervention when the patient relapses into illness or when psychosocial crises occur.4 With the progress of deinstitutionalisation over the past three decades, the vast majority of people with chronic mental illness now live in the community. Most recently, many long-term residents of the "back wards" of mental hospitals have been successfully making the transition to 24-hour intensely supported community residences, staffed by professionals in similar numbers to those in the hospitals. However, these residents are now able to access the full range of community services, including those of general practitioners. The need for general practice psychiatry will continue to increase,1 and the challenge is to ensure that specialist psychiatric services work collaboratively with the patient's primary health care provider, the general practitioner. | ||
The psychiatric service context | |||
|
Box 1:
|
The move away from stand-alone psychiatric hospitals has caused many
psychiatric services to change orientation and focus on community
services in their local area, using local general hospitals for acute
psychiatric admissions.4 Community services have
developed substantially and in many areas offer assertive outreach
(the staff go to the patients), crisis and case management services,
with 24-hour availability.
Community psychiatric services are staffed by a range of disciplines, including nurses, psychologists, occupational therapists, social workers, medical officers (doctors with an interest in psychiatric medicine or trainee psychiatrists) and psychiatrists. These services can perform a variety of interventions that complement the work of general practitioners and private psychiatrists (Box 1). Many services offer crisis assessment and treatment on an outreach basis so that staff can quickly see the patient at home or in a general practice surgery. Such an assessment is often carried out to decide whether intensive management in the community is a viable alternative to hospitalisation. Some patients must be admitted, but early intervention through community outreach can give effective treatment and support in many circumstances that previously required hospitalisation,5,6 or facilitate early discharge for patients who are admitted to hospital. The most effective assistance for helping patients stay in the community comes from intensive case management services. Here patients, particularly those with chronic psychoses who have experienced frequent hospitalisations and lack social supports, are subject to various types of interventions, often on a daily basis. These interventions include assistance with medications, activities of daily living (e.g., household tasks, banking), problem-solving and access to other services (for recreation, social activity, rehabilitation or medical care). The aim is to enhance treatment compliance and psychosocial functioning. | ||
Needs of patients with chronic mental illness | |||
|
Box 2: Treating the whole problem - targets and interventions for patients with chronic psychiatric illness |
The treatment of patients with chronic psychiatric disorders has to
address not only symptoms, but the consequences of the illness in
various domains (Box 2). The way that symptoms affect function in
occupational and social domains will determine a large proportion of
the impact of the illness on the patient. Interventions may need to be
focused on aspects of functioning (such as obtaining accommodation,
finances, basic provisions). Similarly, comprehensive management
may need to address finances and housing to optimise the
outcome.7
The interventions needed to address these outcomes require a variety of professional health service providers, as well as input from non-health social services. Patients with chronic psychiatric disorders (particularly chronic psychoses) may require this comprehensive mix of services indefinitely.8 | ||
Case management | |||
|
Increasingly, psychiatric services are being organised along case
management (or care management) principles.6 Although there is no
consensus as to what constitutes case management, on an individual
patient level it means the coordination of care for patients who
require a number of services from different providers.9
Case managers coordinate access to the whole range of assessment and intervention services needed by the patient, with the aim of fostering independence and improved quality of life for the patient and carers. Case managers are also known as care managers or key workers. Case management tends to be most helpful for patients with multiple needs, and appointment of the manager is often undertaken in a multidisciplinary meeting where the worker with the most appropriate skills can be "matched" to the patient. For instance, if considerable social problems are apparent, a social worker may be the most appropriate case manager (but this is not essential as a case manager can access social work skills elsewhere). The case manager acts as a readily accessible contact point for the patient and carers, ensuring that needed assistance is obtained promptly and that there is continuity of care. The responsibilities and requisite skills of case managers will vary depending on the nature of the clinical problem and service context. General practitioners are well suited to be case managers for many patients with psychiatric problems. In some respects the issue of who is the case manager may be less relevant than clear understanding and agreement between different agents (e.g., a general practitioner, a community mental health service worker and a psychiatrist) and the patient and carer about who is responsible for what service and in what circumstances. | |||
Ways of collaboration | |||
|
Box 3:
|
There are few rigorous prospective trials of shared psychiatric
care, and much of the evaluation of innovative programs has been
qualitative. There are major challenges in setting up shared care,
and research is urgently needed to evaluate different models in
various contexts to ensure the most optimal outcomes.
In the United Kingdom (where there is virtually no private psychiatric sector) many psychiatrists have transferred their outpatient work to general practice surgeries. Psychiatrists provide assessment and treatment in the traditional specialist model, with the advantages of a location closer and more familiar to their patients. Other psychiatrists have established consultation-liaison relationships with general practitioners. Here psychiatrists provide secondary and tertiary consultation, including seeing patients together with general practitioners, discussing cases, clarifying difficulties and so on. An evaluation of such a model in an Australian setting found that it enhanced clinical care and offered opportunities for general practitioners to improve their psychiatric skills.10 Many other services have introduced similar strategies to achieve better communication and liaison with general practitioners. For many patients with chronic mental illness who require input from different professionals, it is necessary for the general practitioner to establish collaboration not just with a psychiatrist but with a whole multidisciplinary team.11 The approach has involved a variety of professionals holding clinics at general practice surgeries, and interacting with general practitioners in consultations or educational activities. A more innovative approach (occasionally referred to as the "attachment model") has involved actually setting up a multidisciplinary primary care psychiatry team within a general practice.12 In the United Kingdom, fund holding by general practitioners has enabled such development to occur. Surveys have shown that some general practices, particularly in inner city locations, see a large number of patients with chronic psychoses and would be appropriate locations for such primary care services.13 In all likelihood, the common pattern of collaboration between community psychiatric services and general practitioners will involve shared, or collaborative, care,14 in which both parties agree to collaborate on overall service provision. The relationship has some similarity to the traditional general practitioner-psychiatrist collaborative pattern, but differs significantly in that the general practitioner will most likely need to relate primarily to a non-medical case manager or multidisciplinary team. | ||
Essential aspects of collaboration | |||
|
Box 4:
|
First of all, the area psychiatric service and the local general
practitioners must establish communication. Education meetings
jointly sponsored by the service and the local Division of General
Practice are a useful opportunity for such networking. Contact is
especially important for those general practitioners whose
patients are being seen by the service, and for those with a special
psychiatric interest who would be able to take cases referred by the
psychiatric service. In our experience the best kind of
collaboration occurs when general practitioners and community
psychiatric service staff get to know about each other's roles and
stay in personal contact.
There are many ways of fostering communication and collaboration between general practitioners and area psychiatric services. Much depends on local factors and personalities. The Divisions of General Practice may constitute the best single organisational link through which collaboration with psychiatric services can be initiated. An example of collaboration is being trialled in Melbourne through an ongoing agreement between the Inner South East Melbourne Division of General Practice and the Department of Community Psychiatry at the Alfred Hospital. Strategies to facilitate a communication network, including an educational program and consultation meetings/case conferences, were endorsed by participants. Basic protocols for collaborative care were developed. General practitioners joined the psychiatric service in providing shared care for patients, most with chronic psychoses, over a period now exceeding two years. For a particular case it is essential that a joint management agreement is established.15 Ideally, this agreement should be based on a case conference. At such a meeting the patient's problems and needs can be considered within that individual's context and preferences, and matched with available treatments, professionals, services and resources. The agreement should be a written plan which specifies the personnel responsible (general practitioner, case manager, psychiatrist, etc.), the responsibilities of the various parties, the plan for handling crises, and date of review16 (Box 4). The patient's consent to the plan and to participation in the collaborative care relationship should be obtained by each of the service providers. Because of the complexities involved, it may be necessary for collaborative relationships to be supported by a coordinator. Mental health service staff are salaried, whereas most general practitioners depend on Medicare payments. It is necessary to compensate general practitioners for the time spent beyond face-to-face contact with the patient, such as case conferences, which are critical to good patient care (either through changes to the Medicare schedule or some other mechanism of State or Federal funding). The absence of appropriate payments to general practitioners will militate against the success of collaborative care.1 There are many possible patterns of service provision within shared care agreements. For many patients, it will be most appropriate for the general practitioner to coordinate consultations and services from other agencies. An agreed care plan may specify consultative reviews by a psychiatrist at an appropriate interval, a protocol for crises/emergencies and a list of other contributing services. The illness or disability characteristics of some patients may require that care coordination be provided by psychiatric service workers. It is entirely possible that changes in the patient's illness and circumstances alter the preferred mechanism for service delivery. The focus of care coordination and the services required may need to shift between the general practitioner and the community mental health service. After a period of intervention, the need for specialist input may diminish or disappear. Many patients with chronic mental illness prefer to receive all necessary treatment from their general practitioner.3 | ||
Difficulties in establishing shared care | |||
|
General practitioners vary in their psychiatric skills, abilities
and interests. Various aspects of psychiatry also hold different
challenges and some general practitioners are much more able to
intervene in acute mood disorders than to address the complex issues
posed by chronic psychiatric illness.
It is important that postgraduate education in general practice assists the practitioner to address the whole range of common psychiatric illness in various phases, and that the time-consuming interventions often needed in chronic psychiatric illness are appropriately funded. Doctors and allied health professionals are trained in disparate and at times conflicting models of care; this can create barriers and breakdowns in communication. For example, in contrast to the conventional medical model, many multidisciplinary mental health teams adopt a rehabilitation model that focuses on patient capabilities rather than deficiencies, and which operates on a very different time frame to the standard medical consultation. Strategies that facilitate communication and common understanding between general practitioners and staff in community psychiatric services are essential for collaborative care. | |||
Rural settings | |||
|
Special problems may affect the possibility of collaborative
arrangements in rural settings: distance, disadvantage of many
patients, lack of medical and psychiatric services. In contrast to
urban settings, it is usual for rural general practitioners to see all
the patients with serious mental illness in their area.
The case for developing multidisciplinary mental health teams through a general practice base is especially strong in rural settings. A successful program has been piloted in Victoria. The lack of services in rural settings for patients with drug/alcohol and personality problems is also a great concern and could be addressed by such developments. In isolated rural areas, access to specialist assistance by teleconferencing or videoconferencing may be a useful option. | |||
Educational and service development needs | |||
|
Many general practitioners identify a need to improve their
psychiatric skills.17 In the recent past, major
efforts have been made to improve skills, particularly in the
recognition and treatment of mood disorders. Continuing medical
education about treating psychoses in primary care remains a major
need.18 In many locations,
Divisions of General Practice and area psychiatric services have
combined to sponsor ongoing educational programs.14
Although the management of psychoses such as schizophrenia requires specialist consultation, much of the medical management is readily carried out in general practice. Innovative means of meeting general practitioner training needs have included attendance at clinic sessions, joint interviews and case discussions.14 Brief protocols for managing patients with chronic psychoses in general practice are much needed,3 as are area-specific service access guides.14 Mental health services, which have had their origins in totally self-contained institutions, also have to address the training needs of staff in order to improve their abilities to collaborate with general practitioners (especially communication skills).19 | |||
References | |||
| |||
Author's details | |||
|
www.mja.com.au
| Psychiatry Services, The Alfred and Monash University Department of
Psychological Medicine, Melbourne, VIC.
Nicholas A Keks, PhD, FRANZCP, Professor. Tobie L Sacks, PhD, FRANZCP, Director of Community Services. Medical Centre, 90 Binney Street, Euroa, VIC. B Malcolm Altson, FRACGP, General Practitioner. Glenside Hospital, Eastwood, SA. Harry H Hustig, FRANZCP, Director of Extended Care. Goulburn Valley Area Mental Health Service, Monash Street, Shepparton, VIC. Amgad Tanaghow, MRCPsych, Director of Psychiatry. Correspondence: Dr N A Keks, Department of Psychological Medicine, The Alfred Healthcare Group, Alfred Hospital, Prahran, VIC 3181.
| ||