Reducing emergency department visits and increasing access to primary care for racialized people with mental health issues

By Sheela Subramanian, Canadian Mental Health Association, Ontario, and CoI Lead; and Emily Wong

In brief

For individuals who are doubly marginalized as racialized individuals and individuals with mental health issues, increasing access to quality primary care plays a significant role in improving health outcomes and reducing visits to the emergency department.

The HF Connecting Health Nurse Practitioner – Led Clinic is a promising practice that aims to use a collaborative, holistic care model of service provision to increase access to primary health care for a range of marginalized communities, including newcomers and racialized populations.

This Promising Practice arose from the work of the Community of Interest for Racialized Populations and Mental Health and Addictions (COI). The COI supports knowledge exchange activities to improve provincial policy, planning and service delivery for racialized populations and mental health and addictions. Currently, work is focused on mental health related
emergency department (ED) use by racialized populations.

In September 2012, the COI conducted a sector scan and follow-up interviews to identify promising practices in this issue area. The HF Connecting Health Nurse Practitioner - Led Clinic was one of several promising practices identified through this process. Read it below or download the PDF.

Additional Promising Practices are available on the COI website. For more information, contact ssubramanian [at] ontario [dot] cmha [dot] ca (Sheela Subramanian) (Canadian Mental Health Association, Ontario).

The HF Connecting Health Nurse Practitioner-led Clinic

HF Connecting Health Nurse Practitioner Leads with Deb Matthews, Minister of Health and Long-Term Care, Deputy Premier

The HF Connecting Health Nurse Practitioner-led Clinic in Scarborough, Ontario, aims to increase access to holistic primary health care for a range of marginalized communities,
including newcomers and racialized populations.

Because the clinic was developed by the Hong Fook Mental Health Association, many of their patients also experience mental health issues.

For individuals who are doubly marginalized as racialized individuals and individuals with mental health issues, increasing access to quality primary care plays a significant role in improving health outcomes and reducing visits to the Emergency Department (ED).

The Clinic began seeing patients on July 29, 2013. The decision to open the clinic was informed by the experience of Hong Fook staff, who had noticed that many clients with mental
health issues had unmet physical health needs because they were unable to find a primary health care provider or their health needs were unmet (i.e. preventive health care and disease management. For that reason, the Clinic aims to use a collaborative, holistic care model of service provision).

The Approach: Integrating mental and physical health services

To decide on the clinic’s location, target population, and approach, an environmental scan was conducted and a great need for primary care among residents of Scarborough, many of whom are newcomers and/or racialized was revealed.

The clinic serves largely South and East Asian individuals of all ages who do not already have access to primary care. Most
clients are referred to the clinic by Hong Fook’s mental health - workers, collaborating physicians, and psychiatrists with unattached clients. As the clinic is located in a busy
shopping plaza at the major intersection of Midland and Finch Avenue E, they also get many walk-in visits.

To ensure clients receive the care and services they need, the clinic recruited staff who speak priority languages — Cantonese, Mandarin, and Tamil — and work with linguistic interpreters. And to expand the client base, an outreach plan is underway that includes health talks at clinics, community centres, and settlement agencies.

Not all of the clinic’s patients have mental health issues. Many clients have chronic diseases, including diabetes and heart disease. All services integrate a focus on both mental and
physical health.

As Poonam Sehgal, Lead nurse practitioner at the clinic, describes, “We are always screening for mental health issues, constantly asking questions to ensure that clients feel supported in that area. It’s a “vital sign” for us. I think everyone at some point will experience some degree of mental health challenges, and it’s important for us to highlight
that there shouldn’t be any stigma around talking about it.” 

How does the Clinic work?

The Clinic differs from other community-based health centres because it is led by nurse practitioners rather than doctors. Nurse practitioners are registered nurses with additional education that allows them to order and interpret diagnostic tests, communicate diagnoses, prescribe medications, and perform specific procedures. The clinic works with a consulting physician, who is available to provide guidance on diagnosis or treatment. There also are psychiatrists who work both within the Clinic and at the satellite location located downtown

Staff include:

  • Two full-time nurse practitioners, one who speaks Cantonese and Mandarin, and the other speaking Punjabi and English 
  • One full-time Cantonese- and Mandarin-speaking registered nurse
  • One part-time Tamil-speaking registered nurse
  • One Mandarin-speaking dietitian
  • One Cantonese- and Mandarin- speaking health promoter
  • One Mandarin and Cantonese-speaking social worker
  • Two administrative assistants that speak Mandarin, Cantonese and Vietnamese

Clinic staff address all types of physical and mental health concerns, including hypertension, cholesterol, diabetes, and a range of mental health issues such as anxiety, depression,
bipolar disorder, and schizophrenia. As people who have mental health issues are at greater risk of having physical health problems, a priority is placed on providing services such as proactive screening to rule out complications, such as diabetes or metabolic syndrome.

Why the clinic works

A number of factors contribute to the clinic’s early success. As Sehgal says, “Just being open and seeing clients in the community is important. Beyond that, our model of care is very wellreceived. It’s a one stop shop to see your primary care provider and then also your dietitian or social worker or both. All your health needs are taken care of in one location.”

The attitude of the clinic’s staff is also key. They are dedicated to improving access to health care, so they look for ways to be flexible to meet needs. Staff bring new ideas to the table,
undertake roles that may not be typical, and try out different ways of providing services. As a result, the clinic’s last round of patient satisfaction survey yielded very positive results: 

Sehgal describes the value of collaborative work.

“Everybody has a wealth of knowledge to bring to the table. We’re very collegial and collaborative. Because we get along so well, we are able to have a positive impact on our clients’ care, and the clients pick up on that.”

Clinic staff pay attention to the social determinants of health that impact on clients. Staff also respect and support clients’ interest in alternative and non-Western approaches to health, such as homeopathy. Many clients face income-related barriers and have no extended health insurance coverage, so the clinic develops relationships with pharmacies that are willing to offer discounted prices or alternative payment methods.

Reducing ED use

One of the clinic’s goals is to reduce the burden on local EDs by providing clients with alternative and ongoing support in the community. To do this, relationships are being developed with local hospital EDs to try to improve coordination and collaboration between the hospital and community.

For Sehgal, a major piece of the puzzle is communication. “Sometimes we wouldn’t know about a client’s ED visit until three weeks later, especially when mental health is involved. It’s
imperative that we know as soon as possible so that we can provide services to the client in hospital, or make follow-up calls after their hospital visit to ensure that they are continuing to be supported in the community. This kind of follow-up can help reduce a repeat ED visit.”

The clinic is also exploring another pilot project involving a communication protocol with a local hospital, where the clinic would receive summaries of the client’s hospital discharge plan. “It’s important that health care providers in the community receive these plans in time, to ensure that the plan is being followed and support continues in the community,” comments Sehgal.

To further promote hospital-community collaboration, Sehgal meets with hospital staff to encourage them to refer unattached clients to the Clinic for primary care. They are also exploring a pilot to provide their own clients with wallet-sized cards with the Clinic’s info to prompt clients and family members to notify the clinic if a hospital visit is made. Clinic staff conduct information sessions with hospitals to increase information about their services.

Looking to the future

As a nurse practitioner led-clinic, it faces some unique challenges. Some clients want to see a doctor and are unfamiliar with the role of the nurse practitioner. And some assume the clinic only sees clients with mental health issues.

There have also been instances where clinic staff face challenges related to stigma and discrimination that people with mental health issues may face when they seek services or supports. To address these issues, clinic staff provide clients with information related to mental health issues and on the role of nurse practitioners. 

As for the goal of increasing access to primary care for marginalized communities, Sehgal cautions, “That is a goal that will always need to be met. As the population grows and changes, the nature of that goal will also evolve, and so will our approach.”