Shared Care: Providing care for mental health and addiction in the community

By Rossana Coriandoli

In brief

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. Shared care was identified as a possibility; this was one of several promising practices identified through this process. The COI identified instances where shared care was either being used or in the process of being implemented, and contacted key informants to obtain more information.

Additional promising practices are available on the COI website. For more information, please contact zismail [at] ontario [dot] cmha [dot] ca (Zahra Ismail) (Canadian Mental Health Association, Ontario).

Background

The Four Villages Community Health Centre (CHC) offers primary care services and programs that include treatment, disease prevention, health promotion, and capacity building in the west end of Toronto. It also provides psychiatric consultations as part of its shared care initiative with St. Joseph's Health Centre and the Centre for Addiction and Mental Health (CAMH). 

As part of this initiative, staff psychiatrists from these two hospitals are at the Four Villages CHC for two to three three-hour sessions each month to provide consultations with clients. They also offer capacity-building opportunities for the centre’s team of professionals, including general practitioners (GPs), nurses, social workers, and occupational therapists.

This collaboration was spearheaded in 2009 by the then-new Chief of Psychiatry at St. Joseph’s, Dr. Jose Silveira. He had previously worked with the Toronto Urban Health Alliance, a collaborative that provides psychiatric consultations to CHCs in Toronto’s east with funding from the Ontario Ministry of Health. When he moved to St. Joseph’s, Dr. Silveira realized there were no shared care initiatives in the west end. So he approached Kasia Filaber, Director of Clinical Services at The Four Villages CHC, and suggested starting a similar initiative.

As a result, Dr. Silveira developed a pilot program, the West End Shared Care pilot, with three west end CHCs – Four Villages, Stonegate Community Health Centre, and Lakeshore Area Multi-Service Project.

Before the initiative was started, “we were finding that providers had difficulty dealing with patients who had mental illness without the support of a psychiatrist,” Kasia explained. It’s difficult for clients who have mental health or addiction needs, she said, because of the long wait times to see a psychiatrist and the stigma that people often feel about seeking mental health care.

To pay for Dr. Silveira’s time, participating CHCs needed funding for sessional fees from the Ministry of Health. But their funding request was denied. So Dr. Silveira – “a very visionary leader,” according to Kasia – decided he would provide psychiatric consultations and charge OHIP to cover the sessions with clients. After about a year, the partnership received the funding it needed to have two psychiatric consultants, and Dr. Silveira was able to step back.

How does the approach work?

As part of the shared care initiative, two psychiatrists have a schedule of sessionals – blocks of three hours – that they offer to Four Villages or the other two CHCs, two to three times each month, for consultations with any clients who have a referral for a mental health assessment. 

A referral is made, for example, when a GP thinks a client may have a mental illness but is not sure about the diagnosis, or if circumstances in a client’s life have changed and the current psychiatric medications are no longer as effective. In such cases, the psychiatrist meets with the client, makes an assessment, and provides the GP with a treatment recommendation.

During each of these sessionals, a psychiatrist sees about two to three clients. Once the primary care provider has the treatment recommendation, they can either implement them or go back to the psychiatrist with clarifying questions.

In some cases, a psychiatrist will consult with a service provider – such as a social worker, nurse, or physiotherapist – who is having a difficult time serving a client with a mental health issue. In these cases, the psychiatrist will offer suggestions on effective approaches rather than see the client in person. Physicians can also consult the psychiatrist about their patients.

Psychiatrists also provide educational sessions for the CHC team on topics related to mental health and addictions, to help them better serve their clients.

Why does shared care works?

Several factors make the West Toronto Shared Care program a success. The first is that clients can have psychiatric assessments in a familiar environment and receive treatment from their regular primary care providers, Kasia explained. 

“Patients already have an established relationship with the provider here, they know the space, they come here often,” Kasia explained. “So coming here to see a psychiatrist is not a big deal. It’s just another visit that they’re coming for. So they’re much more likely to actually have the consult, because it’s in a familiar environment. That definitely facilitates access to the psychiatrist and greater acceptance, because there’s still a lot of stigma around seeing a psychiatrist.” 

Another factor in the success of the initiative is that patients have shorter wait times to see a psychiatrist. “Our patients love it,” she added. “They don’t have to wait. They may need to wait a couple of weeks for the next available sessional, but they don’t have to wait months.”

Also, the psychiatrists benefit from being out in the community, she said. “It is helpful for the psychiatrist to actually be out in the community, and be more familiar with how primary care operates, and what the challenges are in the community,” Kasia explained. “When they practice out of their private clinic or a hospital, they really don’t get to interact with primary care providers. They may write a consult letter, but that’s it. Here, they actually get to meet them in person, so there’s more of that support and exchange of information, and understanding of what the care looks like, what the challenges are for a primary care provider. So it’s not just one way -- it’s a two-way relationship.”

Another important element of the model is the funding that the LHIN provides for shared care to be implemented at the CHC. “Certainly, the fact that we have the funding helps. And that’s very important.”

“In the beginning, we only had Dr. Silvera [who consulted at the CHC]. Then, when we got the funding, Dr. Silvera was able to step away and other psychiatrists came in. So rather than one, we have two psychiatrists,” Kasia explained. “Otherwise, there wouldn’t be any psychiatrists interested, really. So funding is really important to support the psychiatrists who are interested and willing to work in the community.”

Challenges and limitations

One of the challenges associated with the initiative is that under the shared care model, psychiatrists are not paid the same for their consultation time as they are when they see clients in their own office or hospital and bill OHIP, Kasia explained.

Another limitation is that psychiatrists (as are all the other specialists) are paid less when they bill for a consultation if the referring provider is a nurse practitioner, and they can’t bill at all when the referring provider is an allied professional. So any nurse practitioner who feels their patient needs a psychiatric consultation has to get a general practitioner to co-sign the referral. And allied providers can’t refer at all. And within this shared care program they can only consult the psychiatrist about their client, she said.

“The challenges are not really related to the shared care model but to how the health care system funds specialist care. With appropriate funding, this model could be working even better,” Kasia noted.

What’s in store?

“I think that the main success is that this resource is well used, providers are really making good use of it,” Kasia said. 

“And I think that we’re also diagnosing more mental health problems than we used to in the past, because there’s greater knowledge and sensitivity to the issues and greater willingness [among primary care providers] to explore that and send people for assessment.”

“I think that specialists are becoming more aware that they can actually work in the community – they don’t have to be in the private office or in the hospital – that it’s a good connection to have in the community,” she noted. “So I think we’ll actually be expanding to, potentially, also have a geriatric psychiatrist available. We’re going to be testing it out.”

For more information about the Shared Care initiative contact Kasia Filaber, Director, Clinical Services, Four Villages Community Health Centre, 416-604-0640 kasia [at] 4villages [dot] on [dot] ca.