THE RIGHT TO ACCESS
PRIMARY CARE &
ONGOING PSYCHIATRY
SUPPORT
WATERLOO REGIONAL HOMES
FOR MENTAL HEALTH INC.
Mark Breathwaite
Dr. Sujay Patel
Dawn Copeland
Dr. Ben McCutchen
WORKSHOP AGENDA
PROBLEM
*Limited access to sufficient primary care &
psychiatry support for ACTT consumers
SOLUTION
*Physician Assistant (PA) – Psychiatrist model
RESULTS
*Impact of the PA-Psychiatrist model
DISCUSSION & QUESTIONS
WATERLOO REGIONAL HOMES
FOR MENTAL HEALTH INC.’S
ACTT
WATERLOO REGIONAL HOMES FOR MENTAL
HEALTH INC.’S ACTT
▪ One of two ACTTs serving a growing, vibrant region
(population of 0.5 million)
▪ Housed in a small/average-sized community-based
supporting housing agency
▪ In a region with a known shortage of family physicians
& community-based psychiatrists
1. HOW DO WE ENSURE OUR CONSUMERS
GET EQUAL ACCESS TO THE PRIMARY
HEALTH CARE RESOURCES THEY NEED?
Challenges:
▪ Too few family doctors
▪ Unfitting environments of walk-in clinics & emergency
room departments
▪ Some family doctors are uncomfortable, impatient &
irritated with our consumers
▪ Physical symptoms can be overlooked in presence of
psychiatric symptoms
2. HOW DO WE PROVIDE EXPECTED ACTT
SERVICES WITHOUT ADEQUATE PSYCHIATRY
COVERAGE?
Challenges:
▪ Only part-time ACTT psychiatrist
*0.1–0.4 FTE for past 8 years
*0.1-0.2 FTE for past 3 years
▪ Limited access to ACTT psychiatrist
*One year ago = only 25% (20 of our 80) consumers
▪ Complex & time-consuming to get basic services from a
large group of community psychiatrists & family doctors
2. HOW DO WE PROVIDE EXPECTED ACTT
SERVICES WITHOUT ADEQUATE PSYCHIATRY
COVERAGE?
Challenges:
▪ Forms, CTOs, CCB hearings & hospitalizations
▪ Difficult to foster progressive treatment
▪ Clinical decision-making falls to team & team coordinator
▪ Stalls the intake of new consumers
▪ Competitive psychiatry recruitment → team capacity
implications
OUR DREAM ONE YEAR AGO
▪ To multiply our precious but scarce psychiatry services
with more direct contact
▪ Ensure cost-efficiency
▪ Increase the number of consumers
▪ Improve the scope of primary care services
all under our little ACTT umbrella
but, sure, it is just a dream…
Or is
it?!
OUR PROBLEM
Limited access to sufficient primary care & psychiatry
support for ACTT consumers
OUR SOLUTION
*Adding a Physician Assistant (PA) to ACTT
*Developing a PA – Psychiatrist model
WHAT IS A PHYSICIAN ASSISTANT (PA)?
▪ highly skilled health care professional educated in the
medical model
▪ works under the overall supervision of a physician in any
clinical setting to extend physician services
▪ performs services which are consistent with the PA’s
education, training & experience
ex. preventative care, acute complaint presentations,
chronic disease management, health promotion
counseling, ordering & interpreting diagnostic tests,
prescribing medications
The relationship with a supervising physician is essential
to the role of the PA
PHYSICIAN ASSISTANT (PA) – PSYCHIATRIST
MODEL
Training period with ACTT psychiatrist to improve PA’s
psychiatry knowledge & skills
Take on NEW
consumers with no
previous psychiatry
support
EXPAND service for
existing consumers of
ACTT psychiatrist
Psychiatry support
(including continuity of care when psychiatrist away)
Primary care management
Case consultation & documentation
Staff & trainee teaching
PA– PSYCHIATRIST MODEL
Psychiatrist-PA clinic
▪ 1st visit with new
consumer
▪ For PA to meet existing
consumers
▪ Mental health focus
▪ ID of primary care issues
for later assessment by
PA
PA clinic
▪ Follow-up visits of new
consumers
▪ Mental health focus for
stable consumers (new or
existing)
▪ Primary care focus
▪ ID of psychiatric issues
~Once weekly + one extra
clinic per month
~Once weekly
Both available for phone or electronic consult
NEW CONSUMER: SALLY SWEET
▪ ID: 67 year old single female, lives independently, no
close supports, receives support through ODSP,
capacity for treatment & finances unknown
▪ Mental health: psychiatric diagnosis unclear, has not
been assessed by psychiatry in 5 years since last
hospitalization, on number of psychotropic medications
including atypical antipsychotic
▪ Physical health: obesity, poorly controlled type 2
diabetes, on medications for glycemic control
▪ Substance use: longtime smoker, occasional marijuana
& alcohol use
PA– PSYCHIATRIST MODEL
NEW CONSUMER: SALLY SWEET
▪ more anxious & agitated lately, some possible delusional
thinking, complaining that it “burns when [she] pees”
With the PA-psychiatrist model our goal is to provide ongoing
support for her severe & persistent mental health along with
primary care issues.
▪
To start: ▪ full & thorough psychiatric assessment including
review of all past records
▪ physical assessment
▪ medication review
▪ pertinent Ix → including urine R&M, C&S
▪ capacity assessment
NEW CONSUMER: SALLY SWEET
To continue
▪ continue to develop the therapeutic relationship
▪ interpret urine results → treat uncomplicated urinary
tract infection
▪ diabetes education, teaching & possible medication
adjustment
▪ health teaching regarding obesity & healthy lifestyle
▪ smoking cessation counseling
▪ preventative female screening
PREVENTATIVE CARE
Screening
▪ Cervical cancer
▪ Breast cancer
▪ Colon cancer
▪ Prostate cancer
▪ Osteoporosis
▪ AAA
▪ Hypertension
▪ Diabetes
▪ Dyslipidemia
▪ Etc….
ACUTE & CHRONIC HEALTH ISSUES
Examples
▪ Infections
▪ Common skin disorders
▪ Constipation/Diarrhea
▪ Aches & pains
▪ Peripheral edema
▪ Fatigue
▪ Anemia
▪ Thyroid disorder
▪ Immunizations
▪ Diabetes
▪ Dyslipidemia
▪ Osteoporosis
▪ Hypertension
▪ Contraception
▪ Healthy eating
▪ Exercise
▪ Smoking cessation
▪ Sleep hygiene
▪ Frailty
▪ Stress
▪ Referral & consultation
(ie. memory clinic)
HISTORY OF PAs IN ONTARIO
2006: PA strategy announced by HealthForceOntario
2007: Hiring of 50+ military & internationally trained PAs
in Ontario
*early unpublished studies show improved patient care,
access to more timely care & improved patient
satisfaction
2008 -2010: Training of 1st class of PAs at McMaster
University
2011: 20 graduates employed in variety of settings
across Ontario
*including emergency medicine (8), internal medicine (6),
primary care (3), orthopedics (2) & critical care (1)
MOHLTC REPORT 2011
▪ Qualitative → based on employer surveys
▪ No PAs studied in mental health settings
▪ Perceived impact:
1) improved quality of care
2) reduced workload
3) increase # of patients per day
▪ High level of employer satisfaction, perceived level of
preparedness, unclear impact of hiring grants
PHYSICIAN ASSISTANTS (PAs)
IN MENTAL HEALTH
▪ Paucity of literature pertaining to PAs in mental health,
given the relatively new role of PAs in Canada
▪ Some qualitative evidence available related to
physician extenders
in mental health settings
Ex. nurse practitioners
WILLIAMS ET AL. 2009
▪ Can a NP Serve in the Prescriber Role on an ACCT?
▪ NP viewed as a physician extender or psychiatric
prescriber
▪ Naturalistic study comparing 2 ACT teams, with
psychiatrist (ACT-MD) versus with nurse practitioner
(ACT-NP)
▪ Teams assessed for consumer satisfaction, team
cohesion, medication management practices &
fidelity to ACT model
WILLIAMS ET AL. 2009
▪ ACT-MD had significantly higher level of consumer
satisfaction
▪ ACT-NP team had higher fidelity to evidence-based
medication management standards
▪ High levels of team cohesion on both teams
WORTANS ET AL. 2006
▪ Qualitative assessment of consumer satisfaction of
care provided by NP versus psychiatrist in
outpatient mental health clinic
▪ Consumer satisfaction with NP service is high /
equivalent to satisfaction with MD
▪ Highlighted potential benefits, including:
-more open communication with NP
-longer consultations
-increased availability of treatment in home
-greater provision of information
OUR STUDY DESIGN
▪ Qualitative analysis of impact of introducing a PA into the
Waterloo Regional Homes for Mental Health Inc.’s ACTT
▪ Data gathered through combination:
▪ Semi-structured focus interviews
▪ Written questionnaire
▪ Textual data (transcripts) were
conceptualized & indexed
by an independent researcher
THEME 1 - ACCESS TO CARE
▪ Increased number of consumers have access to psychiatry
(~40% of total ACTT consumers now have access vs. 25% in
winter 2014), decreased wait time for appointments, longer
& more collaborative appointments
▪ Improved access to primary care services through ACTT (“one
stop shopping”)
-Concurrent disorders / geriatric / somatically-oriented
patients / semi-urgent issues
▪ Improved access to primary care provider or family health
team (liaison model identified)
▪ Improved communication between appointments
THEME 2 – PERCEIVED IMPACT ON CARE
▪ More emphasis on preventative health, including
smoking cessation, diabetes care, women’s health
▪ More expedient treatment of semi-urgent medical
issues
▪ Collaborative assessments with dual focus on
medical & psychiatric concerns
▪ More opportunities for medication reviews
THEME 3 – SYSTEM NAVIGATION
▪ Improved speed and ease of referrals to tertiary care
Ex. pre-admission physical examinations
▪ Improved access to laboratory testing
▪ Improved liaison with community specialists
▪ Improved access to MOHLTC screening programs
Ex. colon cancer screening
THEME 4 – TEAM DYNAMICS
▪ Sense of team cohesion with “enhanced discussion”,
“more education”
▪ Staff noted equal levels of satisfaction between
psychiatric & PA support
▪ Staff members noted improved accessibility when
concerns arise
▪ Staff noted more time to spend with clients
OBSERVED & AVOIDED OBSTACLES
▪ Caution around “triage” service
▪ Concerns around scope of practice
▪ Division of responsibilities between PA & psychiatry
▪ Concerns around terminology of “PA” & patient
education
SUMMARY
▪ PROBLEM
*Limited access to sufficient primary care &
psychiatry support for ACTT consumers
OUR SOLUTION
*Physician Assistant (PA) – Psychiatrist model
▪ RESULTS
*Implementation of the PA-Psychiatrist model has
been very POSITIVE overall, adding further value to
ACTT
YOUR THOUGHTS & EXPERIENCES?
▪ What challenges have YOU faced in providing
primary care & ongoing psychiatry support to ACTT
consumers?
▪ How do YOU improve access to primary health care
to ACTT consumers?
▪ How do YOU ensure sufficient psychiatry support is
provided to ACTT consumers ?
Let us brainstorm together &
learn from each other!
THANK YOU!!
QUESTIONS??
Mark Breathwaite
ACT Team Manager
[email protected]
519-742-3191