Collaborative care models for integrating mental health and primary care A policy overview

Background: Mental health service demands in Ontario often result in long wait times and a lack of access to specialized services. As a result, primary care providers are frequently required to provide mental health care for patients with complex diagnoses despite a lack of support or sufficient training. To address these issues, a shift toward collaborative models of mental health care delivery is occurring. Objective: This paper aims to assess whether evidence-based policy recommendations to improve collaborative mental health care are addressed in the recent Patients First documents. Methods: To achieve this, a qualitative analysis was conducted using NVivo10©. Results: While many of the evidence-based policy recommendations were mirrored in the Patients First documents, very few addressed collaborative mental health care directly. Implications: More research is required to fully understand the effects of the implementation of Patients First on mental health systems and services. introduction In recent years, there has been an increased focus on the need to reorganize mental health care delivery in Ontario and Canada. This focus on restructuring arguably comes as a response to an increase in patient demand coupled with long wait times or inability to access psychiatric services.1 These circumstances place increased responsibilities on family physicians to treat complex mental health conditions.2 A lack of support for primary care providers to adequately and effectively treat mental health disorders sparked a shift toward collaborative models of care delivery. Such models of mental health care integrate mental health services and primary care through the utilization of existing infrastructures and resources.2 Through these models, different health care providers are connected in a health service network which allows them to share resources and expertise. Studies of these models have demonstrated increased patient and provider satisfaction as well as significant reductions in treatment delays and costs.3-5 collaborative care In 1997, a revolutionary position paper was developed by the Canadian Psychiatric Association and the College of Physicians of Canada on the topic of shared mental health care which generated wide-reaching interest and awareness.6 As a response to this paper, a working group was created to promote models of shared care which focused on encouraging coordination between family physicians and psychiatrists.6 However, in recent years much has changed including a shift from the focus on the physician/psychiatrist relationship to a push for collaboration between a wide range of experts including but not limited to providers of mental health services and primary care.7 Collaborative mental health care emerged in Canada with the goal to address the rising needs of Canadians with mental health concerns as it is now understood that 1 in 5 Canadians experience mental illness in their lifetime.8,9 The objective was to increase the capacity of primary care to address issues related to managing mental health and addictions.2 At its core, collaborative mental health care is a patient-centred approach which relies on different specialties, disciplines, or sectors working together to offer services and support to individuals in need.7 Collaborative mental health care also leverages personal connections, supporting the unique and changing needs of individuals, as well as catering care to cultural and personal preferences. The collaborative mental health model often draws on local resources, skills, and interests of the participating partners. While there is no single model, collaborative mental health care is often operationalized through the use of effective communication, consultation, coordination, co-location and/or integration of mental health and primary care providers into one care team.7 Between 2003 and 2007, the Canadian Collaborative Mental Health Initiative (CCMHI), supported by the Primary Health Care Transition Fund, embarked on improving and promoting collaborative mental health care across Canada.8 Today, however, the incidences of mental health and addictions are still very high, and the heavy reliance on primary care providers to support individuals living with complex mental illness remains despite the lack of resources and inadequate training. In 2011, Kates et al published a revised position paper to update collaborative mental health literature on lessons learned through research, areas and opportunities for improvement, as well as action items for change.7 They suggested that there are many changes that can be made at the policy and practice level to encourage improvement of and access to high-quality collaborative mental health care. Including patients and their families in care planning as well as focusing on early detection of mental illness were among strategies proposed.7 Despite growing evidence showing that collaborative mental health care contributes to reduced wait times and costs and improves overall patient and provider satisfaction, it is


collaborative care
In 1997, a revolutionary position paper was developed by the Canadian Psychiatric Association and the College of Physicians of Canada on the topic of shared mental health care which generated wide-reaching interest and awareness. 6As a response to this paper, a working group was created to promote models of shared care which focused on encouraging coordination between family physicians and psychiatrists. 6However, in recent years much has changed including a shift from the focus on the physician/psychiatrist relationship to a push for collaboration between a wide range of experts including but not limited to providers of mental health services and primary care. 7ollaborative mental health care emerged in Canada with the goal to address the rising needs of Canadians with mental health concerns as it is now understood that 1 in 5 Canadians experience mental illness in their lifetime. 8,9The objective was to increase the capacity of primary care to address issues related to managing mental health and addictions. 2 At its core, collaborative mental health care is a patient-centred approach which relies on different specialties, disciplines, or sectors working together to offer services and support to individuals in need. 7Collaborative mental health care also leverages personal connections, supporting the unique and changing needs of individuals, as well as catering care to cultural and personal preferences.The collaborative mental health model often draws on local resources, skills, and interests of the participating partners.While there is no single model, collaborative mental health care is often operationalized through the use of effective communication, consultation, coordination, co-location and/or integration of mental health and primary care providers into one care team. 7Between 2003 and 2007, the Canadian Collaborative Mental Health Initiative (CCMHI), supported by the Primary Health Care Transition Fund, embarked on improving and promoting collaborative mental health care across Canada. 8Today, however, the incidences of mental health and addictions are still very high, and the heavy reliance on primary care providers to support individuals living with complex mental illness remains despite the lack of resources and inadequate training.
In 2011, Kates et al published a revised position paper to update collaborative mental health literature on lessons learned through research, areas and opportunities for improvement, as well as action items for change. 7They suggested that there are many changes that can be made at the policy and practice level to encourage improvement of and access to high-quality collaborative mental health care.Including patients and their families in care planning as well as focusing on early detection of mental illness were among strategies proposed. 7Despite growing evidence showing that collaborative mental health care contributes to reduced wait times and costs and improves overall patient and provider satisfaction, it is original article not well-understood how these models have been incorporated into health policy.This issue, also known as the knowledge-to-practice gap, is a recognized problem in health research, as federal and provincial policies are often developed using insufficient evidence. 10his paper aims to provide a brief overview of the recent shift in Ontario health policy by assessing whether proposed policy changes adequately incorporate the current evidence and recommendations brought forth in Kates et al's 2011 position paper.

patients first
The Patients First Act is a policy initiative initiated by the Ministry of Health and Long-Term Care (MOHLTC) to improve the province's health system. 11Outlined in four public documents, these proposed policy changes focus on four primary objectives: [12][13][14][15] 1) Provide faster access to correct care, 2) connect services by providing better coordination and integration closer to home, 3) support families and patients through education and transparency to allow for more informed decision making, and 4) protect the universal health system by focusing on value, quality and sustainability.
[14][15] methods The 4 documents outlining these changes were collated and compared to Kates et al's 'Across the System' and 'Provincial and (or) Territorial Governments and Regional Health Authorities' recommendations. 7NVivo 10, a qualitative analysis software, was used by the authors to assess whether the noted policy recommendations were addressed in the Patients First documents.The content of the documents was categorized using the twenty-three recommendations included by Kates et al 7 The qualitative analysis software provided a visual overview of whether recommendations were addressed in Patients First and to what degree.

findings 'Across the System' Recommendations:
The Patients First documents were coded using the twenty-three Kates et al recommendations and were measured by frequency of occurrence (Table 1 and Table 2).3][14][15] The recommendation most frequently mirrored reflected a focus on quality improvement, access, and efficiency.To a lesser degree, the inclusion of individuals, families, and caregivers in project planning and evaluation was also included.For example, in the Patients First: Action Plan for Health Care document, families were often dis-cussed in planning and collaboration. 12Less frequently discussed recommendations include development of strategies to reduce stigma among providers, promotion of mental health and well-being as drivers for change, the use of technology for managing information and linking providers, and including individuals and families in their own care.Lastly, of the 10 Kates et al 'Across the System' recommendations reflected in the Patients First documents, only 2 directly addressed mental health care while several recommendations are not discussed at all.original article 'Provincial and (or) Territorial Governments and Regional Health Authorities' Recommendations: Frequency of occurrence of provincial/territorial and regional health authorities' recommendations was greater and less varied across all documents.Overall, twelve of the thirteen recommendations in this category were present in the Patients First documents with 6 directly pertaining to mental health care.There appeared to be a focus on meeting the needs of marginalized populations, addressing health resource shortages, and the development of strategies to ensure individuals with mental health and addictions receive comprehensive primary care.

conclusion
While the Patients First documents demonstrate substantial thematic overlap with Kates et al's (2011) evidence-based policy recommendations, gaps remain as few directly address collaborative mental health care.However, it is possible that because there is considerable thematic overlap, these important policy changes will translate into improved mental health care.We support further research to understand the full affects of the practical implementation of Patients First policies on mental health systems and services.

Table 1 .
Across the system recommendations from Kates et al

Table 2 .
Provincial, territorial governments, and regional health authorities recommendations from Kates et al discussion Of the twenty-three recommendations discussed in Kates et al, eighteen (78%) were present in the Patients First documents; however, only 8 of the twenty-three recommendations (34%) addressed mental health care directly.Despite the absence of directed guid-ance for mental health care reform, there is a great deal of thematic overlap between Kates et al's recommendations and the Patients First focus on patient-centredness, quality improvement and interdisciplinary collaboration.More research is required to see if these policy changes translate into improved collaborative mental health care.