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Improving Quality of Mental Healthcare by Family Physicians in BC and Unexpected Learnings about Stigma. Liza Kallstrom BSc, MSc, Content and implementation Coordinator for the Practice Support Program, British Columbia Medical Association - PowerPoint PPT Presentation
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www.pspbc.ca
Improving Quality of Mental Healthcare by Family Physicians in BC and
Unexpected Learnings about Stigma
Liza Kallstrom BSc, MSc, Content and implementation Coordinator for the Practice Support Program, British Columbia Medical Association
Dr. Rivian Weinerman MD BSc(Med) FRCPC PSP Physician Quality Ambassador, Practice Support Program, British Columbia Medical Association, Associate Clinical Professor UBC
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774,261 receiving services for mental health issues
703,298 by a family physician (FP)
115,905 by a psychiatrist
116,372 in a community mental health centre
21,048 in acute care
FP focus-best chance to affect most people early on
Picture in BC 2010/11
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Underlying hypothesis
Local mental health clinic group
Noticed
•SU, Bipolar, PTSD, OCD– most often missed in FP referra;s
FPs’ patients not fully engaged in care planning, treatment decisions
Mostly pills in docs’ repertoire, rarely skills
Knew
Time pressure and fee constraints
FPs self admit lack of undergraduate education in mental illness
Fear about not knowing what to do significant factor underlying physician discomfort/lack of confidence in treating mental health issues, and provider stigma- useful tools needed
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CBIS (Cognitive Behavioural Interpersonal Skills) manual an organized Assess/plan/provide skills tool - guideline based ****
To enhance MH capacity /comfort for FPs within realistic
FP time constraints and fitting MSP fee codes
To enhance client partnership and self management
Formed core of BC provincial Practice Support Program (PSP) Adult Mental Health Module
****Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare Quarterly, 2011. 14:1, 36-38
Local Team Developed Training Tool
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Depression used as Lens High prevalence in isolation and comorbid with other MH disorders and chronic disease
Source: Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.
Lifetime prevalence of Lifetime prevalence of
Major Depressive Episode: Major Depressive Episode: 12.2%12.2%
Past-year episodes: Past-year episodes: 4.8%4.8%
Past-month episodes: Past-month episodes: 1.3%1.3%
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AMH MODULE OBJECTIVES After completing the Mental Health module, FPs and health care team
will be able to effectively:
1. Screen/assess for mental health disorders
2. Use 3 Supported Self Management cognitive behavioral therapy (CBT) tools
CBIS (Cognitive Behavioral Interpersonal Skills Manual)
BounceBack program
Antidepressant Skills Workbook
3.Bill for mental health care services provided
4.Implement with patients with mild-moderate dep/anxiety, and use with other MH disorders and chronic stable SMI /chronic disease pts where depression/anxiety is comorbid
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KEY COMPONENTS
CBIS (Cognitive Behavioral Interpersonal Skills Manual)BOUNCEBACKASW (Antidepressant Skills Workbook)
All Self Management toolsCBIS additionally had Assessment and planning tools
Screening tools PHQ 9, GAD 7
Adult Mental Health Module Content
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A. Screening Assessment and TreatmentB. Developing Care PlansC. Using Skills not only PillsD. Improving the patient experienceE. Fully engaging the patient in self management
Using a proactive approach
All within the time constraints of busy family physician practices and fitting fee codes
AIM: To increase Family Physicians skills and confidence in:
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Feel comfortable with mental health pts
Heightened awareness
Know scheduling, materials required
Have materials prepared/placed
Medical Office Assistant First Aid Course
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1. Paid learning and practicing
2. Train the Trainer
3. PDSA QI approach (Plan, Do Study Act)
4. Surveys at end of module, and at 3 to 6 month
5. MOAs simultaneously took Mental Health First Aid
Course
Psychiatrists, Mental Health clinicians from each HA
Method
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At end of module training physicians felt the training and tools:
› Improved patient care (89.1%)
› Enhanced their skills (84.0%) and confidence (85.5%)
› Enhanced skills in conducting a diagnostic interview (85.1%)
› Enabled them to decrease their reliance on medications (39.5%)
› Increased docs’ job satisfaction (67.2%)
› Increased pts’ return to work (78.8%) ability to stay at work (88.8%) with CBIS
Patient experience:
› Increased feeling of partnership and increase in comfort talking to their doctor (82%)
Newly learned practices were sustained or improved at 3 to 6 months followup over time with various cohorts
Results Over 1400/3300 docs in province have been or are being trained (525 surveys)
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Figure 1: FPs' ratings of overall success and impact of the Adult Mental Health module
49.0
57.8
94.6 94.1
30
100
At end of module At 3 to 6 monthsfollow-up
At end of module At 3 to 6 monthsfollow-up
Overall success in implementingskills into practice
. Overall impact on FPs' patients
Per
cent
age
of F
P r
espo
nde
nts
ratin
g th
e ite
m a
s "h
igh"
or
"ver
y hi
gh"
(*p<.05)
(ns)
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Figure 2: FPs' confidence in providing mental health care at module completion and 3 to 6 months post-
training
99.8 100 98.7 100
91.995.9
84.388.6
77.581.1
96.1 96.4
60
100
At
end
ofm
odul
e
At
3 to
6m
onth
s
At
end
ofm
odul
e
At
3 to
6m
onth
s
At
end
ofm
odul
e
At
3 to
6m
onth
s
At
end
ofm
odul
e
At
3 to
6m
onth
s
Confidence indiagnosing
. Confidence intreating
. Confidence indeveloping care
plans
. Confidence inprescribingmedication
Per
cent
age
of "
Co
nfid
ent
" F
P r
espo
nden
ts
Depression Other MH conditions (in general)
(ns)
(ns)(*p<.05)
(*p<.05)
(*p<.05)
(*p<.05)
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730 - # patients with initial PHQ-9 score > 10
17 – average initial PHQ-9 score
10 – average follow up PHQ-9 score
-7 – average change in PHQ-9 score
73 – average days from initial to follow up PHQ-9
Outcomes Results – one Health Authority
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Family Physicians are willing recipients of training when they are reimbursed to attend and the tools are extremely practical and fit within their time constraints
This module was extremely successful in changing Family Physicians practice and feeling they had:
Improved patient careIncreased their job satisfactionDecreased their reliance on prescribing antidepressant medicationsImproved their patients’ ability to work
This change in practice was sustained or improved at 3-6 month followup over time with various cohorts
Patients felt more comfortable and engaged
AND………………………………………….
Conclusions
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AIDs literature – AIDs patients stigmatized1.Stigma reduced with useful interventions to treat/manage problems/illness **
A. Information
B. Coping skills acquisition
Mental Health patients stigmatized1.Family Physicians (FPs) self report: lack training, feel unprepared *** 2.If you feel unprepared, you might fear, avoid, turn away –stigmatization
Stigma
**Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine,
New Orleans, Louisiana,
***Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician, 54,
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less preventionmore crisismore deteriorationmore relapsemore fear vicious circle
Stigma results in
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Major insight evolved as physicians became more knowledgeable and comfortable/confident with the AMH training…..
And linking with the AIDs literature……
Realized -AMH training could lead to less avoidance and stigmatization of patients struggling with mental health problems.
Recent Mental Health Commission data on Module has shown that CBIS/ASW significantly decreased stigmatizing attitudes of physicians, residents after one day training by 10%- largest finding to date.
www.gpscbc.ca/psp-learning/mental-health/tools-resources
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Used AMH as mental health training tool forFamily Practice Residents/PreceptorsNursing students/TeachersNurse practitionersMental Health case managers, clinicians (Pain, Aboriginal, cardiac, eating disorders, addictions)Other chronic disease clinicians (diabetes)
In urban rural or remote areasFor individual or group use One language for all
Other realizations
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CMHA Leadership award
HEABC 2010 award for Innovation
UBC 2011 CME/CPD award for Innovation
Permanent Journal 2012 Special Quality Award and
invitation to submit manuscript to journal
Awards
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Algorithm
www.pspbc.ca
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