The authors have no affiliations, sponsorships, honoraria, monetary support or conflict of interest from any commercial source. Jill E. Sherman, MPH Raymond W. Pong, PhD Centre for Rural and Northern Health Research Presentation Objectives Introduce the OPOP Research Project Discuss findings from a review of international literature on the models of psychiatric outreach to rural and remote communities Explore similarities and differences between the OPOP Model and other models OPOP Research Project Collaboration between CRaNHR and OPOP to examine models of psychiatric outreach in smaller northern Ontario communities What service delivery models exist to increase access to psychiatric services in Northern Ontario, and what factors influence the choice of these models? How do the different approaches affect the organization and delivery of psychiatric services? What are the differences between small communities served by OPOP vs. those not served by OPOP? What innovations can be adopted in Northern Ontario to increase access to mental health services? OPOP Research - Methods Literature Review Survey of OPOP-affiliated Consultants Survey of Family Health Teams Focus Group Interviews with Consultants Community Case Studies Literature Review Database of 300+ references International perspective (mainly Canada, UK, Australia, US) Search strategy evolved over time Rural, remote, frontier, Northern Service delivery models Specialist outreach, psychiatric outreach Primary care Mental health services Shared care, collaborative care Some Early Classics 1: Reviews & Theoretical Models Williams & Clare (1981) Changing patterns of psychiatric care (UK) Bachrach (1983) Psychiatric services in rural areas: A sociological overview (US A) Strathdee & Williams (1983) A survey of psychiatrists in primary care: The silent growth of a new service (UK ) Pincus (1987) Patient-oriented models for linking primary care and mental health care General Hospital Psychiatry (USA) Horder (1988) Working with general practitioners (UK) Creed & Marks (1989) Liaison psychiatry in general practice: A comparison of the liaison-attachment scheme and shifted outpatient clinic models (UK, International) Early Classics 2: Case Studies / Empirical Models Miles (1980) A psychiatric outreach project to a rural community (Canada/British Columbia) Tyrer (1984) Psychiatric clinics in general practice. An extension of community care (UK) Carr & Donovan (1992) Psychiatry in general practice: A pilot scheme using the liaison-attachment model (Australia) Kates, Craven, et al (1997) Integrating mental health services within primary care: A Canadian program (Urban Southern Ontario) Weingarten & Granek (1998) Psychiatric liaison with a primary care clinic 14 years experience (Israel) Reviews Gruen, Weeramanthri, et. al. (2007) Specialist outreach clinics in primary care and rural hospital settings [Systematic Review]. Cochrane Database of Systematic Reviews 2007 (4):1-66, Psychiatry largest specialty represented Outreach clinics associated with Improved access Improved quality of care, outcomes More appropriate use of services Fewer psychiatric hospitalizations Higher quality of evidence from urban-high resource study areas w/limited potential to benefit from outreach Little evidence for rural with greatest potential for benefit - most rural studies were descriptive Gruen et al (2007) Conclusion: The evidence presented provides support for the hypothesis that specialist outreach can improve access to specialist care on a range of patient-based measures, health outcomes to a clinically important degree, efficiency in the use of hospital-based services by reducing duplication and unnecessary referrals and investigations. (p. 14) Early Models Increased throughput Goal: Increase referrals to specialists, by: Education of PCPs to recognize and refer Establishment of specialist-PCP relationships Shifted outpatient / visiting specialist clinic Goal: Increase access to specialist services, by: Bringing specialist into community / PCP clinic setting More Recent Models Liaison-Attachment (outreach version of consultant-liaison) overlaps with shifted outpatient more specific to psychiatry Goal: Reduce unnecessary use of specialist services & increase access to appropriate care, by: Educating and supporting primary care providers Providing clinical care in PCP/community setting Facilitating access to secondary, tertiary services where needed (strong emphasis on liaison function) Multifaceted Outreach complex interventions to increase access, quality, efficiency of care more systems perspective, urban perspective Shared care, collaborative care, multidisciplinary care Integration of psychiatry, mental health, social services (bio-psycho-social) Support services to patients (case manager/care coordinator) Community-based care models (e.g. ACT) Intermittent model Owen, Tennant, et al (1999) A model for clinical and educational psychiatric service delivery in remote communities, Australian and New Zealand Journal of Psychiatry Outreach by urban-based teams psychiatrist + other mental health professional Beyond clinical care - interventions included: direct psychiatric care to clients in their own environment peer support to lone mental health and generic health workers skills development/education for general health staff, other professionals affiliated with health care (e.g. police and ambulance officers) Variations in Outreach Models Who does the outreach? Individual vs. team? Psychiatrist only Psychiatrist + other clinical/MH Professional MH professional + backstopping by Psychiatrist Patterns of interaction ~ Types of collaboration Patient consultation only (parallel model) Patient & provider consultations, but separate Joint consultations (=shared care?) Team-based consultations (may include patient, family/caretakers) (= collaborative care?) Variations, Part II Frequency of outreach? Intermittent vs. regular schedule Weekly, monthly, or? Outreach modes & setting? Face-to-face: FP/GP office, Primary care clinic Virtual: Telepsychiatry; dedicated space? Linkages to other services? Emphasis on liaison function? Facilitate care at outreach providers home base Variations, Part III Inter-visit support services Range none to extensive (may depend on frequency, local provider capacity, ICT capacity) Follow up (+ -) new cases/consultations? Emergencies Telephone,support Telepsychiatry Prescription refills Variations, Part IV Education Larger policy goals who should provide what services? Needs of local providers Local capacity the more local capacity, the more emphasis on education? Relationships with local providers Duration of outreach program (e.g. Israeli 14 year case report) Outreach geography Socio-spatial relationships between consultants home base and outreach community Little attention assumed in the literature Related to liaison function Nearest service center (implied) Hub-and-spoke / Satellite services (intensive/dedicated outreach) Variations, Part V Degree of Integration at what level? Organizational level relies heavily on HIT facilitates referrals, sharing of patient information, system navigation Satellite services model (urban US) integration through acquistion of PC clinics as satellites of hospital ambulatory care services (Nickels 1996) Single system Networked (e.g HMOs) Interpersonal level Where services are not integrated at a formal organizational level, coordination of care relies on individuals, relationships (not systematic, but idiosyncratic) Conclusion 1: Outreach models are embedded within larger models of health care organization Goals & strategies of outreach models may vary depending on context, and dominant philosophies of the right or best way to deliver healthcare Resource constraints, clout of professional groups are strong determinants of model components Success of outreach strongly influenced by upstream systems factors (e.g. financing/payment arrangements) Conclusion 2: Models vary on a number of dimensions Who: Outreach Provider Individual vs. team Psychiatrist or other MH provider What: Components of Outreach Patient care Provider consultations Plus? Support services, Education When: Time (frequency, duration) Where: Space (setting, spatial relations/linkages) How: Patterns & modes of interaction Types of collaboration (continuum) Degree of Integration Why: Context; historical variations in goals of outreach Conclusion 3: Evaluation is difficult but generally positive Outreach can be a victim of success, especially in Psychiatry Outreach can tap a vein of unmet need Can result in increases in revealed demand/need Can be expected to change w/duration of outreach Usual indicators of access are ambiguous Waiting times Change in number/percentage of referrals Change in number/percentage of hospitalizations Successful patient outcome measures fuzzy & often difficult to attribute to outreach Cure vs. management Requires program-level indicators What is the OPOP Model ? Is there an OPOP Model ? Multifaceted Flexible - multiple models? Individual specialist Patterns of interaction/collaboration? Linkages, service integration? Support services? Education? Unique feature - outreach geography providers from south to north not from the nearest service centre (Exception-Queens program) How does this geography affect service delivery? Effectiveness? Liaison & linkages?