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Novel program allows family physicians
to provide better access to mental health care
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By Susie Strachan
Mar/Apr 2019

The young woman in Dr. Sheldon Permack's office was clearly in need of specialized care.

She was suffering from depression and hearing voices, and had already been to the emergency department of her local hospital several times.

Normally, a family doctor like Permack would refer a patient with these kinds of symptoms to a psychologist, counsellor or even a psychiatrist - a move that could lead to delays in care.

But in this case, Permack was able to ensure that the woman received the care she needed right in his own family practice office, thanks to a little-known program called Shared Care Mental Health.

First launched in 2003, the program helps to place mental health-care professionals in the offices of primary-care providers across the city, usually for one to five days a week. This means a psychiatrist or counsellor can see a doctor's patient while working out of that physician's office.

There are about a dozen psychiatrists and 20 counsellors working in the program. They support 26 primary-care sites across the city, including family physicians and their teams in fee-for-service practice, and doctors, physician assistants and nurse practitioners working at the Winnipeg Regional Health Authority's ACCESS and community health centres.

Permack says the program makes it easier to provide care to patients such as the young woman suffering from depression while reducing the stigma that often comes with seeking diagnosis and treatment for individuals suffering from mental health concerns.

"By being able to look after her here, and have her work with the psychiatrist and counsellor, we can support her over the course of her journey. Despite her being challenged by chronic and severe mental health problems that aren't easy to treat, the mental health team in the family doctor's office is able to provide talking therapies and give her the appropriate medications when indicated. We can do this here, keep her out of emergency, and prevent a hospitalization with its attendant consequences," he says.

Permack was one of the first physicians in private practice to welcome a Shared Care Mental Health counsellor after the program first launched. In addition to providing improved care for his patients, the program also gives him an opportunity to build his own capacity to deal with the entire spectrum of mental health issues in family medicine and improve his skills in cognitive behavioural therapy, diagnosis and in writing appropriate prescriptions.

"At the time, it was a radical approach, embedding mental health services in a family practice office," says Permack, who is also Medical Director of the Integrated Primary Health Care Program for the Winnipeg Regional Health Authority.

"So very, many people with mental health issues - depression, anxiety, substance abuse - present first in family medicine. So, by working with both a psychiatrist and a counsellor, and having that inter-professional team, I am able to give much better care to my patients," says Permack.

Jaik Josephson, Manager of Shared Care Mental Health, says the program helps improve access to care for many who need it.

"We know people face challenges when it comes to mental health care access," says Josephson. "The majority of Canadians are struggling, and never actually see a health specialist in this area. Instead, most people talk to their primary-care provider about their mental health concerns."

Photo of Jaik Josephson and Dr. Randy Goossen
Jaik Josephson (left) and Dr. Randy Goossen say the Shared Care Mental Health Program has helped improve access to care for people who need it.

Talking to your family doctor about mental health can be a hit-or-miss proposition, depending on how familiar they are with the available therapies and locations where a patient can receive treatment. Shared Care Mental Health increases that familiarity.

"The mental-health system can be overwhelming to navigate for both patients and primary-care providers," says Permack. "It's hard enough for the patient, but as a family doctor, it's hard to know where to send patients with all the recent changes in services and challenging wait times. So every time I have a patient with a really complicated problem, I have a psychiatrist and counsellor to discuss the services that are available, including those I never knew existed, and often cannot access without specialty support."

Dr. Randy Goossen came to Winnipeg in 2003 to work for the program as the Medical Director of Community Mental Health. At the time, there was federal funding to support health initiatives, so a Shared Care Mental Health pilot project was launched at two sites in Transcona and River East. After the pilot was completed, patients and physicians were asked about its effectiveness.

Patients liked the fact that they could receive mental health care right in their community, and physicians liked the outcomes, especially in patients with anxiety or depression. Physicians also perceived that Shared Care Mental Health prevented hospital admissions, or made for more dignified and efficient hospital admissions, and prevented patients from deteriorating after hospital discharge.

"In the beginning, when we had five or six counsellors, we would send them around to different medical clinics where they would work alongside family doctors," says Goossen. "Patients didn't have to go downtown to an unfamiliar clinic, where they often felt the stigma of being treated for mental health problems."

Today, the dozen psychiatrists working part-time in the program do around 1,500 consultations a year. Most of the patients they see are subsequently diagnosed with anxiety or depression.

"We see patients with OCD (obsessive compulsive disorder), ADHD (attention deficit hyperactivity disorder), eating disorders, multiple personalities, schizophrenia. We'll see people who have panic attacks or are suffering from PTSD (Post-Traumatic Stress Disorder)," says Goossen. "But the majority are people with anxiety or depression."

Patients must be referred to the program, by their primary-care provider, be it their doctor or nurse practitioner. The psychiatrists and counsellors assess the patients, make a diagnosis and can make recommendations regarding talking therapy or medication. The counsellors work with patients on short-term goals, where significant progress can be made in six to eight counselling sessions.

"A counsellor would have the person focus on short-term goals that they would be willing to work on," says Josephson. "A person might need help learning to regulate their emotions, or to manage panic attacks or anxiety. The counsellor would work with their client on identifying what that person's goals for change are."

The 20 counsellors will make as many as 9,000 visits a year with patients, mostly in short-term sessions. Counsellors can also refer people on to longer-term counselling or other appropriate community or acute-care resources.

"Our psychiatrists and counsellors help the doctors and nurses navigate what can be a very confusing mental health-care system," says Josephson. "Ideally, our people will hold a meeting with the doctor or nurse ahead of seeing their patient, and then do a debriefing afterward, in terms of further treatment or medication requirements."

Sheila Korban has been a Shared Care Mental Health counsellor since the program began. She currently works at ACCESS River East and is part of the primary health-care team at the clinic.

"In a typical day, I will see one new client and up to four return clients," she says. "People come to see me to get a better understanding of their mental health concerns and what they can do about them. They get clarity on why they are struggling and are then motivated to make changes in their lives."

Much of her work involves helping people deal with anxiety, she says, adding that she uses a number of different therapies to help people look for patterns in their behaviour. "We look at what might cause them to get stuck, and how to address that," she says.

Korban says she often finds herself helping people sort out struggles in the workplace, interpersonal and couple concerns, parenting issues, and financial difficulties.

"I can do a tremendous amount in six weeks," she says, adding that by being able to catch an issue early through the therapy sessions, it can stop a person's mental health from deteriorating.

Korban works with a psychiatrist at ACCESS River East to help patients clarify their mental health concerns, particularly if and when they would benefit from medication.

Photo of Joanne Klassen and Dr. Sheldon Permack
Counsellor Joanne Klassen (left) works out of the family medicine office of Dr. Sheldon Permack.

"Because she's only here one day every two weeks, part of my job is to be a liaison between her and the primary-care providers in the clinic. I can communicate information both ways," says Korban.

The psychiatrist from ACCESS River East also visits Permack's practice once a month, while counsellor Joanne Klassen is there one day a week. Permack says he finds himself reaching a lot less frequently for the prescription pad since he started working with the psychiatrist and counsellor.

"They remind me about the other things I can do to treat patients, and to leave the medications for when they are really appropriate, and provide more scientific therapies," he says.

He is also able to do what he calls an "indirect consult," where he can send secure e-mails to the psychiatrist, asking about complications in a patient she has already seen. "I might say, 'I've tried all these treatments we've discussed, and we still have not reached our treatment target. What's the next step?' She will e-mail me back promptly," he says.

Permack also makes use of other community-based services for mental health care. "A family doctor needs a lot of arrows in the quiver. It's my job to identify those most in need of counselling right in my office, or to find another way to get a patient the holistic care that they need."

This might take the form of sending patients to group therapy sessions at ACCESS Fort Garry. When his psychiatrist is unavailable for a consultation, he uses the Rapid Access to Consultative Expertise (RACE) service, which allows him to speak to a psychiatrist by phone. Another online service he uses is eConsult, where a specialist will get back with an answer to a mental health problem quickly to avoid emergency room visits or hospitalization.

"eConsult is an electronic, secure transfer of information that acts as a way of speeding up care and building capacity. It allows me to treat people in the community, so they don't have to go on a longer waiting list for treatment elsewhere."

Community is the heart of Shared Care Mental Health, according to Josephson.

"Our model of care is based on the good relationship people have with their primary-care provider. They trust their doctor, so our counsellors and psychiatrists can build upon that trust. The treatment takes place right in their own community, thanks to co-location of services. It's a two-way connection: the patients get better, and the doctors or nurse practitioners learn more about mental health care."

That's a conviction echoed by Permack.

"The reason family doctors sign up for Shared Care Mental Health services is because it speaks to the principles of family medicine," he says. "It is continuous care that's community based. It is also based on relationships and improves the skills of primary-care providers. Shared Care Mental Health meets all the criteria that drive family doctors in the care of their patient populations. Shared Care Mental Health really is an invaluable service."

Susie Strachan is a communications specialist with the Winnipeg Regional Health Authority.

Building better care

The goals of the Shared Care Mental Health program include:

  1. Improved access to mental health services
  2. Improved primary care capacity to manage mental health
  3. Improved communication between primary care and mental health
  4. Increased mental health providers understanding of primary care
  5. Improved patient outcomes