Challenges and Solutions in Providing Primary Care and Psychiatry Support at Waterloo Regional Homes
Limited access to primary care and psychiatry support for consumers at Waterloo Regional Homes poses significant challenges, including a shortage of physicians and psychiatric coverage. The workshop agenda addresses these issues by introducing a Physician Assistant (PA) - Psychiatrist model to improve access to care and enhance consumer outcomes.
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THE RIGHT TO ACCESS PRIMARY CARE & ONGOING PSYCHIATRY SUPPORT WATERLOO REGIONAL HOMES WATERLOO REGIONAL HOMES FOR MENTAL HEALTH INC. FOR MENTAL HEALTH INC. Mark Mark Breathwaite Breathwaite Dr. Dr. Sujay Sujay Patel Dawn Copeland Dawn Copeland Dr. Ben Dr. Ben McCutchen McCutchen Patel
WORKSHOP AGENDA PROBLEM PROBLEM *Limited access to sufficient primary care & psychiatry support for ACTT consumers SOLUTION SOLUTION *Physician Assistant (PA) Psychiatrist model RESULTS RESULTS *Impact of the PA PA- -Psychiatrist model Psychiatrist model DISCUSSION & QUESTIONS 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: 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: 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: 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 Or is Or is it?! it?! all under our little ACTT umbrella but, sure, it is just a just a dream dream
OUR PROBLEM OUR PROBLEM Limited access to sufficient primary care & psychiatry support for ACTT consumers OUR SOLUTION OUR SOLUTION Physician Assistant (PA) to ACTT *Developing a PA Psychiatrist model *Adding a Physician Assistant
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 The relationship with a supervising physician is essential to the role of the PA to the role of the PA essential
PHYSICIAN ASSISTANT (PA) PSYCHIATRIST MODEL Training period 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 PA clinic 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 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 primary care primary care issues. mental health along with full & thorough psychiatric assessment including review of all past records To start: To start: physical assessment medication review pertinent Ix including urine R&M, C&S capacity assessment
NEW CONSUMER: SALLY SWEET To continue 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 Diabetes Dyslipidemia Osteoporosis Hypertension Contraception Healthy eating Exercise Smoking cessation Sleep hygiene Frailty Stress Referral & consultation (ie. memory clinic) Examples Examples Infections Common skin disorders Constipation/Diarrhea Aches & pains Peripheral edema Fatigue Anemia Thyroid disorder Immunizations
HISTORY OF PAs IN ONTARIO 006: : PA PA strategy announced by strategy announced by HealthForceOntario 2 2006 HealthForceOntario 2007 2007: : Hiring in Ontario in Ontario * *early early unpublished studies show improved patient unpublished studies show improved patient care access access to more timely to more timely care & improved care & improved patient satisfaction satisfaction Hiring of 50+ military of 50+ military & internationally & internationally trained PAs trained PAs care, , patient 2008 2008 - -2010 University University 2010: : Training Training of of 1 1st st class class of PAs at McMaster of PAs at McMaster 2011 2011: : 20 graduates 20 graduates employed in variety of settings employed in variety of settings across across Ontario Ontario *including *including emergency medicine (8), internal medicine (6), emergency medicine (8), internal medicine (6), primary care (3), orthopedics (2) primary care (3), orthopedics (2) & critical & critical care (1 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 PROBLEM *Limited access to sufficient primary care & psychiatry support for ACTT consumers OUR SOLUTION OUR SOLUTION *Physician Assistant (PA) Psychiatrist model RESULTS RESULTS *Implementation of the PA been very POSITIVE overall, adding further value to ACTT PA- -Psychiatrist Psychiatrist model has
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 & Let us brainstorm together & learn from each other! learn from each other!
THANK YOU!! QUESTIONS?? Mark Mark Breathwaite Breathwaite ACT Team Manager ACT Team Manager mbreathwaite@waterlooregionalhomes.com mbreathwaite@waterlooregionalhomes.com 519 519- -742 742- -3191 3191
