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Autumn 2007 | Vol 11 No 1

The last word

Is collaborative care moving forward? Yes, but at a slower pace than some of us expected

By Tyrone Turner

Collaborative care is now getting the attention it deserves. It is mentioned repeatedly in policy documents, planning briefs and professional position papers. It has moved beyond the pioneer paradigm of the psychiatrist-GP dyad and is now embraced by professions such as nursing, social work, occupational therapy and psychology. After all, it’s such a good idea. Through shared care, psychiatric expertise can be made available to all who need it, on referral by that most available of all Canadian social benefits – the GP. Primary care physicians and nurse practitioners can attend to both arms of the Cartesian split, dealing with mind and body. They are more likely to speak the language of their patients, know their culture and their families. Shared care is a stigma-fighter when anxious, depressed or psychotic individuals, who would never attend a psychiatric clinic, can merge their mental health care with blood pressure and cholesterol checkups. Shared care psychiatrists can be freed up to provide their expertise to more people. In my own shared care practice, over the past 17 years, working collaboratively on average 1.5 days per week, I have attended to over 5,000 patients. Many of them would call me their psychiatrist, even though I may have seen them only two or three times. Contrast these numbers with the few hundred patients on the caseloads of conventional practices. As a method of opening access to mental health care to much larger populations, collaborative care cannot be beaten.

Why then, is collaborative care not yet standard practice? What stands in the way?

Lack of funding is often cited as a barrier. Shared care is best delivered by interdisciplinary teams, which requires staff and an infrastructure. Furthermore, the traditional fee-for-service method of paying psychiatrists and GPs discourages collaborative care, which involves extra time for telephone, e-mail, face-to-face meetings or even telemedicine. While government policy supports shared care, secure funding mechanisms are not yet in place.

Nevertheless, there is progress. Ontario’s primary care reform initiative now provides funding to engage collaborating psychiatrists (and internists and pediatricians). Many of the nation’s pilot collaborative care programs have involved psychiatrists and GPs in alternatively funded practices (salaried, capitated or sessionalized), in which physicians have more time to engage in the clinical dialogue needed to make shared care work. To move beyond these generally more welcoming types of practices, we need to work harder at engaging the majority of GPs who continue to work on a traditional fee-for-service basis.

Another barrier is that collaborative care challenges the classical psychiatric model into which psychiatrists have been professionalized. One doctor and one patient talk together in a private office for serial 50-minute sessions, which continue until the illness stabilizes or psychotherapy is deemed completed. The health record is highly confidential and the psychiatrist does not customarily collaborate with the GP. Psychiatrists brought up in this model are often uncomfortable sharing care with other professionals. Can they be stimulated to change? This familiar model, reinforced by media, shapes public expectations, and sometimes patients want to be treated by specialists, not generalists. The traditional model also reinforces a deeply held need for confidentiality when sensitive personal information is processed. Can collaborative care ensure that privacy will be protected when care is delivered by teams of professionals in different locations?

At a broader level, are psychiatrists and GPs adequately convinced about the value of shared care? Until they are, how can we expect the public to buy in? The classic model of specialist referral still holds despite the low availability of psychiatrists and long wait times. Some GPs have even given up referring to individual psychiatrists, and now advise their patients to locate one on their own. Many GPs have not yet had shared care made available to them, and thus have no experience with positive outcomes or patient satisfaction. Even when shared care is available, some GPs do not refer, perhaps not being convinced of its effectiveness. Some are waiting for more evidence from outcome studies. Others need to know that patients would be satisfied with a shared care referral. Physicians feel professional gratification when their patients return and say, “Doctor, thank you for that referral.”

Furthermore, it is not reasonable to expect all GPs to have the time, inclination or temperament to treat mentally ill individuals. Some physicians are more oriented toward birthing, pediatrics or seniors’ care. During training, many were assigned to tertiary care mental hospitals or acute inpatient units but received little experience in outpatient psychiatry.

Many psychiatrists, while acknowledging that shared care sounds like a good idea, do not see it as a viable practice option. Some cite financial disincentives; others want the professional satisfaction of providing direct patient care, with a close doctor-patient relationship and clear lines of responsibility (and legal liability). Again, as with GPs, some are waiting for the evidence. For a few sceptics, collaborative care seems like a form of rationing, where scarce psychiatric expertise is spread too thinly to be effective. While the idea of population health can be valued intellectually, it can be hard to grasp its significance for individual practices.

Thus, it is clear that while the collaborative care model is moving forward, barriers persist. Commendably, the collaborative ideal is advancing along multiple fronts, which include funding incentives, research, patient satisfaction surveys and revamped educational curricula.

Overall however, it will be through the repeated experience of satisfied patients receiving effective treatment, with the knowledge that they are supported by mental health professionals, who in turn can access more intensive services, when needed. Nothing works like experience.

Tyrone Turner, MD, CCFP, FRCP(C), is chief of psychiatry and medical program director for Mental Health and Addictions at the St. Joseph’s Health Centre in Toronto.

Editorials do not necessarily reflect the views of CAMH.