Integrated Care: The Canadian Story
Abstract
Integrated care efforts in Canada share some strong similarities to integrated care efforts in the United States. For over 20 years, Nick Kates, M.B.B.S., has been a leader in these efforts and has explored ways to increase access to mental health care, build the capacity of primary care to manage mental health problems, and enhance the experience of the patient and provider. —Jürgen Unützer, M.D., M.P.H.
Canada’s 10 provincial and three territorial health care systems are built upon a strong foundation in primary care, which is usually the entry point to specialized services. While mental health care is seen as central to the role of primary care and an integral part of the Canadian concept of the “patient’s medical home,” as in other jurisdictions, family physicians frequently experience problems with accessing secondary mental health services, the length of waiting times for service, communication with their mental health colleagues, and coordinating the care of their patients.
Over the last 20 years, however, Canada has made substantial progress in improving collaboration between mental health and primary care services and integrating mental health services within primary care settings, guided by two joint position papers produced by the Canadian Psychiatric Association and College of Family Physicians of Canada in 1997 and 2011. These outlined the principles, goals, and practices of effective collaborative care and presented a common framework for new initiatives. Since then, a wide variety of projects aimed at improving collaboration and building new partnerships have emerged across the country, and all share one or more of the goals of (1) increasing access to care; (2) building the capacity of primary care to manage mental health problems; and (3) enhancing the experience of the patient and provider. A national conference brings providers, planners, administrators, and consumers together annually, and a quality framework is now being introduced to define the goals of projects and measurement of their outcomes.
Collaborative mental health care is also increasingly prominent in mental health and primary care service planning both provincially and nationally, although there is local variation in the way collaborative projects have been implemented. In general, these initiatives take one of four approaches:
Making changes to the mental health service to improve communication and coordination of care by working more closely with primary care providers, including telehealth consultation.
Providing educational interventions and resources that increase the skills, comfort, and capacity of primary care providers when managing mental health problems in their practice.
Integrating primary care providers within mental health settings to address the problems of individuals with mental illness who do not have access to a primary care provider.
Integrating mental health services within primary care settings. While this may include a visiting psychiatrist, a visiting team, or a mental health team based permanently in primary care as part of the primary care team and usually working with the entire population of a practice, the common elements in the Canadian approach bear many similarities to the collaborative care model developed at the University of Washington. These include the following:
Key personnel
A care manager or therapist whose roles can include assessment, psychological treatments such as cognitive-behavioral therapy and interpersonal psychotherapy, care coordination and case management, support for self-management, system navigation, and patient education.
A visiting psychiatrist who provides consultations and selected follow-up, case discussions and reviews, telephone back-up,and continuing education for the primary care team.
An engaged family physician who is the lead, ambassador, and liaison for the project and assists in solving problems as they arise.
The care is team-based, patient- and family centered, and evidence-informed.
The physical integration of mental health personnel within the primary care setting is essential.
Personal contacts and “warm handoffs” between providers are central to effective collaboration.
Systematic (proactive) follow-up of patients is required after treatment is initiated or completed.
Progress needs to be measured regularly once treatment has started.
Roles and expectations of all providers in the partnership need to be clear.
Principles to guide care
The care is team-based, patient- and family centered, and evidence-informed.
The physical integration of mental health personnel within the primary care setting is essential.
Personal contacts and “warm handoffs” between providers are central to effective collaboration.
Systematic (proactive) follow-up of patients is required after treatment is initiated or completed.
Progress needs to be measured regularly once treatment has started.
Roles and expectations of all providers in the partnership need to be clear.
Supports to enhance care
Treatment protocols and pathways.
The use of case registries.
Support by leadership in both organizations.
Clear goals for any project.
Opportunities to meet regularly to review the progress and success of the relationship.
Realistic preparation and orientation, and ongoing support of mental health providers.
While initially addressing problems with access and communication, collaborative care has also demonstrated its potential for addressing other issues facing Canada’s health care systems. It allows for the better integration of physical and mental health care and early intervention and relapse prevention while improving access, transitions, and flow, including reducing avoidable emergency room visits. It can also reduce stigma, enhance the patient’s and family’s experience, and promote early childhood development and the identification of children at risk. ■
