The shared care model: CrossCurrents Autumn 2003

CrossCurrents

The traditional model of medical treatment is to visit a general practitioner or family doctor for physical health needs and a psychiatrist for mental health care. "The systems are historically set up so mental health systems are pretty much just focused on caring for the patient's psychiatric problems," says Dr. Benjamin Druss, the Rosalynn Carter chair in mental health at Emory University in Alabama. But research has shown that psychiatrists and family physicians are poor at recognizing and treating physical conditions in psychiatric clients.

Some researchers say that shared care, with integrated medical and psychiatric services available in a single facility, is the best way to address this issue. "One example may be having nurse practitioners in mental health centres, a staff person who feels comfortable with its patients and a place where patients feel at ease," says Druss. "Other models have individuals serving as case managers and monitors. The idea is that the mental health care centre would take a role in screening for physical health conditions."

Druss conducted a randomized trial evaluating an integrated model of primary medical care, which had individual case managers and mental and physical health care providers working together under one roof. Another control group accessed medical help through the usual channel, a family doctor and a psychiatrist at a specialized facility.

Clients treated in the integrated facility had more visits with a primary health care provider and showed significantly greater improvements in physical health. They were less likely to have made an emergency room visit in the ensuing 12 months, were much happier with the courtesy and emotional support they had received and reported greater satisfaction with ongoing treatment. There were no significant differences in total health care cost for either group.

Individual case managers were key to the smooth flow of operations in the integrated facility. Druss sees case management as a vital tool to keep vulnerable clients from falling through the gaps. "It might be a more viable kind of intervention in other kinds of settings because it may not be practical or financially feasible to expect a state hospital or a community mental health centre to actually pay for a primary health care clinic on-site. In a system that's fragmented, case management can become the link across different components of the health system."

Shared care reaches out to the homeless

The Shared Care Clinical Outreach Service of the Schizophrenia Program at the Centre for Addiction and Mental Health, in partnership with the University Health Network and St. Michael's Hospital, works with men and women who are homeless and are experiencing serious and persistent mental health concerns. This service addresses the physical and mental health needs of homeless people who use shelters, hostels and drop-ins in downtown Toronto. Team members include full-time registered nurses, caseworkers, a housing worker, visiting family physicians and visiting psychiatrists as consultants. Shared Care teams work collaboratively with staff from other agencies to deliver respectful and comprehensive care using the principles of psychosocial rehabilitation to facilitate access to a broad range of resources to meet client needs. For more information, contact (416) 535-8501, ext. 2828.

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