Collaborative care one-on-one: A nursing perspective

CrossCurrents

By Lesley Young

If you’re lucky enough to get an opportunity to work in a collaborative care model, jump at it, says registered nurse and shared care consultant Carol Rupcich. After co-piloting a consultation/service-based primary mental health care model nine years ago in Calgary, Alberta, she’s never looked back.

Rupcich works on two collaborative care teams and links the programs whenever she can. In the Collaborative Mental Health Care (CMHC) program, she works with a team of four psychologists, five social workers and one nurse to support primary care providers in delivering mental health care to children up to age 6. In the Shared Mental Health Care (SMHC) program, Rupcich works with seven psychiatrists, three psychologists, a social worker, four nurses and an occupational therapist to enhance adult mental health services delivered in primary care settings. She attends appointments at physician’s offices, usually alone, to meet with the physician and patient. “If team members have a question about something clinical that we’re unsure of, we usually telephone one another for advice.” The psychiatrists in the SMHC program also have set times when they visit physicians.

An evaluation of the SMHC program, published in a 2004 issue of the journal Families, Systems and Health, showed the program to be a major success from the perspective of everyone involved – that an office-based shared mental health care model in a fee-for-service environment is a viable and effective mode of primary care service delivery. The evaluation also uncovered significant information about how the model works in practice. One key finding was that family physicians remain the central care provider in the service, augmented by mental health consultation. Recent evaluation data corroborates these findings.

Working in a collaborative care model offers Rupcich professional development opportunities she says she wouldn’t get with any other job, as well as unique work environments and constant stimulation. “It is quite challenging but very satisfying,” she says. “I really feel that I am part of the primary health care system.” In a one-on-one interview with CrossCurrents, Rupcich talks about on-the-job challenges and rewards.

“Mutual respect is a job requirement.”

For a collaborative team model to work, all members, including the physician and the mental health consultant, whether it’s a social worker, nurse, occupational therapist, psychologist or psychiatrist, need to find common ground. Our goal can only be achieved when there is a mutual respect and recognition of everyone’s skills. We’re all focused on finding out what is happening with the client.

Family doctors are very misunderstood. They’re generalists and they know a great deal about various areas, and for that reason, you need to be open to learning from each other. Some health professionals may not like the medical model and might have a hard time adapting to a collaborative care model. What I’ve discovered and come to respect about family physicians is how quickly they work, and how they are the gatekeepers to other services.

You need to be non-hierarchical in your approach. I’m there as a consultant to the physician. I don’t go into a situation as the expert – I never think of the interview as mine. In fact, if a doctor introduces me to a patient as “our expert in psychiatry,” I’ll correct that, telling the patient that he or she is the expert, and that we each have different knowledge and information with which to find what works for the patient.

“Which brings us the next point: The linchpin of any successful team is understanding and managing the physician-patient dynamic.”

The consultant needs to pay attention to the relationships that exist between the physician and the patient, the patient and the consultant and the physician and the consultant. Without a good working relationship, it just doesn’t work. The physician is the client in SMHC, but the patient is the linchpin that drives the process. One of the most surprising findings to come out of the evaluation of our shared care model was the degree to which patients are attached to their family physicians and how much trust they invest in them. Most patients said they would rather receive mental health help from their physician than get a referral elsewhere.

The trust that exists between the physician and the patient can be a healing component, so you must be careful not to rupture that relationship. I once consulted with a 26-year-old male with alcohol abuse whose GP had attended at his birth. As a consultant coming into the GP’s practice you need the GP’s input to enhance your understanding of what’s happening to the patient and to make the process mutually supportive: As a consultant, you do your work through the GP’s relationship with the patient, and the credibility the GP has is transferred to you. Meanwhile, you have to build your own rapport with the patient. I’ve encountered situations where the physician doesn’t like a patient. I had to speak with the physician about his feelings and handling the patient with more respect. It’s as much about managing the consultation and relationship dynamic as it is about treating the patient. In some instances, it’s like being a broker.

“If you don’t get along with a GP, you try to address this issue and you try to make it work.”

In the years I’ve been doing this, I can recall only one incident where the relationship between the consultant and the physician couldn’t be fixed. Generally, physicians are very receptive to our help. They want to be in collaborative programs because they recognize the benefit of additional assistance for treating mental health in the primary care system. Physicians learn so much, and keep learning, that they don’t want to leave the program. Graduating them is a real challenge.

“You have to be a generalist and a specialist.”

As a consultant in a collaborative care model, you switch gears from generalist to specialist and back again. You need to work with individuals, couples and families, and to communicate well. I never know what’s behind door number one in a physician’s office. It could be a parent with a child or an adolescent problem, a couple with marital problems, someone elderly or suicidal. It’s amazing what GPs handle in their practices. Depression and anxiety are frequently the initial complaint, but we see people with schizophrenia, borderline personality disorder and substance use problems. Here’s an example of how broad care can be: In the SMHC program, we saw a 20-year-old with depression who came in with her mother. Unknown to the GP, the daughter used cocaine. We eventually ensured kinship guardianship for her and saw the entire family, including the estranged father, the daughter’s own child and her sister.

“You have to be flexible in so many ways.”

You need to adapt to primary care professional boundaries. Psychiatry has firm professional boundaries, particularly around issues like self-disclosure, which aren’t always so cut and dried in family medicine. You also have to be able to tolerate uncertainty. You must adapt to different professional cultures, too. The culture of family practice is characterized by brief contacts, whereas mental health tends to have longer contacts. Shared mental health care allows the GP to spend more time with the patient. You need to be bilingual, speaking the language of mental health and family medicine. It’s also important to have a good working relationship with the team psychiatrist. If I need to consult with one, I do so over the phone or I set up a time. The psychiatrists also meet with the GPs regularly. If necessary, both the psychiatrist and the consultant meet with the GP, but that rarely happens and such meetings are not time- or cost-efficient.

“Peer support is your saving grace.”

You have to stretch yourself clinically to address the range of patient problems you encounter. You need to be able to discuss with colleagues what’s happening with your clinical practice. Because you work in a somewhat isolated environment, moving from doctor’s office to doctor’s office, you need peer support. We meet monthly to discuss cases and clinical concerns. We take turns presenting our cases to one another. In SMHC, we meet every three or four months with the entire team to keep in touch and hold monthly consultant meetings to deal with more complicated cases, but you can discuss a case with team members whenever necessary. We continually evaluate what’s working and what’s not, and we change accordingly. In the infant mental health program, we also meet regularly, since these cases tend to be very complicated and can involve going to court.

“Of course there are some barriers.”

There are financial and policy constraints for some areas of the country that may prohibit collaborative care models. We could use more funds to hire more consultants because there’s a wait list for our program. In Calgary’s SMHC, an alternative payment plan enables the family physician to bill for the SMHC consultation services. Obviously, some physicians don’t buy into the collaborative model and don’t want to participate in the interview process. Instead, they want to turn the patient’s care over to you. Some GPs might not buy into the educational component of the model. That’s not collaborative care. We’re also concerned about the eventual shortage of GPs undermining a collaborative approach. The job is very mobile. We have a central touchdown office, but you’re really out most of the time, traveling to doctors’ offices. Every case is different, as is every GP and their practice. A big challenge is that sometimes you can’t find resources or there is a long wait list for the programs you need for patients. You need an arsenal of contacts and connections.

“You’ll love the rewards.”

I love what I do. I get to see how the mental health system works from the other side – the primary care side. I get the opportunity to try new things, such as doing brief therapy with GPs. I enjoy being forced to think quickly on my feet. Two heads can be better than one when looking at a patient’s problem. Today, I have a much broader repertoire of skills in assessment, referral resources and therapy for individuals, couples, families and groups. The ability to interface between primary health care and the mental health system is indispensable, especially given the goal of enabling more and better treatment of mental health issues in the primary care system.

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