Canadian Collaborative Mental Health Initiative

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When Dr. Burley became a psychiatrist, he decided to concentrate on helping other family doctors. He found that the greater good could be realized in the community, working with general practitioners in their practices.

Sharbot Lake, Ontario – On an unusually blustery summer morning, the regulars file into the Doctor’s House for eggs and talk of last night’s Blue Jays pitching. Most of the regulars sit at a Harvest table which is littered with newspapers, coffee cups and ashtrays. At a smaller table, talk turns to the Legion baseball tournament set for Saturday – rain or shine. The pace at Doctor’s House, a former doctor’s residence turned pub and eatery, is slow and easy; no one is in any rush in this lazy little tourist community.

A few metres down the road, in the basement of a large wood and brick, two storey building by the lake, another group of regulars are meeting in an oak-paneled conference room, grabbing their coffee, organizing their notes. It’s the regular Friday meeting at the Sharbot Lake medical centre, the day psychiatrist Joe Burley meets with the centre’s team of mental and community health providers. There is a social worker, community workers, a geriatric mood outreach clinician from Providence Continuing Care Centre (PCCC) in Kingston, a nurse practitioner, a psychiatric resident, a family medicine resident and the practice’s two family doctors, Dr. Peter Bell and Dr. Douglas Black.

This morning, Dr. Burley will see eight patients before he heads out to Northbrook, another rural medical centre, where he will see eight more. At this morning meeting, talk turns to others in the community whom he won’t see, but who are his regular patients. A dozen cases are discussed including several geriatric cases, a half dozen addiction related cases and a couple of others who have threatened suicide.

“Does he have access to guns?” Dr. Burley asks, a common question in a community where the opening of hunting season is celebrated like it was Christmas Day.

“He does, but he says he won’t use guns,” explains a caseworker. “His cousin went that way and he doesn’t want to leave that for his wife. His preferred method is hanging.”

Some cases are dire, some present ethical questions such as the role physicians play in allowing mentally unstable people to get their commercial driver’s licence. Other cases are the stuff of Dr. Phil, such as a woman who is dreading an upcoming wedding anniversary following her husband’s infidelity.

For each case, Dr. Black and Dr. Burley consult their computerized patient record system which has notes on each patient including their medication, their past history and the results of recent visits. Dr. Burley and Leah Robichaud, the geriatric mood clinician, are able to make notes directly into the electronic record. (Despite being a small rural practice, Sharbot Lake has been on the leading edge of electronic record technology, and its team has used this technology for more than five years. The practice is part of only a small minority of family practices which have converted to electronic records.)

Much of the information about patients is anecdotal, resident in the experiences of each member of the team. The family doctors see patients on their regular visits, while the community health workers see them in their homes or community care facilities such as nursing homes and seniors’ residences.

Each team member knows each patient on a different level. It’s classic health coverage. In no way does the patient’s care end when a doctor writes a script. In this shared care model, follow-up, feedback and follow-through are key.

Shared care by necessity

Sharbot Lake Medical Centre serves a practice roster of about 2,500 patients. The practice population has a disproportionate number of elderly and chronic care patients. Disease is resident in all age groups, with many patients who are poor, with poor language skills and low education levels. Unemployment is high.

By necessity, Sharbot Lake has been a model for shared and community care, says Dr. Peter Bell, who has served this community as a family physician for 35 years.

“As long as I’ve been here, we’ve been able to utilize the resource potential in this community, whether it’s Children’s Aid Society, police, adolescent workers in the high schools, or even local ministers,” he says. “People don’t realize how many resources there actually are in an area like this and we’ve used them all.”

Four years ago, Drs. Bell and Black were approached by Dr. Joe Burley, a psychiatrist and former family doctor who had just moved back to Kingston from Eastern Canada. Dr. Burley suggested the idea for a brand new service which would bring the specialty expertise from Kingston into the community on a regular and consistent basis. The team of Dr. Burley, a psychiatric resident, geriatric mood clinician Leah Robichaud comes from Kingston. Social worker Sue Powell, who is with the PCCC Mental Health Service lives in the community and works as part of the day-to-day team which includes Dr. Peter Bell, Dr. Douglas Black, nurse practitioner Mary Woodman and a family medicine resident. Lisa Smith and other community care providers complete the circle of care: it includes a full time family counselor, a full time counselor for women who have been exposed to abuse and a full time adolescent counselor at the high school.

The idea has been a successful one, particularly for the family doctors who have been supported by a team with myriad skills and experience. It’s also been important for those mental health workers in the community, who get the much needed support and consistent care from psychiatry.

“We benefit greatly from hallway consultations,” says Dr. Bell. “We’re quite informal. We have a huge advantage on the site, with information sharing taking place in the same building. We cross paths, we see people together, and we support each other.”

Nurse practitioner Mary Woodman says the collaborative model at Sharbot Lake, which she refers to as “the Burley model”, has broadened her knowledge and understanding of mental health and mental illness. Ms. Woodman calls the Friday morning meeting her “continuing education in mental health care.”

At the weekly meetings, discussions include follow-up of patients that Dr. Burley has already seen; patients who are to be seen that day; patients who are waiting to be seen in the future, but who have problems needing interim advice; patients whom team members would like to obtain management advice about but who may not need to be seen by Dr. Burley. The discussions are free ranging and participants are encouraged to provide advice and input, says Dr. Bell.

Recently, the shared care practice at Sharbot Lake Medical Centre has been chosen as one of Ontario’s 55 Family Health Teams (FHTs) for primary care at the local level. Designed to be flexible, these teams are tailored to meet the needs of the local population  Under the FHT model, partnerships are forged between the community and providers with community representatives, local health care delivery organizations and health care providers working together. The FHTs reflect the unique needs of the population they serve and develop collaborative working relationships that enhance access and continuity of care.

Dr. Bell sees this is an ideal model. He believes in the importance of planning collaborative care around rostered (signed and committed) patient populations who receive care from a collaborative group of family physicians and nurse practitioners. This applies to the following models in the Ontario health care system: Health Service Organizations (HSOs); Primary Care Networks (PCNs); Family Health Networks (FHNs); Family Health Groups (FHGs) and the newest model being initiated, Family Health Teams (FHTs).

“In order to plan rationally for health care, allocate resources equitably and evaluate outcome, you must be able to accurately identify the population served and the team who is providing health care,” says Dr. Bell.

Rosters can be analyzed for age and sex distribution as well as social determinants of health and other unique characteristics.

“This may not actually tell you how much psychiatry or counseling services a population needs, but it does provide a basis for decisions by government and agencies around resource allocation as well as an opportunity to evaluate and audit outcomes.”

Veteran social worker Sue Powell credits the group dynamics of Sharbot Lake as being instrumental in its success.

“We’re all interested in the patient,” she says. “That makes a difference. It’s satisfying being part of a team, that we can share the burden of care.”

Nurse practitioner Mary Woodman agrees.

“Absolutely. We’re truly a collaborative team. It’s based on mutual trust and respect between all clinicians. There’s no hierarchy – we work side by side.”