An expert consensus on core competencies in integrated care for psychiatrists

    An Expert Consensus on Core Competencies in Integrated Care for Psychiatrists Nadiya Sunderji MD, FRCPC, Andrea Waddell MD, MEd, Mona Gupta MD PhD, Sophie Soklaridis PhD, Rosalie Steinberg MD MHSc PII: DOI: Reference:

S0163-8343(16)30084-6 doi: 10.1016/j.genhosppsych.2016.05.003 GHP 7110

To appear in:

General Hospital Psychiatry

Received date: Revised date: Accepted date:

3 April 2016 14 May 2016 15 May 2016

Please cite this article as: Sunderji Nadiya, Waddell Andrea, Gupta Mona, Soklaridis Sophie, Steinberg Rosalie, An Expert Consensus on Core Competencies in Integrated Care for Psychiatrists, General Hospital Psychiatry (2016), doi: 10.1016/j.genhosppsych.2016.05.003

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ACCEPTED MANUSCRIPT An Expert Consensus on Core Competencies in Integrated Care for Psychiatrists

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Author names and affiliations Nadiya Sunderjia, MD, FRCPC Andrea Waddella, MD MEd Mona Guptab MD PhD Sophie Soklaridisa, PhD Rosalie Steinberga, MD MHSc a

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University of Toronto Department of Psychiatry, 250 College Street, Toronto, Canada M5T 1R8 [email protected], [email protected], [email protected], [email protected] b

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Départmente de Psychiatrie, Université de Montreal, PO Box 6128, Station Centre-Ville, Montreal, Canada H3C 3J7, [email protected]

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Corresponding author Dr. Nadiya Sunderji, MD FRCPC Room 17-006b, Cardinal Carter Wing, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8 t: 416-864-6060 x6413, f:416-864-5480, e: [email protected]

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Running title Expert Consensus on Core Competencies in Integrated Care for Psychiatrists

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Article data 3 Tables, 1 Figure, 1 Supplemental 4,149 article text words, 182 abstract words

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ACCEPTED MANUSCRIPT Abstract Objective: All psychiatry residents in Canada are required to train in integrated care (also known as

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“shared care” or “collaborative care”). We sought to define the competencies required for integrated

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care practice, with an emphasis on those competencies necessary for all psychiatric postgraduate learners regardless of their intended future practice setting or population. Method: We conducted a mixed methods study including qualitative interviews with nine psychiatrists practicing integrated care

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across Canada, and a quantitative survey of 35 experts using a modified Delphi method. Results: Our participants believed that integrated care aims to build capacity for improved quality of mental health

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care in unspecialized settings, and as such its practice requires broad clinical expertise, and competencies in interprofessional teamwork, collaborative leadership, knowledge exchange, and

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program consultation. All psychiatrists require knowledge of evidence-based models of integrated care and the ability to work with organizations to implement these models. Conclusion: Psychiatrists are best prepared for integrated care practice through clinical exposure to primary care and/or community

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settings, and didactic teaching regarding the evidence for integrated care, quality improvement

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Highlights

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methods, leadership, health systems, and population health.

Psychiatrists require training to practice in integrated care models.

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Competency for integrated care entails clinical expertise, teamwork, and leadership.

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Psychiatrists need knowledge of evidence-based models and quality improvement skills.

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Keywords Integrated care; Collaborative care; Shared Care; Primary care; Psychiatry residency; Competency

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ACCEPTED MANUSCRIPT Introduction Integrated models of mental health care are increasingly widespread, driven by the high costs of health

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care, inaccessibility of mental health care, and under-recognition and under-treatment of mental illness

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in primary care and other settings (1–4). These emerging models represent complex interventions that vary along a spectrum from co-located care to population-based collaborative care models (CCM). Integrated care is most commonly implemented in primary care settings but can also involve specialty

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settings, telepsychiatry, and enhanced physical care within psychiatric settings (1,5–9). Robust evidence

of care, clinical outcomes, and cost-effectiveness.

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supports the effectiveness of integrated care models in improving access to mental health care, quality

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Major professional organizations and educational scholars alike agree that current and future psychiatrists require preparation for practice in these distinct models of care (1,6,10,11). Training in "shared/collaborative mental health care"1 has now become mandatory for all psychiatric residents

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across Canada and is also increasingly widespread in the United States (12,13). However, this important development has been limited by a lack of clarity on the goals and desired outcomes of training; the

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challenges of introducing resident training in models of care that are themselves evolving (e.g. funding, space, acceptability to providers), and; gaps in faculty preparedness to teach integrated care (1,6,14,15).

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Establishing the desired outcomes of training (i.e. competencies) is a necessary first step toward addressing these deficiencies.

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To date only one study has examined integrated care psychiatrists' activities and their perceptions of the essential skills needed for this type of practice (11,16). Other publications have examined which of the Psychiatry Milestones from the Accreditation Council of Graduate Medical Education (ACGME) and American Board of Psychiatry and Neurology (ABPN) may be readily assessed in integrated care rotations (1,10,17).

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In Canada, where this study was conducted, the commonly used terms are “shared care” or “collaborative care”; in the United States the corresponding terminology is “integrated care”. In the United States the “collaborative care model” (CCM) refers to a particular model of population-based measurement-based care in which psychiatrists provide regular caseload review and supervision of other healthcare providers (e.g. care managers). We use the American terminology throughout this manuscript for clarity and in order to highlight the evidence-to-practice gap in implementation of the CCM in Canada (see Discussion).

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ACCEPTED MANUSCRIPT Our study aimed to define the core competencies required for the practice of integrated care in Canada, with an emphasis on the abilities that all residents should have upon graduation regardless of their intended future practice setting or population. There was a profound gap across Canada despite

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ubiquitous mandatory training; program directors and faculty members required guidance they could

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implement regardless of the particulars of their practice context. Therefore, our goal was to identify whether there is distinct skill set for integrated care that applies across diverse settings and populations,

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and if so to articulate it and map it to the CanMEDS 20152 competencies and milestones (18). Our study incorporated the perspectives of psychiatric practitioners in integrated care (experts by experience), health care providers from diverse disciplines who practice in integrated care settings alongside

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psychiatrists, and scholars/leaders in integrated care. In this paper we report on findings from a mixed

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methods study of training needs in integrated care.

Methods

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Study Design

We conducted a mixed methods study with an exploratory sequential design (see Figure 1) (19). The

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initial qualitative phase consisted of interviews with psychiatrists practicing integrated care in a variety of settings and with diverse populations. This phase enabled the identification and in-depth exploration

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of emerging themes (20,21). The quantitative phase consisted of a modified Delphi consensus process with a second group of psychiatrists, multidisciplinary providers, and scholars/leaders in integrated care

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across Canada, and assessed the extent to which they agreed regarding the necessary competencies for integrated care practice (19,21). We integrated the qualitative and quantitative findings at three points in the study (19,21). First, we used the findings from the qualitative phase to develop the Delphi survey instrument; thus the Delphi enabled us to explore the transferability of the qualitative phase findings across Canada. Second, we used the comments from the Delphi to illuminate and explain why certain survey items may or may not have attained consensus. Finally, we integrated the findings from both study phases in a side-by-side display.

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CanMEDS is the most widely used physician competency framework in the English-speaking world.

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ACCEPTED MANUSCRIPT Ethics This study was approved by the University of Toronto Health Sciences Research Ethics Board.

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Qualitative Interviews Sampling and recruitment

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We used stratified purposive sampling to recruit English- or French-speaking psychiatrists from academic and non-academic general hospitals in cities across five regions in Canada (22). Hospital Chiefs of Psychiatry and postgraduate education leaders nominated colleagues who regularly practice in

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integrated care settings. We included psychiatrists working in diverse settings and populations (e.g. geriatric, child/adolescent, rural outreach) to explore whether we could identify a common set of

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activities and competencies. Data collection and analysis were iterative, and continued until we reached informational saturation (no new emerging themes) with nine in-depth interviews.

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Data collection

Using a semi-structured interview guide we explored the practice settings, contexts and activities of

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psychiatrists delivering integrated care; knowledge, skills and attitudes required; and perceived postgraduate training needs. We conducted interviews ranging from 25-45 minutes in length from April

Data analysis

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the study.

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to October 2014. We audio-recorded all of the interviews and retained the recordings until the end of

The data was analyzed in four steps. First, two research team members created a summary of each interview. Second, we ensured trustworthiness of our data through member checking, i.e. obtaining participants’ feedback on the summary to ensure that their intent was captured accurately (23). Third, two authors inductively and thematically analyzed three summaries, coding them independently and then jointly developing the coding dictionary to which the first author coded the remaining summaries. We iteratively refined the codes using the constant comparative method, whereby codes were created, revised, combined or removed until the codes were consistent (24,25). The codes and summaries were organized using NVivo software. Finally, we listened to all of the audio-recorded interviews again to 5 of 26

ACCEPTED MANUSCRIPT ensure the analysis remained true to the original material and to select exemplary quotes for inclusion in this manuscript.

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Quantitative Survey

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Delphi is a method to collect knowledge, experiences and perceptions and develop consensus amongst panelists on issue under study. Delphi also offers a strategy for assessing the strength of the consensus (26–29) Typically, iterative surveys are interspersed with feedback about the group’s aggregated responses, enabling participants to further consider their own responses and potentially form a consensus (27–29). However, traditional Delphi processes are resource-intensive and the response burden can lead to participant attrition (29,30). We used a novel Real-Time Delphi method, which collapses data collection into a single round through use of an on-line platform (calibrum.com), and which may increase efficiency and interactivity (30–32). After saving their responses participants could immediately view other participants’ anonymous numerical and textual responses to date, and they were invited to further consider their own response. Sampling and recruitment

The selection of experts is a critical step in the Delphi process (27–29). We sought an interprofessional

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panel of experts with diverse clinical experiences and achievements in integrated care education, research, leadership or public policy. We used purposive stratified sampling to ensure regional

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representation across Canada as well as the inclusion of adult, child/adolescent, and geriatric care providers. Psychiatrists who participated in the earlier qualitative phase were ineligible to participate in

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the Delphi. There are no set guidelines for panel size, however some authors have suggested that sample sizes above 25 to 30 may not yield further insights or other advantages (33) and are sufficient to

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develop competencies in health professions education (34,35). We invited the experts' participation via email, with one reminder. Thirty-five experts agreed to participate, four declined due to limited availability during the data collection window, and nine did not respond. Survey Instrument The survey instrument (see Supplemental File) we developed consisted of 87 knowledge, skill and attitude domains potentially relevant to integrated care, based upon the findings from the initial qualitative study phase as feedback from three family physicians who collaborate with psychiatrists in integrated care settings. Participants were asked to consider what abilities relevant to integrated care all graduating psychiatry residents should have regardless of their future practice (34). For each domain 6 of 26

ACCEPTED MANUSCRIPT participants were asked to respond to two Likert scale questions in which they rated their agreement with 1) the domain’s importance to integrated care and 2) the feasibility of assessing resident performance in that domain. An additional open-ended question at the end of the survey solicited

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supplemental domains. Data collection

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Data collection took place during October and November 2014. Participants received a unique username and password and could visit the survey website as often as they wished within the defined three-week data collection window. They were asked to complete the survey at least once in the first week and to

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return at least once in the second or third week in order to optimize the degree of interactivity. Once participants submitted their initial response they could immediately see a histogram summarizing all

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participants' ratings to date and all explanatory comments. They were encouraged to provide explanatory comments for their ratings, especially in the case of an extreme or divergent opinion

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compared to other participants. Data Analysis

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In Delphi methodology consensus is a function of participants' agreement with an item and with each other (36). We pre-specified a threshold of 80% of participants agreeing or strongly agreeing with a

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survey item as a conservative threshold for consensus. We reviewed all explanatory comments offered by participants to enrich our understanding of participants’ beliefs about the necessary abilities for

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Collaborative Care psychiatrists.

Results and Discussion Qualitative Interviews Interview participants worked with a variety of populations and in diverse practice settings in eight cities across Canada; almost all participants worked in primary care settings and many also consulted to other community organizations (see Table 1). Participants discussed the role for integrated care in the healthcare system, the nature of their clinical activities, and the necessary abilities to do this type of work. 7 of 26

ACCEPTED MANUSCRIPT The role for integrated care Given widespread problems with access to specialized mental health care, participants formulated the

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role for integrated care psychiatrists as: a) capacity building for mental health care in unspecialized

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settings, and b) contributing to health system sustainability and psychiatrists’ social accountability. They also supported postgraduate training in integrated care as a way of increasing resident awareness of the

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need to allocate scarce psychiatric resources efficiently. Clinical activities of integrated care psychiatrists

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All of our participants emphasized knowledge exchange and the provision of case-based continuing professional development as key components of their integrated care practice aimed at improving

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quality of care, for example through "hallway consults", teaching points embedded in consultation notes, and role modeling and demonstration (e.g. joint assessments as an opportunity for other providers to observe). Some participants described a formal or informal leadership role within a clinical

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team, which involved optimizing team functioning to enable a diversity of viewpoints to be integrated into a coherent care plan, particularly for complex patients. In some cases, the participants provided

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program consultation to the organization or its leadership to develop and implement policies and training to promote high quality, evidence-based care throughout the organization. Finally, many

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participants played a role in stepped care by making or contributing to decisions regarding the appropriate level of care (e.g. primary, secondary or tertiary) to match an individual’s needs.

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Necessary abilities for integrated care practice Participants described knowledge, skills and attitudes that are critical to the successful provision of integrated care (see Table 2). Of note, four out of the five adult psychiatrists spontaneously described their clinical practice pattern as general psychiatry with an expanded scope of ages and conditions seen), in contrast with hospital-based ambulatory services, which are often organized into specialized services. "Working ... in the [hospital's] mental health service ... I thought I was a general psychiatrist. As it turns out I'm not because my true general psychiatric role comes out when I'm at this primary

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ACCEPTED MANUSCRIPT care clinic, where … I’ll see everything from the individuals with chronic schizophrenia ... to children who have behavioral issues, to seniors who have dementia, etc." [KI-08]

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Participants discussed the importance of valuing and being skilled in forming collaborative working

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relationships but some participants wondered if these characteristics can be taught.

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“I think you can teach it. But it’s more difficult [to teach than other competencies and]... You can’t be the kind of person who just wants to go behind the door and see one patient and shut the door.” [KI-04]

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Delphi Phase

Thirty-two out of 35 experts participated in the Delphi process for a 91.5% response rate (see Table 1 for

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participant characteristics). Of those who participated, 25 experts (78%) interacted with the survey on at least two occasions. Participants made use of and were influenced by the Real-Time Delphi's features such as the ability to view others' responses. All participants modified their responses to at least one

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question and in some cases participants modified their response to a question up to 12 times. All participants provided comments, and a few of the comments specifically expressed a reaction to (e.g.

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agreement with) other participants' comments.

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Areas of consensus

Participants formed a consensus regarding the specific importance of 40 knowledge, skill and attitude

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domains for all future psychiatrists to attain in order to be competent to practice integrated care (see Table 4). There was a high level of agreement regarding the clinical competencies required for integrated care practice. Participants emphasized the ability to manage a broad range of mental health and addictions presentations across the lifespan seen in primary care (e.g. including children, youth, women's reproductive life stages, and geriatrics). This was consistent with the theme of generalism from the prior (qualitative) phase of the study. Also echoing the qualitative phase (see Table 2), participants identified a combination of interpersonal, attitudinal, and communication abilities that enable psychiatrists to build trusting working relationships, which in turn enable co-management of complex patients, knowledge exchange, and risk management. Areas that were not endorsed 9 of 26

ACCEPTED MANUSCRIPT There was less agreement among our expert panelists regarding the necessary abilities with respect to health systems, population health, leadership and management. In reviewing participants' comments several explanations emerge. Some aspects of public health and policy, leadership (e.g. team dynamics,

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organizational functioning), and practice management (e.g. time management, e-mail correspondence),

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were viewed by participants as general to resident training rather than specific to integrated care. Some domains were seen as relevant to integrated care but not specific to the psychiatrist member of the

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team, for example advocating for patients' social and instrumental needs, leading interprofessional case conferences, and coordinating care across settings and over time.

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Certain items were seen as well suited to psychiatrists practicing in integrated care models but inappropriate or unrealistic for residents in training, for example: assessing an organization's needs and

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abilities; participating in or leading organizational changes; contributing to building new care teams; advocating for systems changes to address problems with quality of care, and; providing longitudinal mentorship. In some cases, participants’ expectations were incongruent with the level of performance

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expected at the transition to practice phase of training according to the new CanMEDS 2015 framework, with which they may not have been familiar. It may be realistic for senior residents to engage in some of

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these activities, however unrealistic that they do so in the existing formats for residency training in integrated care (e.g. a one- to two-month block).

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Health systems and population health

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While several individual survey items fell below our pre-determined threshold for consensus, there was a trend suggesting agreement with the overall idea that residents should be exposed to the rationale for, and functioning of, integrated care within a health systems perspective; the evidence and knowledge gaps regarding the different models of integrated and collaborative care, and; issues with knowledge translation and implementation of such models. For example, one participant commented "there is much general talk about the evidence, but the most rigorously assessed models are generally not delivered in Canada" [D32]3. Another participant argued for an understanding of complex interventions and the role of context (37,38):

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We use KI for Key Informants, and D for Delphi participants.

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ACCEPTED MANUSCRIPT "The initiatives that have been demonstrated as being effective (assessed by well-designed empirical studies) may inspire the work force of collaborative care leading to the redesign of local health care organizations. However, collaborative care is not a single universal model... Many

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components of the health care system, including collaborative care, are too complex to be

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modeled deterministically. Collaborative care... must innovate locally to fit the needs of the population and take into account available resources." [D30]

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In short, residents should be equipped with the knowledge to work in the current health care system as well as to participate in future health system change. To that end, participants recommended that

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residents learn about principles of population health [D17, D26, and D32], "health care economics" [D24], the IHI Triple Aim [D30], and primary care reform including: a) "how much mental health care is

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delivered in the primary care setting" [D34], b) how funding and practice models influence "the resources and limitations in the [specific] contexts in which they are working" and thus "the services available to client" [D12, D14 and D15], and c) how this informs the "stresses and factors influencing

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family practitioners" [D10]. Stepped care models and chronic disease management models were also viewed as relevant, illustrating "principles of health promotion and secondary prevention" [D21] as well

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as "matching intensity of symptomatology to intensity of resource provided" [D34]. These recommendations were consistent with prior (qualitative) interviewees' reflections on the role of

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integrated care within the health system.

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Leadership and management

Overall, individual items related to leadership were among the most controversial in our study, yielding the most divergent responses. This parallels findings in the Royal College of Physicians and Surgeons of Canada’s (RCPSC) consultations regarding the revised CanMEDS 2015 framework, in which the change from the Manager to Leader role was strenuously debated. Similar to our interviewees, Delphi participants’ explanatory comments paint a nuanced portrait of leadership competencies including collaboration, contribution to team functioning, humility [D04, D12], self-awareness [D01, D12, D15, D22, D25, D26], and the flexibility to lead or follow/participate depending on the scenario. Participants recommended training in "understanding group/organizational and interpersonal dynamics in the collaborative setting" [D33], "recognizing the leadership structure in place… *whether+ the team is 11 of 26

ACCEPTED MANUSCRIPT functioning well or poorly... and why" [D02], "shared leadership, holding difficult conversations, negotiating change" [D21], and "critical thinking around what leadership means in these settings" [D12].

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For example, in an integrated care context physician leadership may mean "lead[ing] from behind and

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motivat[ing] others to do their best work" [D31], "support[ing] others in leadership and in shared leadership" [D15], and "chang[ing] practice must be negotiated and built over time with consensus,

comment seems to summarize the group's perspective:

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rather than 'ordered' as in a more traditional health care setting" [D12, D22]. One participant's

"Getting training in collaborative leadership is in fact important but this way of saying it is

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dangerous. It could imply that the psychiatrist is de facto the leader in collaborative work - and he isn't. He can be sometimes, sure, but not always. And I think that physicians and psychiatrists need

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not only training on how to be a good leader but also (and most importantly) training on how to work in a team when you are not the leader. This is way more difficult for us doctors." [D28]

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Mentoring other providers

A final area of competency is the ability to mentor other providers to improve quality of mental health

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care in non-psychiatric settings, consistent with the CanMEDS Scholar and ACGME Practice Based Learning roles. Similar to key informants from the qualitative phase, Delphi participants emphasized

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reciprocal learning and knowledge exchange. This was recommended in recognition of "how other professionals can enhance psychiatric practitioner knowledge" [D24], and in the spirit of "doing with"

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rather than "doing to" [D15]. One participant proposed: " If you wish to do this domain justice [i.e. forming a teaching/learning alliance], please develop teaching by primary care practitioners throughout the residency program... Without this dimension, the domain will remain one sided, with the specialist being the teacher and others being the 'taught'." [D02] Potential limitations of the Delphi Our expert participants' responses were anonymized to reduce the risk of bias and level the playing field in terms of the weight/credence given to each participant's input, however, respondents varied in their 12 of 26

ACCEPTED MANUSCRIPT degree of participation, and thus ultimately opted to have more or less of a voice in the group process. We did not statistically compare psychiatrist versus non-psychiatrist perspectives. Given the conservative threshold for consensus and the overall composition of the expert group, there would need

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to be nearly complete divergence in the perspectives of different disciplines in order for psychiatrists’

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perspectives to override other disciplines; our review of the explanatory comments suggests this is unlikely. Items not attaining agreement could reflect such a divergence, but the comments do not

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support this. The Delphi method, although well-established and commonly used to form consensus, represents only one source of information (i.e. expert opinion). Additional sources include national educational frameworks (e.g. CanMEDS and ACGME), population health needs, and health services

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research and policy, as well as service users’ perspectives. Our Delphi participants’ comments touched on many of these considerations, yet a further degree of interpretation and synthesis is needed to

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Other Potential Limitations of the Study

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generate proposed competencies and milestones.

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Our sample, while representative of a range of professional disciplines and types of expertise, was exclusively Canadian leaving some uncertainty regarding the extent to which our findings can be

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transferred to other health care systems. On the other hand, integrated care practices may be best understood through the lens of their role within the health care system, therefore, transferability may

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not be possible or desirable if different systems require different competencies. Preliminary consultation with authors conducting similar research in the United States suggests that our findings may be transferable to other systems experiencing a mismatch between demand and supply, such as the United States under the Patient Protection and Affordable Care Act. Despite these limitations, to our knowledge this study provides the most rigorous expert consensus to date regarding domains for graduate medical training in integrated care, and presents a useful guide for the further refinement and elaboration of this emerging area of training.

Conclusion and Future Directions

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All Canadian psychiatry residents are required to train in integrated care. However, Canadian residency programs have faced numerous challenges in implementing training, reflecting both the lack of clarity

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regarding the goals of training and the challenges of training residents in models of care that relatively

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new and are still developing (39). Efforts are needed to improve the quality and consistency of training nationally. Defining the competencies required for integrated care practice is an overdue but necessary

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first step towards developing appropriate curriculum and faculty development. These competencies include: a broad scope of general medical knowledge and skills to assist in the care

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of complex patients, interpersonal and intra-personal abilities to work collegially and constructively within interprofessional teams, and abilities to participate in knowledge exchange and continuous

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learning, in an interprofessional setting. Furthermore, psychiatrists need to know about evidence-based models of integrated care, be able to assess how well the model implemented in an organization is

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functioning, and be able to promote improvements to systems of care. Spurred by a national training requirement we aimed to develop competencies relevant to all graduating psychiatry residents regardless of their intended future practice. Thus, we did not explore specific

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aspects of medical or psychiatric knowledge that may be required in integrated care practice and that

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may vary according to the practice and population served; this could be explored in future research. Based on our study’s findings, including the expressed opinions of participants, we recommend that all

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residents gain exposure to primary care and/or community agency settings through a longitudinal experience during the transition to practice stage of training, and to a core curriculum that augments experiential learning particularly in the realms of the evidence, implementation and improvement of integrated care models; population-based care, and; health policy, economics and reform. Residency programs will also need to increase attention to the preparation that faculty members will need to strengthen their own integrated care practices and their abilities to teach and assess residents in their integrated care rotations. Furthermore, while the general consensus in our study was that the relevant competencies are teachable, participants acknowledged that learners may have varying affinities and aptitudes for integrated care work, and this may be worth considering in the residency selection process if we wish to see more psychiatrists practicing in these models. Finally, the development of validated 14 of 26

ACCEPTED MANUSCRIPT approaches and tools for performance assessment in integrated care will enable further elaboration and authentication of the competencies.

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Disclosures

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On behalf of all authors, the corresponding author states that there are no financial, personal, or other disclosures or conflicts of interest. The University of Toronto Department of Psychiatry

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provided operational funding this study.

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Acknowledgments

We are grateful to the University of _____ Department of Psychiatry Strategic Plan Implementation

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Fund for their support and funding of this research, and to Dr. _____ for assistance with data collection for two qualitative interviews. We would also like to thank the experts who participated in the Delphi

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survey: _______ [blinded].

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ACCEPTED MANUSCRIPT Bayliss EA, Bonds DE, Boyd CM, Davis MM, Finke B, Fox MH, et al. Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters. Ann Fam Med. 2014 Jun;12(3):260–9.

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ACCEPTED MANUSCRIPT Table 1. Characteristics of study participants, nine psychiatrists interviewed, Canada, 2014 Number of participants 9

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Qualitative interviews Region of Canada Western Canada 2 Prairies 2 Ontario 3 Quebec 1 Atlantic Canada 1 Specialty or subspecialty Adult / General psychiatry 5 Child psychiatry 2 Geriatric psychiatry 2 a Integrated care practice settings Primary care teams 8 Community agencies (e.g. case management agencies, 3 child protection services) Residential settings (e.g. shelters, group homes, nursing 3 homes) Rural outreach (e.g. in person or via telepsychiatry) 3 Delphi Panel 32 Region of Canada Western Canada 5 Prairies 4 Ontariob 12 Quebec 4 Atlantic Canada 7 Profession, including specialty or subspecialty Adult / General Psychiatry 15 Child Psychiatry 3 Geriatric Psychiatry 4 Family Medicine 5 Nursing 2 Social Work 2 Psychology 1 Residency programs represented Programs whose integrated care education leads (nominated by 10 program director) participated a Many participants provided integrated care in more than one setting.

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Note that Ontario has 6 out of the 17 Canadian Psychiatry residency programs. 20 of 26

ACCEPTED MANUSCRIPT Table 2. Professional activities and required abilities of psychiatrists providing integrated care (nine psychiatrists, Canada, 2014) Exemplary Quotes Regarding Knowledge, Skills and Attitudes

Provide access to care beyond hospitals and the health sector

"Where we train our psychiatry residents ... most of it's hospital based and they kind of learn from their preceptors that you just keep seeing people ongoing essentially for as long as you can, and I just think it’s not a good use of resources. And so I think that it’s trying to re-orient most of psychiatry resident training to interacting more with family physicians in a consultative, collaborative model, I think would be a better use of resources and would allow for vastly more people to be seen." [KI-05]

Assist patients and providers in system navigation and care coordination

"Navigating the system is part of it… what should stay here, what should go secondary, what should go tertiary." [KI-02] "Understanding the health system context... is important... that’s about knowing family medicine and knowing what it can do, what family doctors do… even understanding the pressures they’re under, as a family doc, knowing what a day is like... knowing all the uncertainty that comes into play… I have to know… what can they handle in the micro system of that family med unit." [KI-02]

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In developing a new integrated care service as a final year resident "I was able to kind of do the environmental scan and figure out what going on there, what was lacking, what was needed, what were the demographics of the kids that came in, what were the types of mental health problems, who were the people who were working there, and what was needed from a psychiatry point of view and then also coming in and starting to build this coordinated model." [KI-03]

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Professional Activity

Demonstrate flexibility regarding one's role and the ability to accommodate to another milieu

"The family practice milieu is ‘Whatever comes in, I will see’… so you have to have that as a psychiatrist too, which is why I’ll see kids, which is why I will see anything, in fact, they don’t have to screen anything… anything is open... and that’s part to me of being congruent with the family medicine milieu… which is… we’re open to anything, we’ll do whatever needs to be done… I think that really helps." [KI-02]

Navigate one's dual roles as a leader/ expert and an equal team member

"For good collaborative care to occur, you’ve got to really be comfortable coming down off the specialist’s podium a little bit and try seeing things from other people’s point of view... I'm not saying there isn't a role for leadership among physicians, and many physicians are leaders and some non-physicians are leaders of 21 of 26

ACCEPTED MANUSCRIPT teams, but I think that's important." [KI-01] "The other thing that I think is crucial, of course, is you need to be approachable and have good communication skills… They want someone... in the team who they can kind of work with and communicate with and feel comfortable sort of bouncing ideas off of or bouncing questions off of." [KI-08] "I make recommendations back to colleagues and so I guess you have to trust the nursing staff, family physicians and so on—you can’t be totally in control… In the kind of work that I’m doing you do have to sort of delegate and have people that you work with that you can be reliant that they’re going to follow through on your recommendations." [KI-05]

Manage complex patients through team based care

"The one type of psychiatry [practice] I really hate is sitting in my office and I'm the only person dealing with this patient... [you can't do that with many patients], certainly not sick people, people with really serious mental illness... so that's why I like these various models of collaborative care, because I know I'm not alone and I really trust the skills of the people I'm working with" [KI-03]

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Build trusting relationships with non-psychiatrists to support shared patient care and education

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"You have to know how to work with people to bring out the best of them and to be able to... come up with a collaborative decision that everyone feels comfortable with... that's a real skill... to be able to bring people in the room together because you're going to have lots of different ideas about what would be the best course of action" [KI-03]

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Manage risk when sharing responsibility for patient care

Engage in mutual knowledge exchange; mentor nonpsychiatrists in order to promote knowledge translation of evidence into practice

"Risk management in collaboration I think is another [important] one, I mean I think a lot of - not just residents but [practicing] doctors - get really caught up and uptight about this idea: OK, well I'm seeing Joe Blo who's got chronic suicidal ideation with the mental health worker... now I somehow have, you know, responsibility but yet it's the mental health worker who sees them week to week and I see them once in six months" [KI-06] "I’m a big believer in this model—to me…there are a lot advantages... one of them is teaching advantages, if you look at adult pedagogical models, so it's ... case-based, in your office with an ... expert that you have an *ongoing+ relationship with… it’s a very nice knowledge translation, transfer of skills thing this whole model" [KI-02] Psychiatrists providing integrated care require "a capacity and a desire to educate, that's actually probably a large component of it, a delight in educating, being educated so for that matter... an openness to being taught as well by my primary care colleagues... not that it's a lot of it but still... that's an important attitude... being 22 of 26

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receptive and open and I guess humble, and not being overly dogmatic or paternalistic, I think that's crucial." [KI-08]

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ACCEPTED MANUSCRIPT Table 3. Expert consensus on required abilities for integrated care, Canada, 2014 Quantitative Survey – Knowledge, Skills and Attitudes Endorsed

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 Being flexible and adaptable regarding one's role  Negotiating roles when sharing the care of patients with other providers (e.g. addressing overlapping and distinct scopes of practice, availability)  Being attentive to the etiquette of being an external consultant to another setting or organization (e.g. metaphorically being a guest in someone else's home)

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Assess the organization one is consulting to, e.g. population served, providers' abilities, beliefs and needs Demonstrate flexibility regarding one's role and the ability to accommodate to another milieu Build trusting relationships with non-psychiatrists to support shared patient care and education

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The rationale and evidence for Collaborative Care models of health service delivery The general context of community-based care, e.g. community needs and resources Principles of public health / population health The role of the longitudinal relationship that patients have with their family physicians, including for long term support, coordination and continuity of care Interpreting / metabolizing information and requests from other providers Communicating a comprehensive understanding of patient problems from a biological, psychological and social perspective Creating clear and detailed treatment plans that include a contingency plan Conveying information in writing (e.g. embedding teaching within consultation notes) Identifying the value of the FP's longitudinal knowledge of the patient in refining one's assessment and implementing a treatment plan Providing indirect consultation (i.e. an opinion without having assessed the patient directly) Communicating orally (e.g. for informal case discussions) The continuum of mental health services, i.e. from primary to tertiary levels of care Being sensitive to the challenges that other providers face in accessing specialty psychiatric care and navigating the mental health system Assisting with navigating the mental health care system, e.g. facilitating targeted referrals and flow of information The resources specifically available in a particular community The spectrum and frequency of problems seen in primary care The resources and limitations of primary care The training and scopes of practice of other health care providers, including their varied experience and expertise

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Qualitative Theme / Professional Activity Provide access to care beyond hospitals and the health sector

 The day to day work experience of family physicians, e.g. pace, workload, tasks  Forming working relationships with providers from other professions  Building collaborative, trusting, mutually respectful relationships with other providers  Exercising empathy for other healthcare and social service providers  Building mutual understanding through one's communications and over time  Creating and maintaining a psychologically safe and supportive environment for collaborative practice  Having an approach to soliciting feedback

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 Managing risk in team based care  Managing risk in remote care  Forming a teaching/learning alliance  Viewing oneself as having something to learn from, as well as something to teach to, other providers  Tailoring education to the audience's existing knowledge and experience  Role modeling specific clinical skills  Role modeling in general

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Manage risk when sharing responsibility for patient care

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Manage complex patients through team based care

Having a desire to be helpful toward colleagues Respecting the skills and expertise of other providers Valuing open lines of communication with colleagues Being self-aware, including of one's limitations Reflecting upon feedback and implementing necessary practice change Navigating one's dual roles as expert/leader and equal team member Joining an existing care team Knowledge of team dynamics Being attentive to power dynamics in working relationships Participating in an interprofessional case conference Coordinating patient care within a team Valuing a team as greater than the sum of its parts (e.g. having collective knowledge) Having a sense of shared accountability for patient outcomes when sharing patient care with other providers Relinquishing the expectation of having sole control over the care of shared patients Tolerating ambiguity, uncertainty, complexity Knowledge of professional standards of medical practice Being willing to accept shared risk for negative outcomes when sharing patient care

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            

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Figure 1. Design of an exploratory sequential mixed methods study of the core competencies required for integrated mental health care.

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