Integrating mental health services within primary care

ELSEVIER

Integrating Mental Primary Care

Health

Services Within

A Canadian Program Nick Kates, M.B.B.S., F.R.C.l?(C), Marilyn Craven, M.D., Ph.D., C.C.F.P., Anne Marie Crustolo, R.N., Lambrina Nikolaou, B.Sc., and Chris Allen, M.B.B.S.; F.R.&?.(C) Abstract: The increasingly prominent role of the family physician in delivering mental health care can be enhanced if productive and collaborative relationships can be established with local mental health services. This paper describes a Canadian program that has achieved this by bringing mental health counselors and psychiatrists info the offices of 87 family physicians in 35 practices in a community in Southern Ontario. The paper describes the program, the activities of counselors and psychiatrists within the practices, and the administrative structures set up to coordinate these activities. Data is presented from the evaluation of the first year of the program’s operation (13 practices and 45family physicians) during which time 3085 referrals were received. The program made mental health care more available and accessible, increased continuity of care, provided additional support for the family physician, offered nezu opportunities for continuing education, and led to a reduced and more ejficienf use of other mental health services. The components of the program can be adapted to mostcommunities. 0 1997 Elsevier Science Inc.

Introduction The family physician plays a central role in providing mental health care for his/her patients. The prevalence of psychosocial problems in primary care (as measured by the General Health Questionnaire) may be as high as 40% [l-4], and the prevalence of psychiatric disorders is 25% [5-B]. For many of these individuals the family physician may be the sole provider of care.

Hamilton-Wentworth HSO Mental Health Program, Hamilton, Ontario, Canada. Address reprint requests to: Nick Kates, Director, c/o Hamilton-Wentworth H!SO Mental Health Program, 43 Charlton Avenue East, Hamilton, ON, Canada L8N lY3.

324 ISSN 0163-8343/97/$17.00 PI1 50163~8343(97)00051-O

These problems are not always detected or treated. Studies suggest that family physicians may identify just over 50% of the mental health problems presenting in their office [9,10]. Even when a problem is detected, treatment rates may also be low. Data from the U.S. 1990 National Ambulatory Care Medical Survey [ll] found that 5% of all family physician visits involved some form of counselling and 5.9% involved the prescription of psychotropic medication despite the fact that many physical illnesses have an accompanying emotional component and that with appropriate support many “psychiatric” treatments can be implemented effectively in primary care [12]. Referral rates to specialized psychiatry/mental health services are also low. Less than 5% of individuals with an identified psychiatric illness are referred to psychiatry [13] and less than 1% to a community agency 1141. Low referral rates is partly due to the frustration of many family physicians when trying to refer a patient to a mental health service or psychiatrist [15]. Family physicians have consistently complained that their role in delivering mental health care could be enhanced if psychiatric services were more accessible and if support was more readily available. A series of focus groups held with family physicians in seven communities across Ontario consistently identified high levels of dissatisfaction with the accessibility of timely psychiatric consultation and treatment and with poor communication on the part of mental health services. Family physicians frequently felt their judgment was undervalued by psychiatrists with a lack of collegiality [16].

General Hospital Psychiatry 19, 324-332, 1997 0 1997 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010

Integrating Mental Health Services This is consistent with findings from other jurisdictions [17,18]. Overcoming existing difficulties and establishing new productive partnerships between mental health services and family physicians requires innovative models of collaboration [19]. Such models view both family physicians and mental health services as part of an integrated mental health care system. Care is shared by providers whose roles are complementary, with the patient being able to access specialized care when needed with a minimum of impediment. One way of achieving “shared care” is to bring mental health service providers into the family physician’s office [20-271. This paper describes one such program in Hamilton-Wentworth, Ontario, which brings counsellors and psychiatrists into the offices of 87 family physicians in 35 practices serving 170,000 people. It reviews data from the evaluation of the first year of operation of the program and outlines the benefits and implications of this approach.

The Hamilton-Wentworth Health Program

HSO Mental

The Hamilton-Wentworth HSO Mental Health Program, funded by the Community Health Branch of the Ontario Ministry of Health, began operation in October 1994, linking mental health counselors and psychiatrists with 13 primary care practices (Health Service Organizations-HSOs) encompassing 45 family physicians, serving 85,000 people. The Program expanded in April 1996 to include another 23 practices and an additional 42 family physicians, thereby doubling the number of individuals served. Hamilton-Wentworth is a community of 460,000 located in Southern Ontario, Canada. HSOs are rostered family medicine practices, funded by capitation, with the per capita payment being weighted according to projected service utilization. The 78 HSOs in Ontario are currently the only capitated primary care practices in Canada. The Mental Health Program has two components: mental health counselors and psychiatrists who work within each HSO and a Central Management Team, responsible for administering and evaluating the program and implementing programwide activities. The Program aims to enhance the mental health services offered in primary care while strengthening ties between family physicians and mental health services. It also aims to increase the skills

and comfort of family physicians when managing the mental health problems of their patients. From the outset, each HSO has developed its own modus operandi within guidelines and goals laid down by the Program. This has enabled each HSO to respond to its particular needs and the skills of participants.

How the Program Works Counselors and Psychiatrists Physicians’ Ofices

in the .Family

Mental health counselors are attached permanently to each practice, with the amount of time being determined by the size of the HSO. One full time equivalent counselor is allocated for approximately every 8000 patients. Most counselors are MSWs or psychiatric nurses with many years of experience in general counseling or outpatient psychiatry services. Some practices have, however, chosen counselors with specific skills in working with the elderly, children, or non-English speaking patients if these populations figured prominently on their roster. The psychiatric consultant visits every 1-3 weeks, depending on practice size and need. At all times the counselors and psychiatrists work collaboratively with the family physician, rather than setting up parallel activities or separate mental health clinics in the family physician’s office. They attempt to maintain and reinforce the role of the family physician as a provider of community mental health care, rather than tmdermining or usurping this role.

Activities

of the Counselor

The counselor is available to see or discuss patients if the family physician feels that additional expertise is required. The emphasis is on short-term care with individuals and families, thereby ensuring that the counselor remains accessible and eliminating lengthy waiting times for service. Some individuals may, however, need to be seen at regular intervals over longer periods of time. Patients are usually seen within 2 weeks of being referred but urgent cases can be seen immediately. The counselor may also provide the family physician with advice about specific management techniques or local resources (such as a shelter, detox center, or social agencies) which the family physician can then incorporate into the management

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plan. The counselor assists in making referrals to community programs and mental health services, an activity that family physicians had previously complained took up excessive amounts of their time. The counselor may also refer someone to the visiting psychiatrist and will usually meet with the psychiatrist for additional advice and support for cases they are managing. The family physician is available at all times to support the counselor and the psychiatrist is also available by phone if a crisis arises or a patient’s condition should deteriorate. All counselors in the Program meet together monthly to discuss proposed changes in the Program’s functioning or adjustments they might like to see, to learn about local resources or specific clinical issues, and to provide each other with mutual support.

Activities

of the

Psychiatric

Consultant

A psychiatric consultant visits each practice for half a day every 1-3 weeks, depending on the size of the practice and the demand. The psychiatrist has three major spheres of activity: direct case consultation with a limited degree of follow-up, indirect services (the patient is discussed or reviewed, but not seen), and education. When in the HSO, the psychiatrist will see any case if requested to do so by the family physician or counselor. The consultation in the family physician’s office differs in many ways from that conducted in the psychiatrist’s office. The psychiatrist can discuss the problem with the family physician before the patient is seen, getting an idea of specific question(s) to be answered by the consultation. Relevant background history can be summarized efficiently and the outcome of previous or current therapeutic interventions by the family physician or other mental health services reviewed. Following the interview, the psychiatrist and family physician work out a comprehensive management plan before the patient leaves. The family physician knows that the psychiatrist will be returning 1 or 2 weeks after the consultation and will be able to discuss any problems that have arisen in the interim. The psychiatrist is also available by phone to discuss emergencies with the counselor or family physician and work out immediate management plans. The psychiatrist may elect to see a patient for a follow-up visit(s) to stabilize someone who is acutely ill, monitor the outcome of a specific intervention, or to assessa marital or family problem. Follow-up visits are kept to a minimum, as the goal

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is to hand back the care to the family physician or counselor and support his/her ongoing management. In some instances, however, a follow-up visit becomes an important component of short-term management. The psychiatrist will also review and discuss cases with the family physician and/or the counselor. These discussions may be pre-arranged, sometimes with an entire group of family physicians. More frequently these are brief “corridor” contacts which take less than 5 minutes. These may be new casesor a patient who has already been seen or reviewed. Such discussions may deal with a medication question, a management problem, a medico-legal issue, or a potential referral. Often their purpose is to support a family physician in implementing a chosen management plan. A third area of activity for the psychiatrist is providing educational interventions for family physicians. Once the psychiatrist is present within the primary care setting and is meeting with the family physician(s), opportunities arise for both casebased teaching and structured educational presentations around a topic of the family physician’s choosing. These presentations are, of necessity, brief and carry a simple, generalizable messagethat can be reinforced by educational aids (handouts, visual reminders, charts, and so forth). The role of the fumdy physician. In this model, the family physician remains integrally involved in the care of patients with mental health problems, even after a referral to the counselor or psychiatrist. For many patients, however, the family physician will provide ongoing mental health care without needing to refer to the counselor or psychiatrist, although advice about the management of these cases is always available.

Central

Program

Organization

Activities in each HSO are coordinated by a central administrative team that is responsible for organizing the allocation and flow of funds, the recruitment of counselors, and evaluation of activities in each HSO and the Program as a whole. It sets and monitors program standards and targets for ongoing quality improvement and provides regular reports (feedback) to each HSO. Together, the evaluation and quality assurance processes create a mechanism for local accountability. The central team also organizes clinical and educational activities that span all HSOs in the pro-

Integrating Mental Hdth gram. Examples have included the recruitment of child and geriatric psychiatrists to visit selected HSOs monthly, educational workshops, and the provision of educational materials for HSO staff and patients. The program has also organized educational or treatment groups that serve patients from a number of HSOs such as stress management, couple communication, and education about depression. In this way the specialized skills of a counselor from one HSO can be made available to other HSOs that do not have access to such a resource. Some groups have also been run collaboratively with other mental health services. Another centrally coordinated project has been the establishment of a case register of patients with a psychotic illness within each HSO. The register enables the family physician, counselor, and psychiatrist to review management plans for these patients on a regular basis. It also permits the practice to “call back” everyone on the list so that they are seen at least annually. The program is now looking at applying the same principles to other at-risk groups such as older people living alone.

Evaluation The Program has established a comprehensive evaluation procedure that will shape the development of the program and ensure continuing quality improvement. The centerpiece of the evaluation is a comprehensive database which contains demographic, treatment, and outcome data on every patient referred by the family physician to a counselor, psychiatrist, or outside agency for mental health care. Not only can individual episodes of care be described, analyzed, and costed but, by using a permanent unique identifier, the Program can construct a longitudinal record for each person seen and monitor patterns of care and trends that are in use. Clinical data are provided by the family physician (a referral form), the counselor (an assessment form and treatment outcome form), and the psychiatrist (a consultation form, a follow-up form, and a case discussion form). The psychiatrist and counselor also complete logs of their activities. Regular analyses of these data enables the Program to track use, patient demographics, services delivered, and outcomes. Other components of the evaluation are a consumer satisfaction questionnaire, surveys of providers’ satisfaction, measurements of changes in family physician behavior/expertise, and the com-

Services

pilation of data on use of other local Mental Health Services.

Data From the First Year of Operation During the first year of operation the program received 3085 referrals. Thirty percent of referrals were male and 70% female. Twelve percent of referrals were under 18 years of age and 9% were over 65.

Referrals to the Counseloz The family physician identified one or more problems at the time of the referral. The most frequent are summarized in Table 1. The average hours of service provided by a counselor for each client per episode of care was 5.5, with 1.0 session per client involving another family member. Counselors referred 5% of cases they saw to the visiting psychiatrist for further assessment. On average, counselors spent 58% of their time seeing patients, 12% in charting, and 12% in caserelated discussions with the family physician, for a total of 82% being spent in activities directly related to clinical care.

Referrals to HSO Psychiatrists During the first year of operation, the 0.8 FTE psychiatrists in the program received 439 referrals.

Table 1. Presenting problems All Referrals to the Program (N = 3085) ------___ Presentingproblem (more than 1 could be identified) % of Referrals -_-Depression 3s Marital/Relationship 22 Family/Parenting 16 Physical problem (self or relative) 16 Anxiety

15

Family violence Psychosis Work/School Separation/Divorce Life stress Addiction (self or relative) Bereavement Poor self-esteem Somatization Behavior problems Problemswith medication

13 ‘. 0 (1 ti 7 7 I 0 3 3 2

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N. Kates et al. Data were only gathered from November 1994 to September 1995, but if this figure was prorated for an FTE psychiatrist working a full year, the psychiatrist would have seen 572 new referrals. Sixty-one percent of all referrals to the psychiatrist were initiated by the family physician and 39% by the counselor. This varied greatly. In some HSOs, especially those with lesser amounts of counseling time, every referral to the psychiatrist was initiated by the family physician. In others, up to 90% were initiated by the counselor, after discussion with the family physician. The most common reason for making a referral was for advice about medication (85% of all referrals). Other reasons (more than one could be identified for each referral) included clarification/confirmation of a diagnosis (66%), advice regarding therapy/management (36%), or concerns about risk to self/others, and advice about family or marital problems (both 9%). The counselor was present for 32% of all consultations by the psychiatrist and the family physician was present for 7%, although often for only part of the time. Nine percent of referrals to the psychiatrist were seen with another family member in attendance. The average duration of a consultation was 49 minutes, although this ranged from 20 minutes to 3 hours (for an assessment of a child). Twenty percent of people seen had been discharged from a psychiatric service in the previous 6 months and 46% of all people seen were experiencing their first episode of a psychiatric illness. The psychiatrist might find more than one diagnosis relevant to the presenting problem after a consultation. Ninety-six percent of all individuals seen were considered to have a DSM-IV diagnosis, the most frequent of which were mood and anxiety disorders, the problems with the highest community prevalence. 14% were diagnosed as having an adjustment disorder and 9% a phase of life or relationship problem. Diagnoses are summarized in Table 2. In 92% of consultations, the recommendation of the psychiatrist involved beginning, discontinuing, or changing the dose of a medication. In 82% the psychiatrist recommended some form of psychotherapy or counselling either individual (59% of all referrals), or couple or family (19% of all referrals). The psychiatrist also recommended a further referral to a community agency for 10% of patients, mental health service for 8%, and to the H!SO counselor for ongoing care for 8% of all cases seen. The psychiatrist could also elect to see a patient

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Table 2 Diagnosis of referrals (Iv = 439) Diagnosis Mood disorder Anxiety disorder Adjustment disorder Phaseof life/Relationship problem Psychotic disorder Substanceabuse Personality disorder Attention deficit disorder No DSM-IV diagnosis Somatization disorder

to the psychiatrist % of Individuals seen 59 23 12

again; 26% of all patients were seen for at least one follow-up visit. In 77% of casesthis was planned in advance to monitor progress or meet with other family members. In 23% of visits it was because of deterioration in a patient’s condition, medication side effects, or a supervening crisis.

Changes in Use of Mental Health Services The average number of referrals to each of the region’s four psychiatric outpatient clinics for 1992, 1993, and 1994 (before the program started) by participating family physicians was compared to referrals by the same physicians for 1995, the first year of operation. There was a reduction in the number of referrals to each clinic, with a mean reduction of 45% (range 91%-20%). Participating family physicians referred a combined total of 374 patients for outpatient mental health care in the year before the program began (excluding referrals to private psychiatrists for which data is not available), an average of 8 per family physician. In the first year of the program the total number of patients receiving mental health care (the program + outpatient clinics) was 3291, or an average of 73 per physician, an increase of over 900%. In other words, 2917 individuals with mental health problems or psychiatric disorders who might not otherwise have received mental health care were seen after the establishment of the program.

Satisfaction with the Program Family physicians, counselors, and psychiatrists were each asked to rate their satisfaction with the

Integrating Mental &alth program. Using a 5-point Likert Scale, family physicians’ average level of satisfaction with both counselors and psychiatrists was rated at 4.6 (Table 3). Counselors rated their overall satisfaction at 4.6. The major source of dissatisfaction was a lack of support from other local mental health services. Of the 33 counselors, 32 found this work to be at least as satisfying as their previous job. The psychiatrists overall satisfaction rating was also 4.6. Ninety-five percent of counselors and all psychiatrists stated that they would recommend this style of practice to d colleague. Educational

Activities

of the Psychiatrist

During a 3 i/2 hour visit, a psychiatrist would spend an average of 20 minutes in case discussions or educational activities with family physicians (range 5-45 minutes) and 38 minutes in similar activities with the counselor (range O-60). In other words, 25% of the psychiatrists’ time was spent in indirect (patient not seen) activities with primary care staff which aimed at improving their skills or increasing continuity of care. When asked to rate their satisfaction with counselors and psychiatrists as an educational resource, again using a 5-point Likert Scale, a family physician’s average satisfaction rating was 4.7 for both counselors and psychiatrists.

Discussion Goals of strengthening the relationship between psychiatry and primary care include 1) improving communication, 2) enhancing continuity of care, 3) reinforcing the role of the family physicians as pro-

viders of mental health care, 4) providing better access to psychiatric advice and consultation, 5) using mental health services more efficiently. The integration of counselors and psychiatrists within primary care settings appears to be an effective way of achieving each of these.

Improves

with the

Area

Counselor

Psychiatrist

Fit with my practice Understands primary care Does not disrupt my routines Respectful towards patients Keeps me informed Clinical performance Charting Confidence in their performance Overall satisfaction

4.7 4.5 4.9 4.8 4.9 4.3

4.3 4.3 4.0 4.7 4.8 4.8 4.1

4.7 4.6

4.9 4.6

4.2

Communication

The presence of a counselor or psychiatrist in the family physician’s office creates closer working relationships and better communication in the management of cases. Both counselors and psychiatrists spend approximately 10% of their time discussing cases or problems with the (referring) family physician, a higher proportion of time than is usually spent by clinicians working in traditional mental health services. Better communication also enhances the consultation itself. The psychiatrist or counselor can discuss a case with the family physician before an assessment, and review previous reports or interventions as well as clarifying specific yuestions the family physician wishes to have answered. The psychiatrist and/or counselor and family physician will also discuss treatment plans before a patient leaves the office and clarify roles and responsibilities. The existence of a Central Management Team with responsibilities for coordinating activities in each HSO also enables information on mental health services or program changes to be communicated regularly and rapidly to participating practices.

Supports Table 3. Family physician’s satisfaction I program (scores out of 5)

Services

the Role of the Family

Physician

The collaborative approach ensures that the family physician remains involved with the care of his/her patients on a continuing basis. He or she is always informed of the outcome of a consultation, usually before the patient leaves, and participates in developing the management plan and defining respective responsibilities. For patients in crisis, advice is rapidly available and the counselor can assist the family physician in working out an immediate management plan. If the family physician continues to manage the case following an assessment the psychiatrist or counselor is readily available either at a subsequent visit or by phone to discuss any issues that arise.

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N. Kates et al. Case discussions with the psychiatrists/counselors also provide support for the family physician when handling mental health problems. This does not only apply to more complex management problems. Such discussions can also address more straightforward questions such as the need for adjustments in medications or the availability of other resources that might enable the family physician to manage the case more effectively. This is reinforced by telephone access to the psychiatrist to discuss problems in between visits.

Enhances Continuity

of Cure

Care of individuals with mental health problems or disorders is shared. The mental health counselor/ psychiatrist provides a range of services to the family physician and patient throughout a crisis or episode of an illness and may remain involved throughout the episode, in conjunction with the family physician. Providers communicate with each other frequently and treatment plans are worked out collaboratively, taking into consideration the impact of previous interventions. All mental health care providers have access to records of previous interventions, and all notes are written in a single clinical record. The family physician is also informed of any proposed intervention immediately, rather than waiting for a telephone call or consultation note to arrive. The success of a plan can be reviewed at a subsequent visit and any necessary adjustments can be made. Management responsibilities can be allocated in a flexible manner, according to the needs of the case and the skills and comfort of providers. The psychiatrist can hand care back to the family physician but may choose to see a case again until symptoms have stabilized or a drug regimen is successfully implemented. This happens in 26% of all cases, with some individuals being seen up to six times. This approach also allows patients to be reassessed at a future date by the same mental health care provider with a minimum of fuss or administrative red tape.

Increases Accessibility

to Mental

Health Services

Integrating mental health providers in the family physician’s office makes mental health services more accessible. Compared with the period before the program was established, participating family physicians now refer over 9 times as many patients per annum for mental health care. This is particu-

330

larly significant as 72% of individuals with serious mental illnesses receive no treatment during the course of a year even though over 80% will visit their family physician [28]. The presence of counselors and psychiatrists in the HSO may also increase the likelihood of detecting mental health problems by the family physician. Removing barriers to referral also means that the family physician knows that if he identifies a problem that requires a consultation, his patient will be seen relatively quickly and by a provider with whom the family physician is already familiar. Patients appear to prefer their family physician’s office rather than a mental health clinic, which may still carry a possible stigma. They like being seen in a familiar environment and the family physician’s office may be easier to reach. This was reflected in a “no show” rate of 8% for any appointment compared with reports for outpatient clinics which suggest that no-show rates range from 18% to 60% [30].

More Efficient

Use of Mental

Health

Services

Despite the substantial increase in referrals for mental health care, managing these cases within the family physician’s office resulted in a reduction of 45% in the number of cases being referred by participating HSO physicians to outpatient services. The initial assessment in primary care means outpatient services are used more selectively and efficiently, with likely cost savings for the system. Inpatient and outpatient psychiatric services have also been more likely to discharge a case back to the care of the family physician if they know that psychiatric backup is available on site. The success of this model should not, however, be measured solely by reductions in use of specialized services. The program plays a key role in assisting in case-finding, and in some instancesit may be advantageous for a patient to be treated in a clinic that has specialized programs not available in the primary care setting. Primary and secondary mental health care should be seen as complimentary, with ongoing administrative as well as clinical contact between these sectors. As integrating mental health into primary care is likely to change patterns of referrals to outpatient clinics, the possible impacts of these changes should be reviewed by mental health and primary care staff together.

Integrating Mental Health Service\

Other Benefits of Integrating Mental Health Services Within Primary Care Innovative Education

Approaches

to Physician

Continuing

The presence of the mental health workers in the family physician’s office opens up exciting new possibilities in continuing education. Rather than the traditional model of a 3 hour half-day on a specific topic, education takes place in 5-lo-minute segments, based on cases the family physician has seen. This fits with the limited amount of time a family physician usually has during the day to devote to educational activities. The personal contact between the educator and learner allows educational interventions to be individually tailored and as convenient as possible for the physician. Such a sessionmight involve a brief discussion of a problem illustrated by a case from the practice or a more formal but equally brief presentation on a specific topic of interest to a group of family physicians, although the receptiveness of family physicians to taking time out of a busy clinical day for these activities varies. The presentation can be reinforced by handouts or other visual aids. The central management team can also circulate materials from successful presentations to psychiatrists, counselors, and family physicians in other practices.

New Opportunities

for Patient

Education

This model also offers unique opportunities for interventions aimed at enhancing a patient’s understanding of a problem or treatment plan, or increasing compliance with a treatment recommendation. One example is the provision of written information or videos with straightforward messages that can be reinforced by the counselor during a subsequent visit, alone or in conjunction with the family physician. The counselor can also organize an information group for patients of that practice with a common problem (depression, a child with attention-deficit disorder, a recent myocardial infarction).

Assistance for Individuals Problems

with Other Medical

‘The model also has potential for assisting individ-

uals with chronic medical problems or chronic pain adjust to the disorder and its consequences. The

counselor can assist such patients individually or by using treatment groups, possibly in collaboration with staff from a related medical program. Indeed, the model used by this program may be applicable for other medical specialties, which could also deliver selected treatments or follow-up in a primary care setting rather tharl the counselor’s private office.

Valuable Experiences for Learners This program provides unique opportunities for learners from different disciplines to watch family physicians and mental health workers work collaboratively, while learning skills relevant to their future practice. In the first year of the program psychiatry residents, family medicine residents, medical students, and social work students spent time working in the program.

Problems

Encountered

The major problem of the program is trying to maintain regular contact with 87 family physicians and 36 practices and keep them informed about program developments. other problems encountered have included finding adequate office space for counselors in some practices and keeping up with the heavy demand for service. Counselors and psychiatrists have also had to adjust to seeing a broader range of clinical problems and populations than in previous practice settings.

Future

Challenges

The program now needs to collect more specific patient outcome data and conduct a cost-benefit analysis. There are also opportunities to detect common mental health problems at an early stage, to learn about the course of psychiatric disorders in primary care, and to further develop innovative educational projects for family physicians. One further plan is to explore the advantages of integrating counselling into the management of patients with serious medical conditions such as postmyocardial infarction, arthritis, or airways disease.

Summary Integrating counselors and visiting psychiatric consultants into primary care settings can improve communication between mental health services and family physicians and enhance the continuity of

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care. It appears to be an efficient way of providing mental health care for large numbers of individuals with serious mental illnesses, many of whom would not otherwise have received any treatment. It provides additional support for family physicians handling these cases and offers innovative opportunities for family physicians to increase their skills and comfort. Coordinating the activities of the 35 practices within a single management structure has provided support and additional resources for each practice, as well as responsibility for evaluation and liaison with the funding source. It also enables resources to be shared and programs to be targeted more effectively. The integrated attachment model is well received by providers and patients and has led to substantial reductions in the use of both outpatient and inpatient mental health services. In addition, the components of the model are transposable to almost any community, where it can be easily adapted to local needs and resources.

11. 12. 13. 14. 15. 16.

17. 18. 19.

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