A plan for integrated stepped care in psychiatry in Northern Norway

Nils Kolstrup

The message

•We already have technology that can change the way we conduct mental health care in an area•Challenges:

• How to integrate the technologies in a systematic way in a very complex system

• Get authorities and health care workers to see the benefits of this new approach

• Get health care workers to change the way they treat patients using the new technologies

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Mastermind Norway

Integrated stepped care in psychiatry

Mastermind EU

•9 countries, 13 regions, 23 partners in Europe

•5.000 patients

•Depression

•Computer based cognitive therapy

•Video based care

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What do we want to achieve?• Today the system is dysfunctional

• Long waiting lists• Insufficient diagnostic procedures• Treatment with drugs in stead of behavioural changes• Patients becoming more ill while waiting• Long cumbersome distances to get treatment• Too many acute admissions that perhaps can be avoided• Very little competence building in primary care and among the population in general

• We want to shorten the waiting lists, improve the diagnostic procedures, reduce the unnecessary use of drugs, reduce unnecessary travels and increase competence among therapists and the population.

• Are we crazy, or just megalomaniac?

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Mastermind, Norway. Basic concept “The funnel”Integration of Internet Based Cognitive Therapy (ICBT) and video in a

comprehensive stepped care system

GP and patient

ICBT

Self help ICBT

GP Specia-list and patient(video)

Specialist patient

Self help without support

General practitioner (GP)follow up plus self help

GP assisted by specialist

Specialist patient policlinic or admittanceAcute cases

Policlinic, video

Admittance

Background. Why do we think we may be able to do this?

• Video experiences:• Internal communication between District Psychiatric Clinics and University Hospital (DeVaVi)• Communication between specialist and patient at primary health care (E-BUP)• Video conferences between GPs and collaborators

• Other relevant experiences:• Acute teams assisting GPs in treatment of acutely mentally ill patients• Psychologist or psychiatrists advisory visits to GPs offices in elective treatment of patients • Electronic communication between collaborators (FUNNKe)• Standardized electronic diagnostic forms (ELSK) • Since 2005 experience with the internet program MoodGYM, UiT The Arctic University of Norway• Results Norwegian Research Council grant on the use of MoodGYM in general practice

• Administrative conditions:• GPs are paid well for video conferences

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Self help GP + patient GP+pt.+spec. Pt.+specalist Pt. in clinic Internal communication

Home page

Screening

Depressed

ICBT

P

Not interested Not depressed

Better/attrition

Flow chart of the Norwegian plan for the CIP MASTERMIND project

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Suicidal

take

contact

Self help GP + patient GP+pt.+spec. Pt.+specalist Pt. in clinic Internal communication

Home page

Screening

Depressed

ICBT

GP+ ICBT

GP no ICBT

P

Not interested Not depressed

Better/attrition

Better orattrition

Better/attrition

P

Flow chart of the Norwegian plan for the CIP MASTERMIND project

9

Suicidal

take

contact

Self help GP + patient GP+pt.+spec. Pt.+specalist Pt. in clinic Internal communication

Home page

Screening

Depressed

ICBT

GP+ ICBT

GP no ICBT

Acutely ill Admittance

Video pt. + GP + spec.

P

Waiting list

Not interested Not depressed

Better/attrition

Better orattrition

Better/attrition

PP

Specialist on video with GP and patient

Flow chart of the Norwegian plan for the CIP MASTERMIND project

10

Suicidal

take

contact

Self help GP + patient GP+pt.+spec. Pt.+specalist Pt. in clinic Internal communication

Home page

Screening

Depressed

ICBT

GP+ ICBT

GP no ICBT

Acutely ill Admittance

Video pt. + GP + spec.

Pt. home

Policlinic treatment

Video + spec.

P

Waiting list

Not interested Not depressed

Better/attrition

Better orattrition

Better/attrition

PP

Specialist on video with GP and patient

ICBT

Better/attrition

Flow chart of the Norwegian plan for the CIP MASTERMIND project

11

Suicidal

take

contact

Self help GP + patient GP+pt.+spec. Pt.+specalist Pt. in clinic Internal communication

Home page

Screening

Depressed

ICBT

No follow up

GP+ ICBT

GP no ICBT

Follow up by GP

Acutely ill

Admittance

Admittance

Video pt. + GP + spec.

Follow up by GP and video

Video and spesialist

Pt. home

Discharge

Policlinic treatment

Video + spec.

P

Waiting list

Not interested Not depressed

Better/attrition

Better orattrition

Better/attrition

PP

Specialist on video with GP and patient

ICBT

Better/attrition

Flow chart of the Norwegian plan for the CIP MASTERMIND project

12

Diagnostic

screening by

specialistDiagnose

Suicidal

take

contact

Self help GP + patient GP+pt.+spec. Pt.+specalist Pt. in clinic Internal communication

Home page

Screening

Depressed

ICBT

No follow up

GP+ ICBT

GP no ICBT

Follow up by GP

Acutely ill

Admittance

Admittance

Video pt. + GP + spec.

Follow up by GP and video

Video and spesialist

Pt. home

Discharge

Policlinic treatment

Video + spec.

P

Waiting list

Not interested Not depressed

Better/attrition

Better orattrition

Better/attrition

PP

Specialist on video with GP and patient

ICBT

Better/attrition

Video District clinic and

central hospital

Video District clinic and central

hospital

Flow chart of the Norwegian plan for the CIP MASTERMIND project

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Diagnostic

screening by

specialistDiagnose

Suicidal

take

contact

Basic concept “The funnel”Integration of ICBT and video in a comprehensive stepped care system

GP and patient

ICBT

Self help ICBT

GP Specia-list and patient(video)

Specialist

patient

Self help without support

General practitioner (GP)follow up plus self help

GP assisted by specialist

Specialist patient policlinic or admittanceAcute cases

Policlinic, video

Admittance

The fantastic brave people that are on this project

• From Department South, General Psychiatric Clinic, University Hospital North-Norway:• Geir Øyvind Stensland, Head of Department • Didrik Kilvær, Psychiatric Nurse, Advisor• Vemund Myrbak, Psychologist, Adviser/Psychologist with clinical specialty• Morten Borgen, Advisor/project manager, Cognitive Behavioural Therapist• Ove Lintvedt, PhD, Psychologist, computer engineer

• From Norwegian Centre for Integrated Care and Telemedicine, University Hospital North Norway:• Siri Bjørvik, Project leader• Nils Kolstrup, Scientific project leader, senior advisor, researcher GP, PhD; NST and UIT – the arctic university of Norway • Erlend Bønes, Senior advisor, Computer engineer • Siv Hege Fagerheim, Ma, Psychiatric Nurse, Advisor

• Collaborators• Mastermind partners• UIT – the arctic university of Norway

• Institute of psychology • General Practice Research Unit

• Others• Check Ware

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The message

•We already have technology that can change the way we conduct mental health care in an area•Challenges:

• How to integrate the technologies in a systematic way in a very complex system

• Get authorities and health care workers to see the benefits of this new approach

• Get health care workers to change the way they treat patients using the new technologies

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Thanks for listening

Nils KolstrupNils.Kolstrup@telemed.no

www.telemed.no

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