- 1 - Number 26, September 2010 PROCARE PRIMARY MENTAL HEALTH PROGRAMME Building primary mental health capacity “There is no health without mental health” WHO Annual Report, 2001 at a glance What: A primary mental health programme aimed at supporting and enabling ProCare general practitioners (GPs) and practice nurses (PNs) to work more effectively with patients who have mental health needs. Why: Research indicated mental health conditions are common in people presenting in primary care and there are multiple barriers to GPs and PNs addressing the underlying mental health needs. How: By developing a programme of ongoing provider development and capacity building, funding extended consultations and providing access to brief, effective psychological interventions via ProCare Psychological Services (PPS). Target: The programme is delivered via ProCare’s 519 GPs and 450 PNs to the ProCare patient population of 650,000 Aucklanders. Where: Via ProCare’s three Primary Health Organisations (PHOs), encompassing 177 practices in the greater Auckland area. profile ProCare is a primary health provider which provides a range of general practice support services and also a number of primary care services. These include ProCare Psychological Services (PPS), community health coordinator services, health promotion services, and an after hours nurse phone triage service. The Primary Mental Health Programme is one of many programmes provided to support better general practice care. the beginnings In the 1990s, ProCare recognised that unmet mental health need was a key issue amongst its primary health patient population and the ability to effectively meet that need was a challenge for its GPs and PNs. At the time, ProCare partnered with two of the Auckland region district health boards (DHBs) to develop initiatives that would help integrate mental health services with primary and secondary care. However, while good relationships were developed, these initiatives weren’t accepted for implementation by the Ministry of Health. In 2001, the ProCare primary mental health programme started with a mental health governance team that comprised of Dr David Codyre, clinical director and consultant psychiatrist; William Ferguson, a GP who’s remained the champion of the mental health programme; Mark Vela, a ProCare manager who had a real passion for mental health; and Vicki Burnett, a service user.
Transcript
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Number 26, September 2010
PROCARE PRIMARY MENTAL HEALTH
PROGRAMME Building primary mental health capacity
“There is no health without mental health”
WHO Annual Report, 2001
at a glance
What: A primary mental health programme aimed at supporting and enabling ProCare general
practitioners (GPs) and practice nurses (PNs) to work more effectively with patients who have mental
health needs.
Why: Research indicated mental health conditions are common in people presenting in primary care and there
are multiple barriers to GPs and PNs addressing the underlying mental health needs.
How: By developing a programme of ongoing provider development and capacity building, funding extended
consultations and providing access to brief, effective psychological interventions via ProCare
Psychological Services (PPS).
Target: The programme is delivered via ProCare’s 519 GPs and 450 PNs to the ProCare patient population of
650,000 Aucklanders.
Where: Via ProCare’s three Primary Health Organisations (PHOs), encompassing 177 practices in the greater
Auckland area.
profile
ProCare is a primary health provider which provides a range of general practice support services and also a number
of primary care services. These include ProCare Psychological Services (PPS), community health coordinator
services, health promotion services, and an after hours nurse phone triage service.
The Primary Mental Health Programme is one of many programmes provided to support better general practice
care.
the beginnings
In the 1990s, ProCare recognised that unmet mental health need was a key issue amongst its primary health patient
population and the ability to effectively meet that need was a challenge for its GPs and PNs.
At the time, ProCare partnered with two of the Auckland region district health boards (DHBs) to develop initiatives
that would help integrate mental health services with primary and secondary care. However, while good
relationships were developed, these initiatives weren’t accepted for implementation by the Ministry of Health.
In 2001, the ProCare primary mental health programme started with a mental health governance team that
comprised of Dr David Codyre, clinical director and consultant psychiatrist; William Ferguson, a GP who’s remained
the champion of the mental health programme; Mark Vela, a ProCare manager who had a real passion for mental
health; and Vicki Burnett, a service user.
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The team conducted a literature review and ran GP focus groups to gather information and form the foundation of
their programme. GP experience and primary care research indicated there was a large, unmet mental health care
need in terms of the common mental health problems such as depression, which could be best met by primary care
services.
“It was being increasingly recognised within New Zealand and internationally that there was a
huge personal, family, economic and social cost of untreated depression and anxiety, as well as drug
and alcohol conditions – and primary care had been charged with meeting these needs
without necessarily being equipped to do the job”.
Dr David Codyre, clinical director, ProCare Psychological Services
The initial challenge was finding funding within existing sources to support development of the programme.
ProCare had a pool of funds available from ‘referred services’ savings, which came through guideline based
prescribing and lab tests. (For example, the ‘No antibiotics for coughs and colds’ campaign.) ProCare reinvested their
savings in other health initiatives such as the ProCare primary mental health programme.
In 2003/2004, ProCare was successful in having its RFP proposal to run primary mental health pilots in all three of its
PHOs accepted. Those pilots ran from 2004 through to 2007/08.
In 2007/2008, the pilots were evaluated externally and found to be successful, so the primary mental health
programme was provided with sustainable long term funding from the Ministry of Health. It was rolled out over all
PHOs nationally. In the first year it received $13 million nationally, which has grown to $25 million in 2010/2011.
Over time this will extend to $50 million.
ProCare Reception
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the process
Based on the outcome from the literature review and the focus groups, ProCare’s programme was developed based
on three core strands.
The first core strand is provider development and capacity building, which is achieved by continually improving
GP’s and PN’s knowledge and skills about mental health issues through training, education and phone support (with
the ProCare psychiatrist). Initially, this training focused on diagnosis and effective treatment of the common mental
health problems. An important part of this was building GP and PN skills and confidence in engaging and assisting
patients presenting with physical symptoms caused by depression or anxiety, to look beyond their physical
symptoms and accept that there is an underlying mental health problem. Part of this process consists of mental
health education and destigmatisation and then working with patients to develop an agreed plan of how to effectively
address their mental health issues. More recently the training has focussed on recognising and addressing some of
the more complex presentations in primary care.
As the programme has evolved, PPS have also tried to build the capacity of the GPs and their teams by working to
integrate psychological expertise into GP practices. This involves getting GPs and PNs better skilled in effective non-
drug interventions like brief problem solving, teaching relaxation and slow breathing techniques to people
experiencing anxiety and stress and education about e-therapy options.
To remain engaged in the mental health programme, the GPs and PNs have to undertake at least one educational
programme around mental health every two years. As well as large group annual education meetings, PNs and GPs
also have monthly peer groups which often request mental health topics. As an alternative, individual clinicians
complete mental health e-learning modules which use Moodle, a multimedia online educational tool
The second core strand is funding extended consultations for people with mental health needs. Many people with
common mental health problems present to their GP with physical symptoms. A typical GP consultation of 15
minutes is not enough time to deal with the presenting physical symptoms, effectively screen for and assess mental
health issues, and then engage the person in accepting that their underlying problems are stress and anxiety.
A limited pool of funding (called “Engage”) is used at the GP’s discretion for people who can’t fund a longer
appointment themselves and allows GPs to extend a consultation a further 15 minutes at no additional cost to the
patient. This has been the key aspect of the programme to give GPs the confidence to “go there” knowing they have
the time to do the job properly.
The third core strand of the programme is to provide access to brief, effective psychological interventions. ProCare
has a team of mental health professionals (ProCare Psychological Service) who provide this brief intervention,
which is largely based around cognitive behaviour therapy (CBT). The team comprises clinical psychologists,
health psychologists (who largely work at the interface of mental and physical health needs with people who
have for example diabetes and depression or chronic pain) and psychotherapists. The team is supported by
two part-time psychiatrists.
Pam Low says increasing ability to support better care through tools such as electronic decision support is one of the
things that has changed from the early days of the programme. “Within the GP electronic clinical records, GPs have
“I guess we are a bit of a pioneering force as well, in that we
have this whole philosophy of brief intervention and rather
than curing the person, working with what they present with
here and now, recognising that change occurs in
people’s lives, not in therapy “.
Pam Low, Health Psychologist, Centre Clinical Leader.
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access to programmes such as the Chronic Care Management (CCM) Depression programme. So now, if the GP
believes a patient is experiencing depression they go through a depression questionnaire that helps with diagnosis
and then provides all these prompts about what to do next. I think it’s helped a lot of GPs say, ‘maybe now it would
be helpful to prescribe, or this score indicates referral to PPS for psychological intervention’.”
ProCare’s three-strand programme has been developed in such a way that new programme elements can be “clipped
on” to the three core strands. So far, new programme elements include the following.
• Close liaison with and involvement of community health coordinators (CHCs) in outreach to Maori and Pacific
patients and meeting the complex cultural and psychosocial needs many people present with.
• Post-natal depression screening.
• Integrating depression screening into the “Patient Dashboard”.
• CCM-Depression – trialling the use of Chronic Care Management (CCM) methods in improving the
management of depression in primary care.
• Engaging people in the peer-lead self-management groups for people with long-term conditions, which are
being provided within ProCare.
Additional processes are in place to ensure best outcomes for patients.
• As part of the triage process, patients referred from GPs are matched up with the PPS clinician best able to meet
their needs. Then the GPs are kept informed via reports at the time of assessment – a summary of presenting
problems and plan, and at the point of discharge, regarding how they’ve got on and what needs to still happen
for that patient.
• PPS has a strong focus on quality, so outcomes are routinely monitored along with a range of other performance
measures, and this data is used with both individual clinicians and the teams as a whole, to identify and address
areas for improvement.
All PPS staff have weekly peer group meetings, monthly training and in-house supervision. GPs know they are
guaranteed the same level of service and standard of care no matter who at PPS they refer
patients to.
the unique approach
There are some unique elements to the programme that make it stand out from other similar initiatives.
• The PPS customer is seen as the GP or PN. Maintaining the GP as the ongoing point of coordination of care is
an important part of the process. In PPS’s programme GPs remain the point of assessment, coordination and
ongoing care. This was an active decision that was taken within this programme.
“The only place where all of health is held together holistically is with the GP and the primary care team.
Mental health and physical health are intertwined and you can’t separate them out and it is an artefact of
the specialist health system that we even try and do that. It would be a tragedy if we tried to replicate the
whole mind-body split in primary care as well”.
Dr David Codyre
• PPS takes a collaborative approach. Good communication between PPS and the GP is important because it is the
GP who has the ongoing relationship with a patient.
• Unlike other services, ProCare has its own psychological service – rather than referring patients to an external
network of therapists – and an associated psychiatric service. This allows for a much more comprehensive
process of credentialing clinicians, ensuring ongoing intensive supervision and other clinical quality activities
and ensuring we provide the most cost-effective service possible.
From March 2011 a new ‘outcome informed practice’ system will be rolled out gradually through PPS as an
additional tool for the programme. Once the system is live, engagement and outcome measures used will be collected
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session by session. This will go into an international database which gives real-time feedback regarding the progress
of therapy and when steps need to be taken to address evolving issues.
Dr David Codyre believes that they are the first primary mental health programme to implement this new approach.
“It’s something which has got such strong evidence of improving outcomes. Those of our clinicians who have trialled
it have found it a very helpful way of keeping you focused on what the patients’ needs are and that things are
progressing for them.”
“We believe we are the only ones offering this [psychiatric] service in primary care, which is very useful in
terms of accurate diagnosis, getting the medication right, getting those medical aspects right for those
complex, difficult to treat patients.
Malcolm Falconer, Clinical Psychologist, Centre Clinical Leader.
the results
The programme’s success can be measured by results from both the Engage programme (GP delivery of mental
health care) and from the range of measures collected by PPS.
There is also a big focus on how the PPS team use data and there are a number of things that ProCare routinely
measures, tracks and uses as part of quality processes, including:
• Kessler-10 scores (a measure of depression and anxiety) as a whole group and by ethnicity
• ‘no show’ rates as a whole group and also by ethnicity
• the average number of sessions patients are seen
• patient satisfaction.
Feedback from the GPs is also important. David Codyre says he enjoys hearing from GPs about a patient who has
had a few sessions with PPS. “They [the GP] see the impact of that [therapy] rippling out to not only the individual’s
life but often to the whole family/whanau.”
He also notes that people getting skills – on how to better manage stress, how to feel more comfortable living in their
own skin, and how to manage their relationships better –has impacts that go beyond what the individual achieves.
Results are then not only useful to monitor outcomes for service users, they are also used for clinicians’ performance
reviews and are a valuable way to identify where the PPS team can improve their service
The programme’s success is also evident in GP uptake, which has risen from 10-15% of GPs actively using the
Engage programme and frequently referring to PPS in the early days, to 55 – 60 % now. Funding remains crucial and
the programme must maintain a constant fine balance between extending the programme to as many people as
possible within a limited budget.
As clinicians we have to be very accountable because we know
that our funding depends on us getting results. Every patient
that comes in here fills out a Kessler score. Then when they’ve
finished their package of care, they fill it out again and we
measure their difference or improvement. The results that we
get determine our funding. We are very conscious that we
have to be accountable. We can’t just sit down have a cup of
tea and give people a pat on the head. We really have to be
getting somewhere, making a huge difference to the patients.
Ethne Thomas, Health Psychologist, Centre Clinical Leader
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The numbers of people accessing funded primary mental health care has increased exponentially over the years since
the programme began, with numbers accessing the Engage programme increasing from 4000 per year in 2003, to
over 20,000 now; and numbers referred to PPS increasing from less than 1000 per year to over 5000 now.
The increase in committed government funding (from $0 to $2 million in 9 years) and the growth in clinician
numbers from 5 FTEs to almost 30 FTEs, is also an indicator of the programme’s success.
the lessons learnt
Many lessons were learnt over the time the programme developed.
• Upskilling GPs and PNs and getting the programme running well took longer than expected due to previous
lack of education and support around meeting mental health needs, and also the multiple competing demands
for GP and PN time and attention.
• Mental health clinicians have had to learn to adapt and change their practice due to funding restrictions. They
have to work with their patients who have a limited number of sessions in a package and ask “what can I help
them with in the here and now?” and come to believe that they can achieve useful outcomes in a very brief
therapy model.
• After a trying a touch screen mental health screening tool for patients waiting in GP practice rooms, it was
abandoned. This project was unsuccessful and they found that the identification of mental illness has to come
out of the interaction between the patient and the GP
• A waiting time of more than two weeks before a first appointment at PPS leads to increased ‘no show’ rates. This
presents a challenge for the service when referral numbers are high and the budget is finite
• Mental health is an important part of people’s health. It shouldn’t be ignored and it is possible to treat it at a
primary care level
• Primary health services undertake a wide range of activities. If you work with primary care teams and want to
implement new programmes successfully, “keep it simple” is the motto for success.
more information
Main Contact Dr David Codyre, clinical director, ProCare Psychological Services Email: [email protected]
