The authors have no affiliations, sponsorships, honoraria, monetary support or conflict of interest from any commercial source.
Jill E. Sherman, MPHRaymond W. Pong, PhD
Centre for Rural and Northern Health Research
Presentation Objectives
Introduce the OPOP Research Project
Discuss findings from a review of international literature on the models of psychiatric outreach to rural and remote communities
Explore similarities and differences between the “OPOP Model” and other models
OPOP Research Project Collaboration between CRaNHR and OPOP to examine
models of psychiatric outreach in smaller northern Ontario communities
What service delivery models exist to increase access to psychiatric services in Northern Ontario, and what factors influence the choice of these models?
How do the different approaches affect the organization and delivery of psychiatric services?
What are the differences between small communities served by OPOP vs. those not served by OPOP?
What innovations can be adopted in Northern Ontario to increase access to mental health services?
OPOP Research - MethodsLiterature ReviewSurvey of OPOP-affiliated ConsultantsSurvey of Family Health TeamsFocus Group Interviews with ConsultantsCommunity Case Studies
Literature Review
Database of 300+ referencesInternational perspective (mainly Canada, UK,
Australia, US)Search strategy evolved over time
Rural, remote, frontier, NorthernService delivery modelsSpecialist outreach, psychiatric outreachPrimary careMental health servicesShared care, collaborative care
Some “Early Classics” 1: Reviews & Theoretical Models
Williams & Clare (1981) “Changing patterns of psychiatric care” (UK) Bachrach (1983) “Psychiatric services in rural areas: A sociological
overview” (US A)Strathdee & Williams (1983) “A survey of psychiatrists in primary
care: The silent growth of a new service” (UK )Pincus (1987) Patient-oriented models for linking primary care and
mental health care” General Hospital Psychiatry (USA)Horder (1988) “Working with general practitioners” (UK)Creed & Marks (1989) “Liaison psychiatry in general practice: A
comparison of the liaison-attachment scheme and shifted outpatient clinic models” (UK, International)
“Early Classics” 2:Case Studies / Empirical Models
Miles (1980) “A psychiatric outreach project to a rural community” (Canada/British Columbia)
Tyrer (1984) “Psychiatric clinics in general practice. An extension of community care” (UK)
Carr & Donovan (1992) “Psychiatry in general practice: A pilot scheme using the liaison-attachment model” (Australia)
Kates, Craven, et al (1997) “Integrating mental health services within primary care: A Canadian program” (Urban Southern Ontario)
Weingarten & Granek (1998) “Psychiatric liaison with a primary care clinic – 14 years’ experience” (Israel)
ReviewsGruen, Weeramanthri, et. al. (2007) Specialist outreach clinics in
primary care and rural hospital settings [Systematic Review]. Cochrane Database of Systematic Reviews 2007 (4):1-66, 2007.
Psychiatry – largest specialty representedOutreach clinics associated with
Improved accessImproved quality of care, outcomesMore appropriate use of servicesFewer psychiatric hospitalizationsHigher “quality of evidence” from urban-high resource
study areas w/limited potential to benefit from outreachLittle evidence for rural with greatest potential for benefit
- most rural studies were descriptive
Gruen et al (2007) Conclusion:“The evidence presented provides support for the
hypothesis that specialist outreach can improve access to specialist care on a range of patient-based
measures,health outcomes to a clinically important degree,efficiency in the use of hospital-based services by
reducing duplication and unnecessary referrals and investigations.” (p. 14)
Early Models
“Increased throughput”Goal: Increase referrals to specialists, by:
Education of PCPs to “recognize and refer” Establishment of specialist-PCP relationships
Shifted outpatient / visiting specialist clinicGoal: Increase access to specialist services, by:
Bringing specialist into community / PCP clinic setting
“More Recent” ModelsLiaison-Attachment (outreach version of “consultant-liaison”) –
overlaps with shifted outpatient – more specific to psychiatryGoal: Reduce “unnecessary” use of specialist services & increase access
to “appropriate” care, by: Educating and supporting primary care providers Providing clinical care in PCP/community setting Facilitating access to secondary, tertiary services where needed (strong
emphasis on liaison function)
“Multifaceted” Outreach – complex interventions to increase access, quality, efficiency of care – more systems perspective, urban perspectiveShared care, collaborative care, multidisciplinary care Integration of psychiatry, mental health, social services (bio-psycho-social)Support services to patients (case manager/care coordinator)Community-based care models (e.g. ACT)
“Intermittent model”Owen, Tennant, et al (1999) “A model for clinical and
educational psychiatric service delivery in remote communities,” Australian and New Zealand Journal of Psychiatry
Outreach by urban-based teams – psychiatrist + other mental health professional
Beyond clinical care - interventions included:direct psychiatric care to clients in their own environmentpeer support to lone mental health and generic health workersskills development/education for general health staff, other
professionals affiliated with health care (e.g. police and ambulance officers)
Variations in Outreach ModelsWho does the outreach?
Individual vs. team? Psychiatrist only Psychiatrist + other clinical/MH Professional MH professional + backstopping by Psychiatrist
Patterns of interaction ~ Types of collaborationPatient consultation only (parallel model)Patient & provider consultations, but separateJoint consultations (=shared care?)Team-based consultations (may include patient,
family/caretakers) (= collaborative care?)
Variations, Part IIFrequency of outreach?
“Intermittent” vs. regular scheduleWeekly, monthly, or?
Outreach modes & setting?Face-to-face: FP/GP office, Primary care clinicVirtual: Telepsychiatry; dedicated space?
Linkages to other services?Emphasis on “liaison” function?Facilitate care at outreach providers’ “home base”
Variations, Part III
Inter-visit support servicesRange – none to extensive (may depend on frequency,
local provider capacity, ICT capacity) Follow up (+ -) new cases/consultations? Emergencies Telephone, email support Telepsychiatry Prescription refills
Variations, Part IVEducation
Larger policy goals – who should provide what services?Needs of local providers
Local capacity – the more local capacity, the more emphasis on education? Relationships with local providers Duration of outreach program (e.g. Israeli 14 year case report)
“Outreach geography” – Socio-spatial relationships between consultants’ “home base” and outreach communityLittle attention – assumed in the literatureRelated to liaison functionNearest service center (implied)“Hub-and-spoke” / Satellite services (intensive/dedicated outreach)
Variations, Part VDegree of Integration – at what level?
Organizational level – relies heavily on HIT – facilitates referrals, sharing of patient information, system navigation“Satellite services model” (urban US) – integration through
acquistion of PC clinics as “satellites” of hospital ambulatory care services (Nickels 1996) – Single system
Networked (e.g HMOs)
Interpersonal level – Where services are not integrated at a formal organizational
level, coordination of care relies on individuals, relationships (not systematic, but idiosyncratic)
Conclusion 1: Outreach models are embedded within
larger models of health care organizationGoals & strategies of outreach models may vary
depending on context, and dominant philosophies of the “right” or best way to deliver healthcare
Resource constraints, clout of professional groups are strong determinants of model components
Success of outreach strongly influenced by “upstream” systems factors (e.g. financing/payment arrangements)
Conclusion 2: Models vary on a number of dimensions
Who: Outreach Provider Individual vs. teamPsychiatrist or other MH provider
What: Components of OutreachPatient careProvider consultationsPlus…? Support services, Education
When: Time (frequency, duration)Where: Space (setting, spatial relations/linkages)How:
Patterns & modes of interactionTypes of collaboration (continuum)Degree of Integration
Why: Context; historical variations in goals of outreach
Conclusion 3: Evaluation is difficult but generally positiveOutreach – can be a “victim of success,” especially in
PsychiatryOutreach can tap a vein of unmet need
Can result in increases in revealed demand/need Can be expected to change w/duration of outreach
“Usual” indicators of access are ambiguous Waiting times Change in number/percentage of referrals Change in number/percentage of hospitalizations
Successful patient “outcome” measures – fuzzy & often difficult to attribute to outreach “Cure” vs. management
Requires program-level indicators
What is the “OPOP Model” ?Is there an “OPOP Model” ?
MultifacetedFlexible - multiple models?
Individual specialist Patterns of interaction/collaboration? Linkages, service integration? Support services? Education?
Unique feature - outreach geography providers from south to north – not from the nearest
service centre (Exception-Queens program) How does this geography affect service delivery?
Effectiveness? Liaison & linkages?
