Persons with severe and persistent mental illnesses (SPMI) are at higher risk for medical problems as they are having inadequate access to primary care and preventive services and often do not have their general medical needs adequately addressed. Reports suggest that both urban and rural British Columbia (BC) has a severe shortage of mental health services, and access to resources is minimal. Literature reviews reveal that mental illness occurs at higher rates among the incarcerated population than in the overall U.S. population. Though the majority of people with mental disorders voluntarily get admitted to hospital, it is experienced that a large number with serious mental disorders refuse to accept psychiatric treatment, and under such circumstances, the Mental Health Act provides ‘authority, criteria, and procedures for involuntary admission, at the same time protecting individual freedom. Collaborative Mental Health Care Network (CMHCN) developed by Ontario College of Family Physicians is considered as the suitable model for implementing mental health programs in British Columbia. A more structured, evidence-based approach to mental health care and systematic follow-up of patients to assess clinical status and/or medication adherence are crucial for improving clinical outcomes.
Persons with ‘severe and persistent mental illnesses (SPMI) are at higher risk for medical problems, such as hypertension, coronary heart disease, and diabetes, and have ‘significantly shorter life expectancy than persons without mental illness. They are having inadequate access to primary care and preventive services and often do not have their general medical needs adequately addressed. Since people with chronic mental illness generally present themselves to the primary care providers, integrating mental health into primary care settings brings the care to the patient’s doorsteps, which will improve “the treatment of the “whole” patient with concomitant improvement in outcomes and reduced utilization”( Integration of mental health/substance abuse and primary care, 2008, p. 18). “The Report of the President’s New Freedom Commission on Mental Health identified the need for better coordination between primary care and mental health care and called for the dissemination of evidence-based models to improve care at the interface of general medicine and mental health.” (Butler, et al, 2008, p.9). Under such circumstances, the traditional practice of separating mental and physical health care should be replaced with integrated models of care, as it has the potential to improve access to treatment and improve quality.
British Columbia scenario of mental health services
Reports suggest that both urban and rural British Columbia (BC) has a severe shortage of mental health services, and access to resources is minimal, which results in an increased burden to society. The first major attempt to assess mental health issues and needs in rural British Columbia was conducted in 1970 under a government-funded research project. Researchers held extensive structured interviews with mental health staff, local medical practitioners, and social organizations impacted by mental health. A detailed survey was also conducted to determine the performance of existing services in meeting the specific needs of the particular community and areas, as wells as the level and type of mental health needs of communities without specific services. The study found that most of the existing mental health centers were providing “adequate service for their local communities but were lacking in outreach services, travel being a significant problem.” (Maddess, 2006, pp.172-173). Even though there was the highest need for mental health services in British Columbia (BC) access to service was extremely low, and the only resource was a local general practitioner. A general practitioner is allowed to bill four 20-minute sessions per year for anyone patient at $ 48.57 per session, which is inadequate even to discuss the problem. It is worth noting that most of the people in rural areas do not have any coverage and cannot afford to pay privately. The situation is further exacerbated with limited access to psychiatric facilities and those psychiatrists located in rural BC have to travel much with limited support. All these factors contribute to inadequate attention to mental health issues that make the degree of disorder and dysfunction often becoming unmanageable. It is suggested that adequate government funding, the establishment of “GP psychotherapy” that exists in other provinces in Canada, and covering registered psychologists by the medical plan would provide “a broader interdisciplinary service to a much larger population” (Maddess, 2006, pp.172-173).
Mental health problems among the incarcerated population
According to the Bureau of Justice Statistics (BJS), U.S jails process “an estimated 12 million admissions and releases each year,” and the “lives of many who cycle in and out of jail are unstable” because of substance addiction, ,job and housing instability, mental illness, and host of health problems are day-to-day realities of the majority of this population (Solomon, et al, 2008). With the increasing awareness about the effects of reentry on public safety and community well-beisocially-orientednted practitioners recognize that jail reentry programs and strategies with active collaboration of community-based organizations will help transform the situation. “Collaboration across disciplines and jurisdictional boundaries is the core of jail reentry” because collaboration among these disciplines could lend “support to programmatic interventions and also serve to reduce victimization” (Solomon et al, 2008, p. xv). However, it is worth noting that “even when individuals receive adequate training, treatment, and care during incarceration, they often face limited access and insufficient linkages to community-based resources and treatment services upon release” (Hemmet et al, 2001 cited by Solomon et al, 200, p. 15).
Literature reviews reveal that mental illness occur at higher rates among the incarcerated population than in the overall U.S. population. It is evidenced that “homelessness, unemployment, substance abuse and dependency, and histories of physical abuse are more acute among inmates and prisoners with mental health problems, and serious mental illness is correlated with higher rates of violence and longer criminal histories” (James & Glaze, 2006, cited by Solomon et al, 2008, p.16). Inmates with mental health problems encounter ‘limited access to continuity of care’ and a period of incarceration create void in Medicaid eligibility leading to interruption in access to prescription drugs that put individuals at high risk of relapse. An interruption in medication of jail inmates with mental health illness after release may result in relapse and instability that may promote recidivism. This issue is addressed by ensuring adequate supply of medication at the time of release that will last till their first appointment in the community.
British Columbia Mental Health Act
“All Canadian provinces and territories have legislation to treat and protect people with severe mental disorders and to protect the public,” and the British Columbia’s ‘Mental Health Act’ (the Act) became law in 1964. (Obtaining copies of the mental health act, regulations and forms, 2005). Its purpose is to ensure “…the treatment of the mentally disordered who need protection and care…” and the Act helps provide treatment and care for people with mental disorders when they are not willing to accept it. Though majority of people with mental disorders voluntarily get admitted to hospital, it is experienced that a large number with serious mental disorders refuse to accept psychiatric treatment, ‘causing significant disruption and harm to their lives and the lives of others.’ Under such circumstances the Mental Health Act provides ‘authority, criteria, and procedures for involuntary admission,’ at the same time protecting individual freedom by ensuring that ‘the provisions of the Act are applied in an appropriate and lawful manner.’ Involuntary patient admissions are made to ‘designated facility’ that include inpatient ‘Provincial mental health facilities,’ ‘psychiatric units,’ and ‘observation units’ and no other hospital or health care facility has legal authority to hold or admit an involuntary psychiatric patient. Adults and young persons 16 years of age or above can voluntarily seek admission to a designated facility after signing in prescribed forms and get treatment and may discharge themselves “just like non-psychiatric patients admitted to a hospital under the Hospital Act.” (Obtaining copies of the mental health act, regulations and forms, 2005). Children under age 16 may be admitted by their parent or guardian, and such children be admitted under the Mental Health Act, rather than the Hospital Act, because “Mental Health Act provides direction on admitting children and youth and protects their rights by providing for regular reviews and access to Review Panel” (Obtaining copies of the mental health act, regulations and forms, 2005).In the case of emergency and when a person is acting in a manner likely to endanger their own safety or that of others police should be called, who will determine that “the criteria under section 28(1) of the Act are met and the police would return the person to a designated facility, and Medical Certificate may be issued “(Obtaining copies of the mental health act, regulations and forms, 2005). The Medical Certificate provides authority for the police, paramedics or others to apprehend and transport the person to a designated facility. Only a “physician licensed to practice medicine in British Columbia may complete a Medical Certificate” that allows the person to be in involuntary admission for up to 48 hours. (Obtaining copies of the mental health act, regulations and forms, 2005). Under extraordinary circumstances in which it is impossible for physician or police to intervene for arranging involuntary admission of a person with apparent mental disorder judicial intervention is permissible under the Act. Mental Health Act also defines treatment as “safe and effective psychiatric treatment and includes any procedures necessarily relate to the provision of psychiatric treatment. Section 8(a) states that the director: “…must ensure that each patient admitted to the designated facility is provided with professional service, care and treatment appropriate to the patient’s condition and appropriate to the function of the designated facility and, for those purpose, a director may sign consent to treatment forms for a patient detained under Section 22, 28, 29, 30 or 42…” (The Act, 2005, p. 18). Thus, people with mental disorders can be provided with the treatment and care they need, even when they are not willing to accept it, by procuring a judicial order under the provisions of Mental Health Act.
Intervention model suitable for British Columbia
Randomized controlled trials and high quality quasi-experimental design studies conducted by Butler and colleagues (2008) observe that “in general, integrated care achieved positive outcomes; there is strong body of evidence to encourage integrated care, at least for depression; and efforts to implement integrated care will have to address financial barriers.”
“Financial barriers are a major impediment, primarily because many activities associated with integrated care, such as many management functions, consultations, and other communication activities between providers, and telephone consultations with patients, are not rationally reimbursed under typical “fee-for-service care” (Butler et al, 2008, p.3). Systematic review of trials designed to improve general medical care in people with mental addictive disorders by Butler and colleagues (2008) had also found that “collaborative care” models demonstrated intermediate to high levels of involvement by primary care providers, with regular contact between medical and mental health staff. The development of “shared care models of collaboration between family practitioners and psychiatrists” is considered as most viable approach to improve communication between disciplines and increase access to psychiatric care and consultation. (Rockman, et al, 2004) Considering the fact that family physicians (FPs) are the primary contact for patients with mental disorders and approximately one third of visits to FPs are for mental health problems Rockman et al (2004) argue that partnerships between FPs and psychiatrists could relieve the burden of day-to-day responsibility of providing primary mental health care. Collaborative Mental Health Care Network (CMHCN) developed by Ontario College of Family Physicians, launched in 2001, is cited as a successful model for meeting the challenges from difficult-to-treat conditions of mental health illness. CMHCN is a “unique mentoring program using General Practice (GP) psychotherapists and psychiatrists to help its FP members provide mental health care to their patients.” (Rockman, et al, 2004, p.398). Objectives of the program among other things include “improving collaboration between FPs and specialists in exchange of information and knowledge; enhancing mental health care as defined by the goals of the program, to increase physician’s satisfaction with collegial relationships; improving patient’s adherence to treatment; reducing time to consultation, and providing optimal treatment and relief to patients’ symptoms”(Rockman, et al, 2004). For better assessment and management of patients with mental health problems, it is suggested that physicians should be involved in continuing medical education (CME) sessions. However, this collaborative approach also had barriers and limitations, particularly communication barriers, in implementation. Major barriers identified in CMHCN were: “FPs and mentors preferring different modes of communication, being in different geographic locations, and not having access to the internet and email services” Rockman, et al, 2004).
CMHCN program encountered certain limitations derived from a “perceived need to better match physicians and mentors by geographic locations”, a need for “mentors to reach out to cultivate mentoring relationships,” slow response by physicians and mentors, and a “lack of formalized FP and mentor expectations” (Rockman, et al, 2004). Since British Columbia has many geographic barriers and lacks of IT assisted communication facilities implementing the CMHCN program may encounter more challenges. Recruiting mentors located in geographically close proximity, increasing the number of small group sessions that comprise case discussions, videoconferences, and teleconferences, as well as efficient use of Network funds will help overcome these hurdles. Eliminating “face-to-face meetings” and introducing more telephonic and email communication between mentors and GP psychotherapists will permit “greater geographic flexibility” and “increase access to mental health expertise.” (Rockman, et al, 2004)
Conclusion
Mental health providers encompass not only psychology and psychiatric professionals, but also nursing and care management providers, whose professional roles focus on the mental health needs of patients. A more structured, evidence-based approach to mental health care should be multifaceted and target other elements of care process. A multifaceted approach of educating the patients about the nature of disorder and self management, introduction to evidence-based guidelines for care, providing new therapies in primary care settings, and systematic follow-up of patients to assess clinical status and/or medication adherence are crucial for improving clinical outcomes. Through restructuring of personnel and workflows, as well as connecting administrative functions, clinical records management, financing and claims processing, and disease management programs at the organizational or systems level will facilitate clinical integration.
Reference
- Butler, Mary., et al. (2008). Integration of mental health/substance abuse and primary care.Minnesota Agency for Healthcare Research and Quality: Evidence Report Technology Assessment. 1. Web.
- Maddess, Rapph, J. (2006). Mental health care in rural British Columbia. BC Medical Journal, 48 (4), 172-173.
- Obtaining copies of the mental health act, regulations and forms. (2005). British Columbia Ministry of Health. 4.
- Rockman, Patricia, et al. (2004). Shared mental health care: Model for supporting and mentoring family physicians. Canadian Family Physicians, 50, 398.
- Solomon, A.L., et al. (2008). Life after Lockup: Improving reentry from jail to the community. Washington: Urban Institute. Web.