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Educational Resource Column Evaluation of a Collaborative Mental Health Program in Residency Training Michelle Naimer, M.D., MHSc, CCFP Allan Peterkin, M.D., FRCP, FCFP Maureen McGillivray, MSW, RSW Joanne A. Permaul, BSc(Hons), CCRP T here is a growing body of evidence suggesting that col- laborative mental health care between family doctors and psychiatrists will enhance patient care (13). In primary care, the need for mental health support from psychiatry exceeds available resources, and patients may be reluctant to access psychiatric support, even if it were available to them. The literature on collaborative mental health care is becoming more robust as clinicians write of new ways to share carewith colleagues possessing varied levels of skill and with those from different disciplines (46). A recent randomized controlled study (3) found collaborative care (mental health professionals working in a primary-care practice) to be effective in treating common mental disor- ders and signicantly more efcient than usual care on indi- cators such as referral delay, duration of treatment, number of appointments, and costs related to treatment. Another study (6) compared the perspectives of residency training directors in psychiatry and primary care on the primary-care mental health programs at their institutions. The results showed that although there was general agreement that primary-care physicians should be able to treat most un- complicated psychiatric cases, there was overall dissatisfac- tion with the psychiatric training in primary-care residency programs. In 2005, the Departments of Family Medicine and Psy- chiatry at Mount Sinai Hospital in Toronto developed a res- ident Collaborative Mental Health (CMH) program. The goal was to teach and model shared carebetween psychi- atry residents and family medicine (FM) residents during their training. The program was evaluated with a survey over 2 academic years. Details of the program and results of the evaluation are described here, with the hope that other training programs may be interested in replicating ideas from this important endeavor during residency training. Methods During the 2005/6 and 2006/7 academic years, FM resi- dents and psychiatry residents were "buddied" with one another to form the Mount Sinai Hospital family medicine and psychiatry resident CMH program. At the beginning of each academic year, an orientation session for the psychiatry and family medicine residents was conducted by the CMH program coordinators. The purpose of this session was to introduce residents to each other, explain the philosophy behind a collaborative mental health program, and explain the methods for communication and documentation be- tween family medicine residents, psychiatry residents, and supervising psychiatry staff. Residents were given a sum- mary of the principles of shared care, which emphasized the patient-centered aspect, options for consultation, ap- propriate documentation, and patient condentiality; e-mail addresses and phone numbers were exchanged and FM residents were encouraged to e-mail their psychiatry buddies whenever they had questions on management, psycho- pharmacology, challenging clinical encounters, or the availability/suitability of specic mental health resources. It was specied that urgent clinical matters should not be addressed through e-mail but should be referred to proper channels, including on-site clinical supervisors or the Emer- gency Room. Psychiatry residents were each assigned a clinical supervisor within the Department of Psychiatry. Residents were asked to review their email replies with their supervisor before sending them. The goal was to turn around replies within 48 to 72 hours; often, an ongoing dialogue about patient care ensued. To evaluate this program, two questionnaires (one for psychiatry and one for FM residents) were developed by the program coordinators (a family physician, psychiatrist, social worker, and research associate). The questionnaires were tested and revised by a family physician and psy- chiatrist who were not part of the CMH program. The goal of the survey was to obtain information about resident satisfaction with the program, its usefulness, and areas for program enhancement. Ethics approval was received from the Mount Sinai Hospital Ethics Board, and com- pletion of the questionnaires implied consent. The ques- tionnaires were returned anonymously, using a coding system to match FM buddies with their corresponding Received April 22, 2010; revised September 8, 2010; January 18, February 23, 2011; accepted February 23, 2011. From the Dept. of Family and Community Medicine, and the Dept. of Psychiatry, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada. Send correspondence to Michelle Naimer, M.D., Family Medicine, Mount Sinai Hospital, Univer- sity of Toronto, Toronto, Ontario, Canada; e-mail: [email protected] Copyright © 2012 Academic Psychiatry Academic Psychiatry, 36:5, September-October 2012 http://ap.psychiatryonline.org 411

Evaluation of a Collaborative Mental Health Program in Residency Training

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Educational Resource Column

Evaluation of a Collaborative Mental HealthProgram in Residency Training

Michelle Naimer, M.D., MHSc, CCFPAllan Peterkin, M.D., FRCP, FCFPMaureen McGillivray, MSW, RSW

Joanne A. Permaul, BSc(Hons), CCRP

There is a growing body of evidence suggesting that col-laborative mental health care between family doctors

and psychiatrists will enhance patient care (1–3). In primarycare, the need for mental health support from psychiatryexceeds available resources, and patients may be reluctantto access psychiatric support, even if it were available tothem. The literature on collaborative mental health care isbecoming more robust as clinicians write of new ways to“share care”with colleagues possessing varied levels of skilland with those from different disciplines (4–6). A recentrandomized controlled study (3) found collaborative care(mental health professionals working in a primary-carepractice) to be effective in treating common mental disor-ders and significantly more efficient than usual care on indi-cators such as referral delay, duration of treatment, numberof appointments, and costs related to treatment. Anotherstudy (6) compared the perspectives of residency trainingdirectors in psychiatry and primary care on the primary-caremental health programs at their institutions. The resultsshowed that although there was general agreement thatprimary-care physicians should be able to treat most un-complicated psychiatric cases, there was overall dissatisfac-tion with the psychiatric training in primary-care residencyprograms.

In 2005, the Departments of Family Medicine and Psy-chiatry at Mount Sinai Hospital in Toronto developed a res-ident Collaborative Mental Health (CMH) program. Thegoal was to teach and model “shared care” between psychi-atry residents and family medicine (FM) residents duringtheir training. The program was evaluated with a surveyover 2 academic years. Details of the program and resultsof the evaluation are described here, with the hope thatother training programs may be interested in replicating

ideas from this important endeavor during residencytraining.

Methods

During the 2005/6 and 2006/7 academic years, FM resi-dents and psychiatry residents were "buddied" with oneanother to form the Mount Sinai Hospital family medicineand psychiatry resident CMH program. At the beginning ofeach academic year, an orientation session for the psychiatryand family medicine residents was conducted by the CMHprogram coordinators. The purpose of this session was tointroduce residents to each other, explain the philosophybehind a collaborative mental health program, and explainthe methods for communication and documentation be-tween family medicine residents, psychiatry residents, andsupervising psychiatry staff. Residents were given a sum-mary of the principles of shared care, which emphasizedthe patient-centered aspect, options for consultation, ap-propriate documentation, and patient confidentiality; e-mailaddresses and phone numbers were exchanged and FMresidents were encouraged to e-mail their psychiatry buddieswhenever they had questions on management, psycho-pharmacology, challenging clinical encounters, or theavailability/suitability of specific mental health resources.It was specified that urgent clinical matters should not beaddressed through e-mail but should be referred to properchannels, including on-site clinical supervisors or the Emer-gency Room. Psychiatry residents were each assigned aclinical supervisor within the Department of Psychiatry.Residents were asked to review their email replies with theirsupervisor before sending them. The goalwas to turn aroundreplies within 48 to 72 hours; often, an ongoing dialogueabout patient care ensued.

To evaluate this program, two questionnaires (one forpsychiatry and one for FM residents) were developed bythe program coordinators (a family physician, psychiatrist,social worker, and research associate). The questionnaireswere tested and revised by a family physician and psy-chiatrist who were not part of the CMH program. The goalof the survey was to obtain information about residentsatisfaction with the program, its usefulness, and areasfor program enhancement. Ethics approval was receivedfrom the Mount Sinai Hospital Ethics Board, and com-pletion of the questionnaires implied consent. The ques-tionnaires were returned anonymously, using a codingsystem to match FM buddies with their corresponding

Received April 22, 2010; revised September 8, 2010; January 18, February23, 2011; accepted February 23, 2011. From the Dept. of Family andCommunity Medicine, and the Dept. of Psychiatry, Mount Sinai Hospital,University of Toronto, Toronto, Ontario, Canada. Send correspondence toMichelle Naimer, M.D., Family Medicine, Mount Sinai Hospital, Univer-sity of Toronto, Toronto,Ontario, Canada; e-mail: [email protected]

Copyright © 2012 Academic Psychiatry

Academic Psychiatry, 36:5, September-October 2012 http://ap.psychiatryonline.org 411

psychiatry buddies. An e-mail reminder was sent to non-responders.

Results

Most of the FM residents and all of the psychiatry resi-dents attended the introductory and orientation session of-fered by the program coordinators. All residents found thisface-to-face introduction to be useful. A total of 22 first-and second-year FM residents participated in 2005/6, and21 FM residents participated in 2006/7. Two psychiatryresidents each year volunteered to participate after the pro-gram was presented to them by the staff psychiatrist in-volved with collaborative mental health care (Year 1: onethird-year, one fifth-year resident; Year 2: two second-yearresidents). The involvement of only two psychiatry resi-dents per year for this pilot project reflected senior-residentavailability, as the involvement was voluntary, and in ad-dition to other required duties. The psychiatry residentswere buddied with 10–11 family medicine residents for theyear; 30 of the FM residents and all 4 of the psychiatry res-idents completed the survey, for an overall response rate of34/47, or 72%.

Program UtilizationMost of the FM resident respondents (80%) had consulted

their psychiatry buddy about a FM patient during the aca-demic year. Those who had not had either forgotten aboutcontacting him/her, or had patients who were already beingfollowedbya psychiatrist. Thenumber of casesonwhich eachFM resident did consult with their psychiatry buddy rangedfrom 1 to 6 cases. The most common reasons for the consul-tation were medication advice, resources for referral/supportservices, management issues other than medication, diagno-sis, and psychotherapy questions.Most FM residents (87.5%) preferred to contact their

psychiatry buddies by e-mail; the remaining residentspreferred to contact them by phone. All of the psychiatryresidents indicated that they preferred to be contacted bye-mail. The number of communication exchanges betweenFM residents and their psychiatry buddies ranged from 1to 3 per case, with 2 exchanges the most common (62.5%of cases). According to the FM residents, they usuallyreceived a response to their questions within 24 to 72hours. The psychiatry residents reported that their typicalresponse time was within 24 to 48 hours. Few FM resi-dents (13%) claimed that they contacted their psychiatrybuddy each time before making each formal psychiatryconsultation.

DocumentationDuring the orientation session, FM residents were

instructed to print e-mail exchanges with their psychiatrybuddy and file the correspondence in the specific patient’shealth record. Psychiatry residents were also asked to printthe exchanges (although they had only the patient’s initialsand date of birth in order to maintain confidentiality in thecontext of e-mail) and to keep them in a file folder main-tained by the program coordinator. When surveyed, it wasfound that FM residents kept a record of their exchangesfiled in the patient’s record about half of the time. Only onepsychiatry resident in the 2 years agreed that they alwayskept a record of their exchanges. This is an important re-minder that further attention needs to be paid to appropriatedocumentation of exchanges, while emphasizing the im-portance of protecting patient privacy and confidentiality.

Resident SatisfactionIn 2006, 93% of FM residents stated that their psychiatry

buddy answered their questions to their satisfaction. In2007, this number fell to 50%. This difference could beattributed to the fact that the psychiatry residents in 2006were more experienced than those in 2007. Also, seniorpsychiatry residents have more flexibility in their schedules,whereas the second-year psychiatry schedule is very struc-tured. Senior residents would have had more time to re-search and respond to questions. The perception of thequality and availability of supervision to psychiatry resi-dents was not polled, but would be useful information toobtain in a future survey.

Program UsefulnessAll of the psychiatry residents reported that the resident

CMH program is valuable. Half of these residents agreedthat the program enhanced their knowledge of managingpsychiatric issues. Themost common reasons for exchangesbetween buddies were medication advice, asking aboutresources for patients, and other management issues. Upongraduation, 75% of psychiatry and 90% of FM residentsstated they would like to be involved in a similar CMHprogram in practice. Similarly, 75% of psychiatry residentsand 89% of FM residents recommended continuing theCMH program during residency training.

Discussion

Overall, this resident CMHprogram provides an exciting,reproducible opportunity for family medicine and psychia-try programs to consider. According to the residents who

412 http://ap.psychiatryonline.org Academic Psychiatry, 36:5, September-October 2012

TRAINING IN COLLABORATIVE MENTAL HEALTH

evaluated the program, the resident CMH program has beenhelpful in patient management, and has provided psychiatryresidents with the opportunity to put knowledge into practicein another clinical setting. The program models collabo-rative mental health care for future practice, and estab-lishes an excellent venue to support the high load of mentalhealth problems seen by FM residents at large teachingcenters.

Our advice to others in setting up a CMH program is tooffer this program to more senior psychiatry residents, asthey typically have more flexibility in their schedules, andhave had more time to develop their skills. It is important tooffer an orientation session where residents have an op-portunity to meet face to face, socialize, exchange contactinformation, and learn about shared care together. It is alsoimportant to define parameters of exchange (e-mail versusfax versus case conference), confidentiality, documentation,timeliness of responses, and supervision of responses bypsychiatry faculty.

To keep the program active, it is useful to send remindersto residents and faculty midway through the year to re-inforce the use of the program. It is also important to provideeducation about the program through faculty developmentwith FM teachers to reinforce use of the CMH programwhen supervising FM residents.

Future research questions to address could includewhetherCMH programs in residency training better prepare psychi-atry residents to meet the needs of family physicians whoconsult them after graduation. Also, do these programs leadto future system efficiencies and cost savings? Are familydoctors better able to formulate their consultation ques-tions after this exposure? Will this exposure enhancefamily physicians’ skill in managing similar situationsin the future?

In 2009, the Royal College of Physicians and Surgeonsof Canada introduced new training requirements for res-idents completing their specialty training in psychiatry(7). A shared-care experience with family physicians,specialist physicians, and other mental health professionalshas become mandatory. We believe that this CMH modelwill be applicable and easily implemented in most trainingsettings. In the future, there will be opportunities to evaluatesystem-wide implications of resident CMH programs, suchas involvement in collaborative care in future practice, pro-vider and patient satisfaction, and change in health-systemefficiencies and costs.

References

1. Kates N, Craven MA, Crustolo AM, et al: Sharing care: thepsychiatrist in the family physician’s office. Can J Psychiatry1997; 42:960–965

2. Sullivan MP, Parenteau P, Dolansky D, et al: Shared geriatricmental health care in a rural community. Can J RuralMed 2007;12:22–29

3. van Orden M, Hoffman T, Haffmans J, et al: Collaborativemental health care versus care as usual in a primary care setting:a randomized controlled trial. Psychiatr Serv 2009; 60:74–79

4. Craven MA, Bland R: Better practices in collaborative mentalhealth care: an analysis of the evidence base. Can J Psychiatry2006; 51(Suppl 1):7S–72S

5. Hunter JJ, Rockman P, Gingrich N, et al: A novel network formentoring family physicians on mental health issues usingE-mail. Acad Psychiatry 2008; 32:510–514

6. Leigh H, Mallios R, Stewart D: Teaching psychiatry in primarycare residencies: do training directors of primary care andpsychiatry see eye to eye? Acad Psychiatry 2008; 32:504–509

7. http://rcpsc.medical.org/residency/certification/training/psychiatry_e.pdf. Royal College of Physicians and Surgeons of Canada -Specialty Training Requirements in Psychiatry. 2009. EditorialRevision 2012. Version 1.0. Page 3. Last accessed July 26, 2012.

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