Better coordination among primary and mental health care is desperately needed
Mental health care has been repeatedly identified as an area requiring improvement within the health system. In Canada, only 7% of publicly funded health care spending is dedicated to mental health, despite the fact that one in five Canadians will suffer from mental illness in their lifetime. Furthermore, it is estimated that in Ontario, mental health care is underfunded by $1.5 billion.
What results is a system riddled with inefficiencies. People seeking mental health services often endure long wait times for treatment, and frequently report high levels of dissatisfaction and difficulty navigating the mental health care system. In many cases, barriers exasperate a person’s underlying health challenge by prolonging the time before treatment is received. And yet, limited provincial and national action has been taken to improve accessibility.
Problems with mental health service provision often begin when the individual first seeks access to mental health services. Primary care providers, such as family physicians, are often the first to be consulted for mental health concerns. However, most physicians lack the appropriate training to administer most mental health services; thus, referral is emphasized in treatment guidelines. Even so, referrals aren’t made often enough. Only one in six Canadian children with a psychiatric disorder are seen by mental health providers. This problem is not restricted to family physicians. In a 2015 study of mental health-related emergency department visits in Canada, only a third of individuals were referred to mental health specialists by an ED doctor. In addition, physicians prefer to refer to specialists more over affordable community care providers. This is despite that community care services are available in rural and non-rural areas alike.
This is problematic as specialists often have expansive wait lists. And their services may not be covered by provincial insurance (in the case of psychologists, for example) and could cost patients thousands of dollars over several visits. This is particularly contentious as individuals who seek primary care for mental health concerns are more likely to have lower socioeconomic status and higher symptom severity. To be sure, there are cases, such as patients with bipolar depression or schizophrenia, where specialist care is more appropriate than community services but many patients who could be helped by community services aren’t getting access to them.
Community mental health services have shorter wait times (averaging one to 13 days before appointment) than mental health specialists, which can be as long as 11 weeks for non-urgent cases. And in many cases, community mental health services are free to patients.
Part of the reason physicians don’t refer patients to community services is that physicians are often unaware that these services exist. Improving funding for coordination and outreach between community mental health services and primary care services can address this issue, but this requires resources. Importantly, the Ontario Ministry of Health and Long-term Care has committed $2 million to bolster Indigenous mental health services, and $4 million in the next two years to expand housing for people with mental health and addictions issues, as well as other investments in community mental health care. But the amounts pale in comparison to what is required to close the funding gap between mental health and all health care services.
Coordination will also help improve delays when providers do refer patients to mental health services. For example, service providers often utilize screening tools (such as depression questionnaires) that were uniquely created by their organization. This means that patients who are referred from one provider to another must often go through the second intake process as new clients. They must attend a second assessment appointment at the new service provider before they can book their first counselling appointment or get access to treatment. This unnecessarily lengthens a patient’s wait time before treatment. The need for common assessment tools has been recognized by community care and primary care providers alike. Assessment tools must be standardized between both primary care and community mental health settings to achieve better outcomes for patients.
Presently, common intake and screening tools are utilized amongst community mental health services in the Southwest LHIN. Similarly, St. Joseph’s Hospital and London Health Sciences Centre implemented a coordinated access program to improve the transfer of psychiatric patients between these two hospitals. Improvements that resulted from this model included streamlined referral, continuity of patient care and increased patient satisfaction. A similar model was piloted at the Mayo Clinic and described in a 2013 study. Integrating primary and on-site social work programs led to improvements in patient outcomes, patient and provider satisfaction, treatment and associated costs. Expanding such programs could greatly enhance the efficiency of current care, while also creating greater visibility of community services.
It is clear that mental health services can become more accessible by better integration and standardization. The resulting improvements in service efficiency will ensure health care cost savings, fewer inappropriate hospitalizations, and better patient outcomes.
Victoria Wiebe is a Research Analyst at the Ivey International Centre for Health Innovation and a Psychology student at Western University.