Integrating care to fill the gap for seniors’ physical, mental health

In 2016, Trillium Health Partners launched an innovative program aimed at providing wraparound supports to seniors with both physical and mental health issues. It’s a group for whom care can be uncoordinated, often requiring multiple medications that need to be managed carefully to avoid interactions and side effects. They need community programs, counselling and help navigating various systems. But their health care is fragmented between specialists in hospitals and providers in community clinics and between those treating their physical ailments and responding to their mental health concerns.

As Robert Reid, the Hazel McCallion Research Chair in Learning Health Systems and the chief scientist of the Institute for Better Health, puts it, “Traditionally, what happens in health care is that mental health and physical health are done independently. And that’s just not reality. They’re fundamentally linked conditions. How you fare mentally impacts entirely how well you do with your physical conditions. And vice versa. And so when you’re actually fundamentally linking the care for those conditions, that’s a real different model of care.”

That’s why the Seniors Outpatient Collaborative Care was formed. The program provides team-based support for this high-needs population, people who are “at a high risk of being hospitalized or requiring intensive care,” explains Elizabeth Mansfield, a scientist at Trillium’s Institute for Better Health, which is evaluating and supporting the program.

So far, the program has enrolled almost 200 seniors. Though COVID pressures have put it on a temporary hiatus, Trillium is planning to reinstate and improve it going forward. During enrolment, 64 per cent of patients reported moderate to severe depression. That dropped to 26 per cent after three to four months of treatment. Anxiety decreased to 23 per cent from 52 per cent.

The program assigns care coordinators who visit patients at their homes, assess their health needs, help connect them with supports in the community and share information with the family provider and geriatric specialists. The coordinator – a social worker, occupational therapist, or nurse – is trained in psychotherapy to provide counselling during their visits in addition to connecting patients to community supports. Two to four times a month, geriatricians and psychiatrists at Trillium have case conferences about patients enrolled in the program with the family doctors and care coordinators to ensure patients are taking appropriate medications and dosages and troubleshoot challenges.

To design the program, Richard Schulman, director of Seniors Mental Health Services at Trillium Health Partners, examined U.S. collaborative programs to determine what works, like how often case conferences are scheduled. He then adapted the program for the local setting and population. Providers said the program shouldn’t have rigid requirements on what physical and mental symptoms were included, for instance.

“Traditionally, mental and physical health are done independently. And that’s just not reality. They’re fundamentally linked.”

“We integrated geriatric medicine and geriatric psychiatry, which no one had done before,” says Schulman. “There were lots of examples of success for collaborative models treating depression but it was usually related to one other disease, like diabetes. We made it more open to make it more realistic.”

But like all new programs, there were snags, especially early on. Doctors in the community often couldn’t make it to the conferences even though their input was invaluable. So the clinicians and researchers took a drastic step – they stopped the program for a few weeks.

They realized part of the problem was family doctors didn’t understand how the program worked. “They were asking, ‘How long is this going to last? And what happens when you take the service away?’” says Mansfield.

The team realized the doctors needed more information about the program and the evidence behind the model. When the program was restarted, the team catered the information sharing and scheduling to individual family doctors’ needs, who then became more engaged and available. “We could have mis-thought that this was a failure,” says Mansfield. “Often, something’s not a failure. It’s just a learning journey.”

Now with less strain on the health system and home check-ins starting again, Trillium Health Partners is looking at integrating the program in a sustainable way going forward.

It was, after all, successful. “The families felt, for the first time, that their loved one’s care was integrated,” Reid says.

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  • Margaret Kennedy says:

    This sounds like a very good plan. I wish more regions would have something like this for seniors.
    Many seniors I know are not getting the psychological help they badly need. It is impossible to get psychiatric help other than a one off visit to to assess your problem and then back to the GP for prescription renewals. Most family doctors do not have the training far less the time to do counselling. If you are lucky enough to have some form of private health insurance you can get ongoing help from a psychologist. Most seniors are not in that position.
    It would make such a difference in a senior’s life to have all problems both physical and psychological overseen in the way described in the article.

  • Elizabeth Rankin says:

    Good article that underlies the need for medical education programs to include subjects like this that students in medicine don’t often study.
    It seems “the default” for many professionals (&TV ads) regarding health care topics is: “ask your doctor.”
    I’ve advocated for years that medical studies include the health-related professions through opportunities for inter-group study programs, where they actually learn how to work as a group to problem-solve a typical patient’s case. How can students in the health care sciences ever understand how to approach one another if they don’t have these opportunities. Traditionally, Medicine has taken the top down approach. I personally witness how this has affected the “medical intelligence” of both students and practitioners. By working/learning together to understand the various health care issues patients face and, they too as patients, all health professionals and patients would benefit if inter-professional studies became the norm, not the exception.


Wendy Glauser


Wendy is a freelance health and science journalist and a former staff reporter with Healthy Debate.

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