Developing Collaborative Mental Health Care for the Homeless at a Drop-In CentreNews
Introduction by the column editors: This column demonstrates the use of an electronic mailing list (e-list) to generate a collaborative problem-solving process. The process is modeled on a module of the academic curriculum of the Columbia University Public Psychiatry Fellowship (PPF - ppf.hs.columbia.edu) in which PPF alumni who encounter a management problem at their work site present the problem to current PPF fellows and faculty and lead a discussion aimed at developing solutions. In this column, an e-list is used to stimulate the discussion. Readers of Psychiatric Services are invited to submit management problems to Dr. Ranz at firstname.lastname@example.org who will submit selected problems to the PPF e-list and work with Dr. Deakins to summarize discussions in future columns
1 Jules Ranz, MD and Susan Deakins, MD are editors of this column, and director and associate director, respectively, of the Columbia University Public Psychiatry Fellowship
2 Dr. Tam is affiliated with Inner City Health Associates, St. Michael's Hospital, Toronto, Canada (email@example.com).
Homelessness remains a pressing problem across Canada. In Toronto, Canada's largest city with a population of approximately 2.5 million people, over 5000 individuals are homeless on a given night (1, 2). A high prevalence of both physical illness and mental illness exists in the homeless population (3, 4). Despite their high needs, homeless people frequently experience difficulties in accessing the medical care that they require. Many are not in possession of Ontario Health Cards, documents essential to enable medical services received to be paid for by provincial health insurance. They do not have the means to travel to medical appointments and may have experienced negative attitudes from health care professionals (5). Homeless individuals often rely on emergency department visits or inpatient hospitalization stays to meet their health needs (4, 5).
In 2006, Inner City Health Associates (ICHA) was created. ICHA consists of over forty physicians who provide primary care and psychiatric services to the homeless in Toronto in settings such as shelters, residences, and drop-in centers. They also consult to outreach teams which provide intensive case management (ICM) or assertive community treatment (ACT). ICHA physicians receive competitive stipends for both clinical and nonclinical time, thereby alleviating the immediate need for their patients to have Ontario Health Cards. In addition to providing clinical services, ICHA tries to improve coordination between different providers, educates medical students and residents, and participates in research on homeless health care.
Background to the Problem
Collaborative mental health care involves both primary care and mental health providers working together to offer complementary services and mutual support, ensuring that individuals with mental health needs receive coordinated care in a timely fashion (6). The complex medical and social needs of the homeless population calls for such a service delivery model (7).
In February 2009, an ICHA psychiatrist and a non-ICHA family physician established outreach services using a collaborative mental health care model at a community drop-in centre in Toronto. The family physician and the psychiatrist consult to the agency’s housing and outreach program. Staffing consists of a coordinator, an outreach worker, two housing follow-up workers, and two drop-in workers. The program assists drop-in clients with their housing, financial, mental health, and substance use issues.
The psychiatric clinic operates one morning every week, and the primary care clinic runs the same morning every two weeks. The physicians meet with the team in the morning for an hour to discuss client issues prior to conducting their respective clinics in borrowed offices in the agency down the hall from each other. Case managers frequently sit in on appointments and assist in providing history and implementing follow-up plans. All
clients provide written consent allowing their clinical information to be shared amongst team members.
The physicians formally meet face-to-face every two weeks during morning meetings. To facilitate communication between physicians, the collaborative care literature recommends the use of a joint medical record (8). A joint medical record, however, cannot be created and maintained at the agency. The agency’s primary goal is to provide social services, and as such, is not a "Health Information Custodian (HIC)" as defined under the Personal Health Information Protection Act, 2004 (9). As a result, the psychiatrist and the family physician maintain separate files. The psychiatrist’s records are stored electronically on OSCAR-CAISI (Client Access to Integrated Services and Information), an open-source server developed by McMaster University in Hamilton, Ontario, at ICHA. The family physician stores his records on an electronic server at his office. Each physician prints his records for the other, and, upon receipt, rescans them into his respective files. These "housekeeping" tasks result in a large expenditure of time. In the absence of a joint electronic record, how might the two physicians improve their collaboration?
Respondents began by asking if there are ways in which the drop-in agency could apply to become a HIC:
"I wonder if part of the agency has to be designated as some kind of health facility so that [it] can then be a HIC"?
"…Is there a way to [amend] the Personal Health Information Protection Act to have an exemption for social services agencies [that also offer] both medical and psychiatric care"?
The first author responded:
"The PHIPA actually does not exclude social agencies per se from being HICs. [According to PHIPA], a social service agency can decide to become a HIC if it declares that the delivery of health care is one of its main functions…The agency's primary mandate is to provide social services. The agency does not have any staff who are health care professionals…Given this, I think it would be difficult for the agency to be designated a HIC."
The majority of respondents struggled with coming up with ways to develop a joint medical record in the current setting. One respondent approached the problem from a different perspective, asking whether the family physician could have access to CAISI:
"I think you should both use the single electronic medical record provided through ICHA….Although the primary care provider you are working with is not part of ICHA, [he is] providing medical consultation on ICHA clients and therefore it would seem reasonable for [him] to have limited access to the CAISI electronic medical record for those clients to whom you are both providing care. In this scenario, ICHA acts as the HIC."
"…I like your suggestion about the family physician being granted limited access on CAISI to those patients whom we share...He would first have to sign on and be approved as a CAISI user [but then he could] have access to clinical impressions and recommendations. This would do away with the need for me to print off my records."
Other respondents discussed relying on other means for the physicians to communicate clinical information in a timely matter. One respondent suggested establishing a formal separate meeting for the two physicians:
"There's a model that some New York State Office of Mental Health PCs use for this exact issue – basically a quarterly (or monthly) meeting dedicated only to medical issues…attended by both the [primary care physician] and the psychiatrist."
"We find it helpful to discuss with the team present so that the outreach workers (who referred the patient to us initially) are also kept apprised of what the management plans are since they are instrumental in facilitating some of the plans. Regarding mental health matters, I also use the opportunity to do some education about specific diagnoses, symptoms, etc."
"[I] don't see this as a substitute for more in-depth discussions at team meetings, but using email…helps with some practical matters."
Still another respondent asked whether the current circumstances presented in this management case are problematic at all:
"The fact that both the psychiatrists and [primary care physicians] are concerned about the lag in communication is encouraging and impressive. But is there really a problem with a two week lag in info? How exactly does this impact quality of care? I assume that if there is an urgent matter, there is a concerted effort to call each other."
"It is already good that we have co-located services at the drop-in centre. [For] non-urgent issues, a two week lag in implementation of recommendations may not be problematic. [The ideal is if we] always had two clinics running at the same time. Physicians would have access to one another, and clients could see both physicians on one day. That of course is the ideal situation. Perhaps we can try and schedule those clients whom we know have both mental health and physical health concerns to come in on those weeks when both clinics are running."
The psychiatrist felt that it was important for the family physician to have timely access to assessments and recommendations of the psychiatrist. In response to a suggestion posted in the PPF listserv, the psychiatrist discussed with his organization, ICHA, the possibility of granting the family physician access to view the records maintained by the psychiatrist on his server. The medical director of ICHA approved this request. The family physician will soon have the ability to view the medical records of the psychiatrist for clients that are shared between the two physicians, eliminating the burden of having the psychiatrist print out his own reports.
The family physician found that he was seeing the same clients at both the drop-in centre and in the community health centre where his main office is located. Many of these clients also have mental health concerns. He decided to see them only at the drop-in centre and to operate a primary care clinic every week. As was hoped for on the listserv, clients can now potentially obtain medical services, psychiatric services, and case management services, all on the same day at one place and by one team.
The majority of discussions take place with the team during morning meetings. In line with what other respondents have suggested, both physicians are taking advantage of other means for communicating with one another. Since both physicians are located along the same hallway, the physicians sometimes meet in between appointments or at the end of the clinic to discuss clinical issues and to collaborate on a treatment plan for
the client. Outside the morning meetings and the clinics, the physicians use e-mail to communicate issues pertaining to clients. The case managers, who often sit in on client appointments, pass on messages to the other physician when requested. Similar to the experience of a PPF alumna, these informal interactions have eliminated the need to schedule an additional meeting for themselves in the clinic.
The discussion highlights the fact that the ideals and standards physicians strive for in the delivery of health care must be tempered when working in nontraditional settings with difficult-to-reach population such as the homeless. A joint medical record is preferred but is not always possible. It was thus invaluable to hear PPF alumni discuss innovative and alternative approaches to facilitating communication, ranging from email or impromptu discussions around appointments to asking more broadly about the applicability of PHIPA to social services agencies which are increasingly becoming sites for the establishment of outreach clinics. The discussion about this problem highlights the gradual progress being made towards improved communication between psychiatric and medical caregivers of homeless individuals. Clinics which are co-located and integrated with community service providers are well positioned to meet the complex health needs of the homeless.
1. City of Toronto: Toronto Facts, Toronto’s Racial Diversity [online], cited April 23, 2009, from http://www.toronto.ca/toronto_facts/diversity.htm
2. Toronto Shelter Support and Housing Administration, 2006 Street
Needs Assessment: Results and Key Findings (Toronto: City of Toronto,
2006), [online], cited April 15, 2009, from
3. Hwang SW. Homelessness and health. Canadian Medical
Association Journal 164, 2 (2001): 229-233.
4. D'Amore J, et al. The epidemiology of the homeless population
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Medicine 8, 11 (2001): 1051-5.
5. Street Health. The Street Health Report 2007. Toronto: Street
6. Craven M, Bland R. Better practices in collaborative mental
health care: an analysis of the evidence base. Canadian Journal of
Psychiatry. 2006; 51 (Suppl 1):1S-72S.
7. Stergiopoulos V, Rouleau K, Yoder S. Shelter-based
collaborative mental health care for the homeless. Psychiatric Times.
8. Macfarlane D., Current state of collaborative mental health care. Mississauga, ON: Canadian Collaborative Mental Health Initiative; June 2005. Available at: www.ccmhi.ca
9. Personal Health Information Protection Act, 2004: An Overview for Health Information Custodians. (Ministry of Health and Long-Term Care, August 2004), [online], cited April 23, 2009, from http://www.health.gov.on.ca/english/providers/legislation/priv_legislation/info_custodians.pdf
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