"If necessity is the mother of invention, then adversity must be
one of the fathers….”
In the early 1990s,
there was the widespread recognition at the grass roots that mental illness and
addictions greatly contributed to human suffering. This was evident in
communities, in the workplace, in family doctors offices, during inpatient and outpatient visits at
hospitals and in long term care facilities. And everyone did their best within
the existing system of health care. When issues were identified, a referral for
consultation with mental health professionals, private or publicly funded,
was usually arranged and the process was no different than being sent to a
cardiologist for issues identified with the cardiovascular system.
However, there was
something very different about seeking and receiving care when it involved
mental health and addictions. I believe many people, their families, health
care providers and managers of health services were aware of a myriad of issues
that contributed to this difference, and the complexity of the problems were
However, all journeys start with the first steps, and in Canada,
the formalizing of what came to be called "Shared Mental Health care” embodied
these initial incremental efforts. Family Doctors in rural communities and
smaller centers have long managed complex medical issues through "shared care”
with specialists. The process involved "getting to know one another” at doctors
lounges or during minor league baseball. Smaller communities lend themselves to
more opportunities to meet and greater ease of networking resulting in
partnerships that grow over time and through shared experiences.
A small group of
psychiatrists and family doctors in Toronto, Ontario started to experiment with
the idea of psychiatrists coming to the family doctors office for an afternoon
to help deal with issues rather than the traditional referral letter arriving
in their mail. It became evident that this simple change was yielding great
benefits to the doctors and their patients.
Dr. Nick Kates and Dr.
Marilyn Craven , approached their National organizations, the Canadian
Psychiatric Association and the College of Family Physicians of Canada, and
presented this model to them. This resulted not only in these two professional organizations deciding to form a working group to develop this model further
but also brought individuals with a systems level view to the table. The group
was influenced by Global initiatives such as the
of Alma-Ata" in 1978,
for All by 2000”, which emphasizes the role of primary care,
- "World Development Report 1993: Investing
in Health" which emphasized concentrating on economic benefits of "single
item” interventions, and
- "The World Health
Report 2008 − Primary Health Care: Now More Than Ever".
A literature review of
Shared mental health care/ Collaborative care practices was completed by Drs.
Roger Bland and Marilyn Craven and was an important milestone as well as a
foundational piece for the future directions of this journey.
What ensued in the
next ten years was a rapid acceleration of this journey.
The first position
paper , "Shared Mental Health Care in Canada” was published in 1997 and
generated widespread interest and awareness of this model. Canada’s Primary
Care Reform was underway in the early 2000s and provided two Federal grants
that funded shared mental health care pilot projects across
the country and the development of the Canadian Collaborative Mental Health
. CCMHI developed Collaborative care
toolkits and a charter that expanded this model to include people and their
families, nurses, pharmacists, dieticians, occupational therapists, social
workers and psychologists. Annual provincial conferences on Shared mental
health care were held which invited presentations from groups that had
implemented these models in their clinical settings and placed a focus on
evaluation, research and knowledge exchange in this area.
funding-incentives promoting collaborative networks of practice and learning
gave system level support to this model across the country.
The Canadian Armed
Force Initiative, RX 2000 considered this model for their strategic planning.
The Canadian Medical Protective Association acknowledged collaborative models
of medical practice in support of practitioners who were now working
differently within these emerging initiatives.
An important milestone
was achieved when the Royal College of Physicians and Surgeons of Canada
adopted training guidelines for psychiatry residents in Collaborative mental
At this time, the
Federal government had formed the Mental Health Commission of Canada to develop
a Mental Health Strategy for the country. The establishment of CHEER in 2011 ( Collaborative Healthcare
exchange, evaluation & research) within the framework of the national
strategy heralded the widespread recognition of the merits and value of this
model of care at all levels of the system of health care. Dr. Nick Kates and
Dr. Francine Lemire from the Canadian Psychiatric Association and the College
of Family Physicians of Canada are the Co-chairs of CHEER.
The Mental Health Strategy for
Directions, Changing lives, was just released in May
2012. The six strategic directions in the strategy aim to transform the system
of health services by integrating mental health and addictions related services
from the grass roots of health promotion to management of chronic and severe
mental illness and addictions across the lifespan of humans. It extends the
expectation that the needs of families, communities and workplaces must be
considered and supported as this journey of change transforms us individually
The timing of the 12th
Collaborative Mental Health Conference held in Halifax during June of 2011 was
such that several of these major developments were incorporated into the
content and presentations at the conference. During this time, the Minister of
Health and Wellness, Maureen MacDonald, with her grass roots experience as a
social worker, was resolved to develop a provincial mental health and
addictions strategy to address the complex myriad of difficulties in providing
and receiving mental health and addictions care in Nova Scotia.
She selected an advisory committee of
diverse members to develop recommendations for the provincial strategy. The
committee held consultations across the province, studied existing literature
and commissioned reports to better understand and identify gaps in the current
system. "Come Together", was the culmination of over two
years of work and had 61 recommendations intended to snap together to address
the complex gaps identified. It called for a cross jurisdictional approach
within government and the districts within the province, reducing
inefficiencies and waste of resources, strategic investment of new funds to
develop early detection and management of issues within primary care, within
families, school, communities and workplaces.
Collaborative care was presented as
a means by which meaningful partnerships and working relationships could be
forged in addressing system wide, deep seated issues that urgently needed
change. The response from the government was to accept all the committee's recommendations . In "Together We Can”,
Nova Scotia has started its own journey towards health and wellness through
collaborative care based processes that are intended to lead to improved access
to high quality care that is sustainable for our province.
And as I write the final words of
this article, we are poised to release the recorded content from the ground
breaking Collaborative Mental Health Care conference held in Halifax in June
2011, to a global audience. You are welcome to go to www.shared-care.ca,
and follow the links to the "First Online Collaborative Mental Health care
conference”. The content is sure to inform and inspire you!
This journey started due to
necessity and as expected has met much adversity along with way. It has known
the sweetness of success as well as the bitterness of initiatives that have
gone awry. We have all continued to learn through engagement in this journey
and the evolution of Collaborative care itself has been a rewarding process to
shape and observe. And…what a ride it has been to get to the tipping point of
|Dr "AJ" Jayabarathan is a family physician in Halifax. |
She was recently awarded Nova Scotia College of Family Physicians 2012 Award of Excellence for her advocacy for "Excellence in Advocating for Accessible Quality Mental Health Care for All Nova Scotians".
AJ will present a plenary session at CFHA's October 4-6, 2012 Conference in Austin, TX. She is a regular blogger with CFHA, including posts here, here, and here.