What is the system challenge?

St. Joseph’s Care Group (SJCG) in Thunder Bay wanted to strengthen its Collaborative Care model of practice - a model of mental health care designed to improve access and reduce wait times for specialist mental health services. The model, which places clients at the center of their care, was developed in partnership with family physicians and local family health teams.

By implementing Collaborative Care (formerly known as Shared Care),  SJCG’s goal was to better serve mental health patients by streamlining access and incorporating specialized psychiatry services within a primary care setting. The model is designed to ease the load on the mental health care system while improving the ability of primary care staff to provide mental health services to their patients. Primary care providers would benefit by having timely access to consultations, as well as direct and indirect service and education from a psychiatrist and mental health nurses.

However, due to the expansion of the program, enhancements were necessary to ensure continued effectiveness and improve efficiency. 

What are we doing about it?

SJCG approached the PSSP Northwest Region team to assist in increasing the efficiency of their Collaborative Care program. 

Using an Implementation Science lens, PSSP assisted by offering a neutral sounding board and providing resources specifically aimed at implementation support and coaching; conducting targeted interviews to better understand the program and potential gaps and/or barriers; and identifying possible solutions.

The result has been a collaborative effort that brings specialized psychiatry services into a primary care setting. Evidence suggests that Collaborative Care can improve the system by focusing on the following key elements:

  • accessibility;
  • structures and systems which support collaboration;
  • patient-centered care;
  • common goals and language;
  • interdisciplinary teams and coordinated care; and
  • continuity of care.

The Collaborative Care model works because specialized teams are able to have a psychiatrist complete assessments and diagnose the patient, then have the physician provide the follow-up care with support from others on the psychiatric team. Patients requiring mental health services will now be able to access more timely services in a more navigable system.

An added benefit of the Collaborative Care model is that it creates in-situ mental health education opportunities for physicians and other primary care providers to learn about different illnesses, medications, treatments, and evidence informed interventions.

Including specialized psychiatric teams who can offer mental health services in a primary care setting will lessen some of the hurdles currently faced by patients. With a psychiatrist and mental health nurse working directly with family physicians, direct pathways will now improve access to mental health services, including direct client service, indirect client service, and external referrals.

?What's this?

Full Implementation

Patients requiring mental health services are now able to access timely services in a more navigable system. Incorporating specialized psychiatric teams offering mental health services from a primary care setting alleviates some of the hurdles faced by patients. With a psychiatrist and mental health nurse working directly with family physicians, several direct pathways now improve access to mental health services, including direct client service, indirect client service, and external referrals. 

The Northwest PSSP team will stay connected with the program staff, and remain available for continued follow-up and support, if necessary. 

Next Steps

Maintain ongoing communication with the program for updates and information sharing.

Who is involved?

  • CAMH PSSP Northwest Region
  • St. Joseph’s Care Group