HAMILTON URBAN CORE COMMUNITY HEALTH CENTRE Integrating Shared Mental Health Care in Primary Health Care Practice Final Report 2006 INTRODUCTION

Transcription

1 HAMILTON URBAN CORE COMMUNITY HEALTH CENTRE Integrating Shared Mental Health Care in Primary Health Care Practice Final Report 2006 INTRODUCTION In the spring of 2004, Hamilton Urban Core Community Health Centre (HUCCHC) received funding from the Primary Health Care Transition Fund for a demonstration project to integrate primary mental health services into primary health care at the Centre. This funding enabled the hiring of the following staff: a project coordinator, evaluator, social worker, nurse, administrative support, a physician, and eventually a consulting psychiatrist for the last few months of the project. The team had twenty months in which to implement this project meant to expand and enhance mental health services at the Centre. This report is focused on the background and objectives of the project, the project model, the progression and evaluation of the project, and the overall outcomes. While the formal name of the project is Integrating Shared Mental Health Care in Primary Health Care Practice, the project is commonly known and referred to as the Mental Health Integration Project, or MHIP. Background The rationale for implementing this project results from the location of and population served by Hamilton Urban Core Community Health Centre, as well as the structure and function of Community Health Centres. As a Community Health Centre, Hamilton Urban Core is a non-profit agency that is governed by a board of directors, comprised of individuals who are representative of the community and volunteer their time and skills in this capacity. The approach of CHCs to the health of the community is based on addressing various determinants of health. This approach leads to practice that does not focus solely on providing for physical health care, but also includes linking families and individuals with the community, advocating for clients, and increasing the capacity of people to care for their own well-being and the well-being of others. Hamilton Urban Core Community Health Centre operates through a holistic, multidisciplinary approach to address determinants of health within its range of services. The people served by Hamilton Urban Core including homeless and under-housed individuals and families, immigrants and refugees, low-income individuals and families, people living with mental illness, street involved youth, and isolated seniors are able to access primary health care, health promotion, health education, oral health services, chiropody services, counseling, support groups, advocacy, information sessions, laundry and shower 1

2 facilities, along with many other programs. While access to various programs and services at Hamilton Urban Core Community Health Centre is open to all community members within its catchment area of approximately 65,000 people, access to physician and nurse practitioner services (clinical services) is limited. The number of people in the area who are in need of medical services far exceeds the ability of the Hamilton Urban Core Community Health Centre clinic to provide these services. Therefore, there is an eligibility process and an existing waitlist to be accepted as a clinic client. Although an individual or family may not be able to access clinical services at the Centre, they are able and encouraged to participate in other health and health-related services and programs provided. As suggested by its name, Hamilton Urban Core Community Health Centre is located in downtown Hamilton, Ontario a city with a population of nearly 500,000 that reflects diversity in various ways (for example, race, nationality, culture, language, faith, spirituality). Like many industrial centres in North America, the city has experienced economic decline during the last decades. The suburban areas are growing, while the city core struggles. The downtown core has the highest concentration of homelessness, poverty, low-income, and people living with mental health issues in the city. Hamilton is also the third largest receiving area of newly arrived immigrants and refugees, who also are concentrated in the downtown core. At the same time, particularly in the realm of health care, Hamilton is experiencing resource shortages, such as access to psychiatrists, physicians, and nurse practitioners, as is the case in many areas of the country. Moreover, while Hamilton is one of the main receiving areas for new immigrants and refugees, there is a lack of understanding and expertise in the effects of war, torture, and terrorism, as well as other mental health issues, such as Post Traumatic Stress Disorder. Therefore, recent immigrants and refugees who have survived these experiences are much underserved. In addition, the Hamilton area also lacks a coordinated strategy regarding substance abuse issues, and service provision for people for whom substance abuse is one of the concurrent disorders is inadequate. For example, many treatment programs for mental health issues require that a person does not consume any alcohol or drugs in order to be accepted as a client. Given the nature of addiction and the interaction between the issues of substance use and mental health, abstinence is not possible for some people. Therefore, they often go untreated. In its current state, Hamilton is facing a crisis in terms of poverty, homelessness, and mental health, and this crisis is exacerbated by the connections among various social, economic, and health issues. Hamilton has a poverty rate of 20%, which is greater than the provincial average. Moreover, due to racism and other oppressions and inequities, certain citizen groups experience even higher poverty rates (recent immigrants 52%; people with aboriginal status 44%; people with visible minority status 37%; people living with activity limitations 30%; seniors over age 75 29%; and children under 12 years old 25%) (Incomes and Poverty in Hamilton, Nov 2004, Social Planning and Research Council of Hamilton-Wentworth). Given the problem of poverty, it stands to reason that many citizens cannot afford housing. Indeed, almost half of renter households spend more than 30% of their income on housing, while another quarter of renter households use more than 50% of their income on housing (A Social Vision for 2

3 the New City of Hamilton, Sept 2002, Caledon Institute of Social Policy). In addition to the affordability issue is the issue of availability. While it is difficult to find safe, clean, affordable housing in Hamilton, the social housing waitlist continues to grow as does the demand for emergency shelter (Summary of the Progress Report on Homelessness, 2003, Social Planning and Research Council of Hamilton-Wentworth). Women s shelters are turning more women away, having reached capacity. At the same time, Hamilton has the highest number of social assistance recipients in southwestern Ontario. In terms of mental health, the Canadian Mental Health Association estimates that 20% of all Canadians will personally experience a mental illness in their lifetime, regardless of age, income or educational level, or culture. In addition to this statistic that does not discriminate, there are social forces that impact the likelihood and experience of mental health issues. The high rates of poverty and the difficulty with finding and maintaining housing create significant stress and anxiety for the citizens of Hamilton. In addition, the stigma of mental illness also erects additional barriers for people trying to find and maintain employment and housing. When social systems ignore the connection between issues, such as poverty, homelessness, and mental health, services remain fragmented and cannot effectively assist those in need. Even before MHIP began, Hamilton Urban Core Community Health Centre was necessarily recognizing and addressing the mental health issues and needs of its clients. As part of its comprehensive service delivery and multidisciplinary approach, Hamilton Urban Core has employed social workers and counselors, as well as having medical professionals (physicians and nurse practitioners) who address the mental health of clients to the best of their abilities. In addition, Hamilton Urban Core has also had access to successive consulting psychiatrists in the past, whose services were provided through the Hamilton-Wentworth HSO Mental Health and Nutrition Program outreach services. Given the location and population served, in which the incidence of mental health issues is greater than the estimates given by the Canadian Mental Health Association, mental health and mental illness has always been a factor in the work and services of the Centre. In this context, the purpose of the project was to expand and enhance mental health services, as well as document and formalize the integrated approach to mental health services, rather than simply offering services that were not already available. Project Objectives The objectives of the project, then, were set in accordance to the background and context of the Centre. The five stated objectives are as follows: 1) To increase mental health care services at the primary care level at Hamilton Urban Core Community Health Centre 2) To increase access to primary health care through the integration of primary mental health services and primary health care 3

4 3) To increase health providers access at Hamilton Urban Core Community Health Centre to mental health professionals 4) To decrease reliance on hospital based mental health services 5) To increase knowledge among health providers THE MODEL PROPOSED The initial project proposal did not propose a particular model, but indicated that a model would be developed during the project. Thus, the ensuing description of the proposed model is a synthesis developed in hindsight, combining the underlying assumptions and principles that influenced decisions about client service paths and clinical governance as the project unfolded in its initial stages. Later in this report, this model will be revisited. A number of opportunities for transformation have been identified as a result of making explicit both the working model of client care and what the ideal model would be. The CHC Model Prior to the project, there was an established approach to primary health care delivery in community health centre (CHC) settings, based on addressing all the determinants of health, which was reflected in the working models and structures at Hamilton Urban Core. There are three permanent teams of staff: the administrative team, the community and health promotion team, and the clinical team. The administrative team includes all of the clerical, data management and information technology staff, who facilitate communication among staff and between staff and clients (including scheduling appointments), and ensure that data is managed for reporting purposes. The community and health promotion team consists of staff from various disciplines (counselors, social workers, community workers, an early childhood education specialist, an oral health coordinator, a chiropodist, nurses doing outreach work) who are primarily responsible for addressing some of the social determinants of health, such as overcoming barriers due to poverty, homelessness, immigration status, race, and gender. In general, the community and health promotion team provides health promotion programs, education, advocacy, counseling, support and referrals. Note that at least some of the members of the community and health promotion team are professionals with clinical skills that are being applied in a community health context rather than a clinical context. Also, some of the counselors and members of the community and health promotion team bring certain cultural-specific and language skills to enable outreach work with particular ethno-specific groups, particularly refugees and recent immigrants. The community and health promotion team is not solely responsible for addressing issues based on the social determinants of health (the clinical team also uses this approach in its work), but the existence of the community and health promotion team distinguishes a community health centre such as Hamilton Urban Core from other clinical settings. The clinical team consists of physicians, nurse practitioners and nurses who provide clinical services, including health education and counseling. 4

5 Within the clinical team, clients are seen by the most appropriate provider, so that they may not always see a physician, and indeed their primary clinical contact may be with a nurse practitioner or a nurse. In this way, CHCs are different from other medical structures where the physician is the primary provider and any other health care provider is seen as an adjunct to the physician. Innovations at Hamilton Urban Core CHC The concept of a most responsible physician (MRP) was developed at Hamilton Urban Core in response to a specific number of clients with chronic and complex health conditions. Although this approach may seem contrary to the shared care approach where the providers are equally responsible for the care of clients, in order to ensure the quality and continuity of care for those clients with the most complex or multiple health needs, often involving mental health issues, one of the physicians was designated as a most responsible physician for these high-need clients. The MRP would be the provider to most closely follow the client s course of care in an effort to provide continuity. This concept was developed on a trial basis and in a context where clients are enrolled to the Centre and not to a particular practitioner. This was not necessarily an exclusive relationship, as there may have been times when the client would have seen another physician or another provider for a number of possible reasons, including scheduling issues. Thus it is a modification to a shared care system, and is a most responsible physician rather than an only responsible physician. At the start of the project, Hamilton Urban Core was only eight years old. During these eight years, the number of staff members had increased dramatically (from an initial handful to approximately 30 staff), as had the number of clients served (to a client database of approximately 10,000). Systems had been developed at the Centre to ensure that clients had access to services by the most appropriate provider. Members of the community and health promotion team were responsible for intake work, thus relieving clinical staff from having to ask invasive (or clinically irrelevant) questions about income, housing, immigration status, relationship status, and the like, which enable staff to make decisions about prioritizing access to clinical services. It is important to note that the Centre was at a stage in its growth where it was fine-tuning some of these processes around client intake and client service paths, and the initiation of a new project with additional staff resources both enhanced and complicated these processes. When the project was first initiated, it meant that there was an influx of new mental health professionals, faced with a large population of people with complex and chronic mental health needs. Faced with these high needs and demand for services, the initial model that was developed was one of how to most quickly and effectively screen clients through an intake process that would result in clients receiving mental health services from a mental health care professional. This model had the advantage of meeting client needs that were presented, and of eliminating any wait-list for mental health services. 5

6 As is the case with many community health centres, Hamilton Urban Core has established a wait list for clinical (medical) services at the CHC. The wait list is a temporary and revolving arrangement put in place to assist the Centre in managing emerging trends and ongoing increased demands for service. The wait list is carefully and routinely monitored by an interdisciplinary committee, representative of the various teams within the Centre (New Clinical Client Committee). The project was able to improve access to mental health services through the intake process, by connecting clients with therapeutic support provided by the social worker, case management services provided by the psychiatric nurse and social worker, and improved management of complex health needs through physician services and the psychiatric nurse. However, this model began to break down as the mental health practitioners approached a saturation point in terms of being able to provide one-on-one mental health services, and also as the demand for physicians was such that there was a waitlist for clinical (physician) services, and there was a certain resistance to provide mental health services to clients who did not have access to clinical services within the Centre. The concept of a wait list is about prioritizing needs where there are limited resources. In a model that assumes that mental health services can only be delivered by mental health professionals, then of course there are limited resources and there will be a wait list. In a model that assumes that any number of services can improve mental health, from working with a wide range of health workers (not just mental health professionals) to interacting with peers to self-help, resources are not as limited and there need be no concept of a wait list. Even in instances where a client may be waiting for access to a physician or clinical services, there is a full range of other important services available to clients at the Centre, including a wide selection of group activities (involving stress reduction, anger management, parenting, arts and crafts, cooking, and others) designed to address certain skills or provide specific opportunities for clients. For example, the arts and crafts group is intended to address the issue of social isolation and provides an avenue for outreach and relationship building, while Cooking at the Core is directed towards helping people living with low income to increase their access to, and understanding of, nutrition as it impacts their health and the health of their families. The open access to various programs and services, besides clinical services, is particularly important as many of the issues presented by the client population involve advocacy, access to housing, retrieving identification documents, and access to income. In addition, other factors such as substance abuse, isolation, poverty, immigration status or experiences of discrimination affect clients access to services and supports and the ability to manage daily life tasks. Programs such as the Street Drop In, which is provided at the Centre twice per week is available to the project staff, and the project nurse is available to identify, assess or respond to mental health needs where people present and in a non intrusive manner. Comparing Mental Health Services in other CHCs 6

7 Thus, in developing the model about accessing mental health services, it was important to come to a common understanding about what kinds of services comprised mental health services. A representative sample of other CHCs in the province was contacted to ask about what mental health services they offered, for comparison purposes. One CHC (Women s Health in Women s Hands) offers one-on-one short-term counseling for 15 weeks, but if someone with a mental illness, such as schizophrenia, presents, the client is told that the mental health condition is out of the scope of the services provided, and referred elsewhere. This is in Toronto where there are a range of services available and so appropriate referrals are possible. In some communities, rather than a model of referrals, there is more of a partnership model. For example in Ottawa, a CHC reported that there were lots of mental health resources available in the community, with which they worked closely. The Ottawa CHC has two different consulting psychiatrists, one for two hours per month and one for three hours per month, who do case conferencing on the most complicated cases. The following resources are available for all clients (not just those identified with mental health issues): addiction counselors, homelessness team, housing counselors, home management counselor, group programs, seniors outreach, and ten social workers (6FTEs). Many CHCs contacted reported on advocacy workers (similar to the community and health promotion team at Hamilton Urban Core) as part of their mental health services. Even those CHCs that are structured as a family practice unit (such as Central Toronto CHC) reported that much of their mental health services are delivered by non-clinical personnel, and that for clients who need medications, they can never get access immediately. They ask clients to give a couple of days notice if they want a prescription refill. Another CHC in Hamilton (North Hamilton) described their mental health services as consisting of a patient advocate, a mental health nurse, a social worker, and a consulting psychiatrist. Those CHCs that had access to psychiatrists usually used them in a consulting capacity, where they were available to consult with health care staff, but did not see clients directly. The only exception to this was at Central Toronto CHC, where a psychiatrist is available for one day per week, who takes internal referrals only, and only those who are homeless or without OHIP, for short term (those with long-term needs are referred elsewhere). At another CHC (Parkdale), a psychiatrist who is available for a limited number of hours per week does the initial assessment and helps the social workers manage each case, but typically does not see the client again after the initial visit. Modeling Collaborative Shared Care Outside of the CHC context, there had also been work done elsewhere on models for collaborative inter-disciplinary mental health care. These inter-disciplinary models developed elsewhere were precisely that, between disciplines, and typically modeled relationships between psychiatrists and family physicians, but did not account for advocates, housing or homelessness workers, community health workers or other services that form an important part of a CHC model. The emphasis on housing or homelessness initiatives encountered in CHCs is not accidental, when one considers that until the de-institutionalization processes in Ontario in the 80s and 90s, the majority 7

8 of the most seriously mentally ill were housed in institutions. In Hamilton for example, the Hamilton Psychiatric Hospital provided leadership in psychiatric nursing in Canada for more than a century, and provided a full range of services including food, shelter and clothing in addition to clinical services. The combined issues of homelessness and mental illness is one of the most pressing needs that this project was designed to address, whether one traces this need to the historical process of de-institutionalization or the current failure of mainstream mental health services to provide advocacy services based on the social determinants of health. In keeping with the concept of connecting clients to the most appropriate provider, the project used an intake and assessment process to determine the needs and presenting issues of each client. This process was adapted from the Centre s existing practices. Once the client intake was completed, clients were referred to the most appropriate provider where a more in-depth assessment based on the area of involvement was conducted. In general, clients were directed to the social worker and nurse for ongoing psychosocial or therapeutic counseling, case management, education and monitoring of health status. The physician was generally engaged in addressing complex health issues, chronic conditions, medications, mental health status assessment and consultations. These roles were interlinked and interdependent and often less rigid than defined here in order to provide optimal care and services. Within the project, decisions as to which health care provider (the nurse or the social worker) was appropriate for each client were also made according to the differences in their approaches to case management. The social worker s role in case management focused on the coordination of services and supports with both internal and external providers, and the role of the nurse included case management that focused more on client education, monitoring, and management of medical symptoms. The project model was designed to improve the integration and co-ordination of services across the continuum of care. Through bi-weekly case conferencing and the use of a most responsible physician (discussed above), providers were able to better address issues related to complex health needs. Case conference meetings were scheduled twice per month (every two weeks) for an hour-and-a-half, and involved representatives from front line providers in all areas of the Centre. Any provider or team member may bring forward a case to the case conference meeting for discussion and typically these cases were unresolved, needed additional provider involvement, and were the most difficult or are complex. Through these meetings, providers from this project were able to bring forward clients for discussion, and were also able to comment on mental health issues for clients brought forward from another team. For example, at a case conference held approximately a month before the project ended (March 31, 2006), the psychiatric nurse presented a client who was very high needs and who had been involved with most of the staff at the CHC due to the nature of his mental illness. The psychiatric nurse helped to establish a more standardized response to decrease multiple contacts and to respond to the client in a more appropriate and effective manner. 8

9 The physician with the project essentially served as the most responsible physician for those clients who had been identified as appropriate for enhanced mental health services. However, the most responsible physician designation for clients who had been identified as appropriate for enhanced mental health services did not necessarily shift to the project physician if the client was already established with the clinic. The practitioners hired for this project generally did not have previous experience working in CHC environments (and thus were accustomed to more hierarchical working arrangements and less of a shared care model), and also the conventional training and workplace experience of most health professionals is not in environments where innovation and flexibility are continually required in order to effectively reach the client population in an inner-city environment. One of the practitioners was a proponent of a case management system whereby one person was the case manager, and that person carefully managed any interactions that the client might have with other providers. This is a very different model than one in which there would be true collaboration at a case management level. Thus it became difficult to fully implement a collaborative sharedcare model when the practitioners responsible for implementing the model were proponents of different models of intake and case management. In general the benefit of the education required to re-orient providers could not be fully realized within the short period of the project, and there is a need for substantial and ongoing education and re-orientation for those with conventional health setting experience who have an interest in working with inner city populations. This was powerfully demonstrated when the staff roles were re-organized such that a physician who had been a long-time staff physician at Hamilton Urban Core took on the role of providing physician services for the MHIP project. Because this physician already had experience in the CHC environment and experience working with the clientele, integration was accelerated dramatically in terms of integrating primary health care and mental health services. With this kind of integration, immediately the project team began identifying some cross-correlations between mental health issues and other health issues such as diabetes or Hepatitis C. Here it was learned that if an integration project can be set-up in a model which uses pre-existing staff for the integration work, this is a preferred model particularly for time-limited projects. Inner City Populations, Stigma, Prejudice and Discrimination The inner city population whose mental health needs are being addressed survive in a context of stigma, prejudice and discrimination. Issues of stigma attached to mental illness are well-documented elsewhere, and other mental health agencies have antistigma programs. At some of the early MHIP team meetings, the question of stigma was raised, and the practitioners were in consensus that stigma was not an issue that was preventing any clients from accessing mental health services at Hamilton Urban Core, and that the services were in high demand. However, the issue should be considered in a broader systemic context. In Canada, our societal beliefs about health care are reflected in the core principles of the Canada Health Act: universality, accessibility, and comprehensives. There is a relative comprehensiveness of medical 9

10 care in Canada, in that most medical treatments and procedures are fully funded, and on a formal level (if not a substantive level), services are available and accessible to all. Thus there is a prevailing attitude that if health care services are available and accessible to all, that somehow if there are people experiencing barriers to access, that it is their fault. Indeed, some clients experiencing barriers to access are labeled as noncompliant, and in effect the barriers are enforced (e.g. stipulating consequences for missing scheduled appointments) rather than removed. The issue of stigma, prejudice or discrimination is easily masked or hidden; for example it is easy to contextualize comments about clients who smell in the need for good hygiene. It is easy to mask resistance to working with interpreters across language barriers to shifting the blame to administrative processes. In order to develop a model which is truly effective in eliminating barriers, one must be alert to the possibility of locating barriers within the system of health care provision, rather than locating the barriers within the psyche or the conduct of the clients themselves. In other words, one of the learnings from this project is that the health care service delivery model needs to consider issues of stigma, prejudice and discrimination in a systemic way, rather than relying on the goodwill and skills of individual health care providers to be bias-free and to appear as being bias-free. As University of Saskatchewan professor Donna Greschner advised the Romanow Commission on the Future of Health Care, Governments will need to justify exclusions with evidence about the reasons for the exclusion; in short, they will need to prove that the exclusion is supported by sound medical evidence or other cogent reasons that are unrelated to any prejudice or stereotyping about the persons who wish to have the service (Greschner, 2002, p. 8). Hamilton has the highest poverty rates in the province, and Hamilton Urban Core CHC works with some of the most marginalized people in the city. Those with complex health, mental health and social issues are the hardest to reach. Therefore this project was conceived to find new ways of working with some of the most marginalized people in all of Ontario. The complex and chronic health problems faced by this population will not be solved without a willingness to explore new and more integrated approaches. It should not be a surprise that there were some growing pains and setbacks in putting together a qualified team of professionals who could work together in a collaborative and integrative manner to make progress on both providing effective client service and on documenting and developing new models of client service paths and integrated teamwork. PROJECT PROGRESSION Personnel The personnel plan for the project included a project coordinator, administrative support, evaluator, social worker, nurse practitioner, physician, and a consulting psychiatrist. An administrative support person, project coordinator and project evaluator were in place by August 2004, and this three-member team sketched out the administration of the 10

11 project and planned the evaluation framework. In late August, the social worker joined the team and a physician was hired in October. Due to personal reasons, the administrative support person left in late October, while the project coordinator position was vacated and re-filled in November. While the project initially planned for a nurse practitioner, the position was difficult to fill due to a lack of qualified applicants who were willing and able to accept limited contract employment, and a psychiatric nurse was hired in January The physician s services were withdrawn due to the physician s leave of absence at the end of May At the beginning of July 2005, one of the Centre s staff physicians agreed to fulfill the physician role for the project. Also, during the month of July, another administrative support person was hired (although some administrative support had also been provided on a contractual basis). In September, the project coordinator s role and responsibilities were scaled back in order to facilitate her return to post-secondary education while maintaining some continuity for the project. A psychiatrist was finally hired in November 2005, and took on a project leadership role as well as providing psychiatric consultation and education for staff. Activities MHIP providers began seeing clients soon after they first began employment. The social worker s first appointments with clients were on September 21, 2004, while the physician started seeing clients on October 21, Unfortunately, the nature of service provision and, indeed, the overall purpose and function of the project had not been consensually established and understood when the providers began client appointments. The MHIP staff involved in the administrative functions (project coordinator, project evaluator, and project administrative support) was familiarizing themselves with HUCCHC policy and procedures and believed that the input of the providers was necessary before the project activities, function, and purpose could ultimately be decided. However, this produced long-standing issues for the project. When the providers arrived, they came with particular work histories and did not understand the new environment. All of the MHIP team members were provided with an orientation to the Centre, including written materials that they were able to keep, but the true understanding of policies, procedures, and structure occurred slowly over the course of the project. People become clients of Hamilton Urban Core through an intake process and orientation to the various services and programs. During a private interaction with an intake worker, the potential client and the worker complete a form that covers specific demographic information, health and social concerns, identified needs and appropriate referrals. If the potential client does not have a family doctor and wants access to the medical services at Hamilton Urban Core, their intake information is forwarded to the New Clinical Client Committee (as previously mentioned, this committee is comprised of representatives from the various teams, and works to manage the wait list for clinical services at Hamilton Urban Core). However, at this point in the intake process, a person who may be wait listed for clinical services is a client of the Centre and has access to the many other services and programs offered. Likewise, the Centre has clients who do not require clinical services and attend Hamilton Urban Core for the other 11

12 services and programs. Despite the distinction between those who access clinical services and those who do not, all are clients of the Hamilton Urban Core Community Health Centre. The project, just like all other programs and services at the Centre, was meant to respond to the needs of the existing clients of the Centre, and access to the project s services was to occur through the same Centre-wide intake and referral processes described above. However, the conceptualization issues and lack of understanding among the MHIP team members led to difficulties. The project providers were invested as a separate mental health team rather than as facilitators and capacity builders within the Centre. They believed initially that because physician services were included in the project, clients who became involved with the project would necessarily have access to the physician services. In addition, the MHIP team also concerned themselves with external referrals instead of allowing the existing Hamilton Urban Core intake and referral processes to manage these referrals as it was designed to do. This resulted in a situation in which individuals who became involved with MHIP were becoming de facto clinical clients and accessing clinical services without their situation first being reviewed by HUCCHC s New Clinical Client Committee. Therefore, some of the clients who were involved with MHIP early on in the project were allowed to effectively bypass the clinical waitlist. This situation was rectified through listing MHIPinvolved clients who had not become clinical clients through the established method and policy of the Centre and submitting that list to the New Clinical Client Committee for eligibility and review. However, the situation of clients who could access clinical services and clients who could not continued to be an issue for the project providers throughout the project. They felt that it was counter-productive to the objectives of the project and, as evidenced by meeting minutes and conversations, could never fully come to terms with it. As previously stated, most of the provider activities in terms of service provision was through direct one-to-one encounters with clients. During the 16 months that records were kept regarding the social worker s appointments, she logged 1245 appointments during 223 work days, which translates to an average of 5.6 appointments per day. In addition to providing one-to-one counselling and behaviour therapy, the social worker provided case management, ensuring that the needs of the clients were met by appropriate providers both internally and externally. Approximately one quarter of the social worker s time involved collaboration with other staff within HUCCHC (particularly clinic staff, as well as community health and outreach workers), as well as external providers and agencies involved with the clients (such as Children s Aid Society workers, Ontario Works and ODSP workers, Public Health Outreach, lodging home workers, external physicians, counselors, and, on occasion, psychiatrists). The social worker, like other staff at HUCCHC, also spent time advocating for clients, particularly in the areas of immigration and access to benefits and services, which involved meetings, composing letters, and making phone calls. In addition, the social worker was utilized as a responder in crisis situations at the Centre, and helped defuse a number of volatile situations. As part of the project, the social worker attended a number of educational 12

13 and professional development opportunities, and also presented a staff education session and involved herself in established groups towards the end of the project. The role of the physician mainly involved the provision of primary health care, along with collaboration and communication with other providers, both internal and, on a limited basis, external. Two different physicians filled this role during the project and, due to the leave taken by the first physician, the project was without a designated physician for 1 of the 15 months in which data was recorded. During this month when the project was without a designated physician, the existing primary health care staff at the Centre provided support and service to the psychiatric nurse and social worker so that all client needs continued to be met by the interdisciplinary team, which is consistent with the CHC model and also further indicates the potential benefits of an integrated approach. From October 2004 to May 2005 (8 month data collection), the physician worked 43.5 days and kept 264 appointments, for a daily average of 6.1 appointments. The physician took advantage of as many educational and professional development opportunities as possible during these months. After this position was vacated, a staff physician stepped in to provide the medical care for MHIP-involved clients. From July 2005 to December 2005 (6 month data collection) the physician logged 396 appointments over 42.5 days, producing an average of 9.3 appointments per day. In order to facilitate the staff physician assuming responsibility for the project physician role, the staff physician s work agreement was adjusted with the Centre to accommodate the needs of the clients involved with the project. The addition of the staff physician as the project physician was beneficial to the project progression in that the physician was completely knowledgeable of the Centre s processes, policies, and functioning. As well, she was also quite familiar with the client population and, therefore, had an existing foundation with the clients so that trust and rapport were easily built. At the time of the physician s assumption of the project physician role, the status of the project-involved clients was reviewed, including health status, level of involvement, and current needs. Through this review, it was found that the physician s actual hours could be reduced and that time better spent in consultation with the psychiatric nurse and, later, with the psychiatrist. Since the psychiatric nurse was available to monitor clients, administer medications, and provide education, support, and advocacy, which also served to ensure that the physician s time was better utilized. In addition to providing primary health care services to clients, the physician attended MHIP meetings, assisted in re-directing the project, participated in HUCCHC clientcentred events, including presenting workshops at the Women s Health and Wellness Conferences of 2005 and 2006, and participated in the Collaborative Mental Health Network, so that the project might have some consultation with a psychiatrist. She also attended a number of educational sessions and professional development opportunities, often with the company of the social worker and psychiatric nurse. The psychiatric nurse was the last direct-to-client service provider role filled in the project. While the original intention was to retain a nurse practitioner, this intention had to be modified as a suitable candidate could not be found. As previously mentioned, the shortage of nurse practitioners made this position difficult to fill. Moreover, the project position was neither permanent nor full time, which also worked against the Centre s 13

14 ability to hire even though there were a number of inquiries. The decision was made to hire a qualified psychiatric nurse who would be familiar with mental illness and issues surrounding mental health. Throughout the project, the search continued for a nurse practitioner without success. The psychiatric nurse joined the project in January 2005 and provided direct one-to-one counselling, health teaching, advocacy, collaboration with both internal and external providers, as well as some case management. Along with the physician, and to a lesser extent, the social worker, the psychiatric nurse also monitored psychiatric medications and their effects on clients. Fortunately, the psychiatric nurse was partly funded by another source and was able to work full-time. In addition to her full-time status, the psychiatric nurse worked with the project and as a member of the community and health promotion team. This enabled her access to a variety of settings and circumstances where clients present, and enabled clients to have open access to the psychiatric nurse as opposed to only having access during specific project scheduled time. Thus, this integrated approach better facilitated client access to services and supports. Through her dual role at HUCCHC, she was able to establish an on-going stress management workshop to which all clients of the Centre are able to drop-in registration was not required. In her capacity with MHIP, the psychiatric nurse provided 513 appointments for clients over 92.5 work days, with an average of 5.5 appointments per day. As with the other MHIP providers, the psychiatric nurse attended a number of educational and professional development opportunities, and also participated in the Women s Health and Wellness Conferences by presenting workshops on overcoming anxiety. Just like the social worker, she was also a valuable resource to other staff members when a crisis situation or an immediate assessment need arose. The administrative support person added much value to the project in various ways. Like the psychiatric nurse, another funding source was used and consequently she divided her time between the MHIP project and the community and health promotion team. Therefore, she also had increased opportunity to gain a fuller understanding of the Centre and to experience how client needs are presented across the spectrum of providers and services. The administrative support person organized and scheduled meetings, recorded meeting minutes, compiled and maintained a file of all meeting documentation, and organized all of the existing files, which, prior to her arrival, were disorganized and under-used. The MHIP providers, particularly the social worker, charged her with the tasks of creating forms and documents for their use, as well as photocopying. The administrative support person also inventoried the mental health resources (pamphlets, educational materials, and the like), created and prepared both stationary and portable displays, and prepared presentation packages, flyers, and brochures, and also readied spaces and resources for meetings and presentations. In addition to some of her work listed here, the administrative support person was readily involved and incorporated herself into all HUCCHC activities, including committee membership (Year End Celebration, Annual Picnic, Women s Health and Wellness Conference) and working as the registrar for the Women s Health and Wellness Conference. There was additional administrative support provided to the project on a contractual basis to assist with medical record management, scheduling specialist and diagnostic appointments, reception, and other administrative duties as required. 14

15 The role of the project evaluator consisted of devising, implementing, and analyzing the project evaluation. The project evaluator, in conjunction with other MHIP staff and the Executive Director, created evaluation tools, collected data, and wrote various reports based on that data. She was also involved on HUCCHC s Data Committee and the Health and Safety Committee, as well as some of the committees for client-centred activities, such as the Year End Celebration, Annual Picnic, Women s Health and Wellness Conference, and Celebrate the Core. She also attended and wrote the report for the Dare to Care Roundtable, initiated by the HUCCHC Board. As with all other staff, she also participated in HUCCHC events by preparing and serving food, decorating, preparing spaces and cleaning up. The project evaluator s involvement in these varied activities, just like that of the other MHIP team members, was due to the project being part of the Centre as opposed to a separate or outside entity. Like all staff of the Centre, the MHIP team members were also expected to participate in all of the activities of the Centre. This structure also contributed to overall staff functioning and the integrated approach. The psychiatrist role was filled during the final 4 to 5 months of the project. Her role was consultative and capacity building in nature. In addition, due to the scaled-back involvement of the project coordinator, she also took responsibility for leading the project to its conclusion. During her time with the project, the psychiatrist spoke with many HUCCHC staff members to understand some of the needs and gaps in terms of mental health knowledge and resources at the Centre. She attended a meeting, along with a Community Health Team member, at a local high school with many newly arrived immigrant students to discuss with the principal the impact of post-traumatic stress among the students. She was available to HUCCHC staff for consultation about difficult cases and also presented educational sessions to the staff. She also presented a workshop on depression at the Women s Health and Wellness Conference. The project coordinator role was filled early in the project, but there was an incident of turnover after 4 months, and then a shift in responsibilities approximately 10 months after the second project coordinator began. The primary responsibilities of the project coordinator included: mapping out the project s goals, functioning, and activities in collaboration with the other team members; overseeing task assignment and completion of other team members; handling certain human resource tasks, such as verifying and submitting time-off requests; communicating with both internal and external parties about the project; ensuring project progression towards stated goals and objectives; and documenting the project model and writing certain reports, such as the progress reports to the Primary Health Care Transition Fund, Ministry of Health and Long Term Care. When the second project coordinator reduced her availability to the project, some of these tasks were distributed among the Executive Director, the project evaluator, and the psychiatrist. In addition to the project specific tasks, the project coordinator also participated in many HUCCHC activities (Annual Health Street Fair, Annual Client Picnic, Year End Celebration, etc), acted as chairperson for the 2005 Women s Health and Wellness Conference, and worked on other Centre committees, including the Data Committee. 15