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Integrate care to fill the gap in physical and mental health for older people

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In 2016, Trillium Health Partners launched an innovative program aimed at providing comprehensive support to seniors with physical and mental health issues. It is a group for which care can be uncoordinated, often requiring multiple medications that must be managed carefully to avoid interactions and side effects. They need community programs, counseling, and help navigating various systems. But his medical care is fragmented between specialists in hospitals and providers in community clinics and between those who treat his physical ailments and respond to his mental health concerns.

As Robert Reid, Hazel McCallion Research Chair at Learning Health Systems and Chief Scientist at the Institute for Better Health, He says, “Traditionally, what happens in health care is that mental health and physical health are done independently. And that is not the reality. They are fundamentally linked conditions. How you do mentally completely affects how well you do with your physical conditions. And vice versa. So when you’re actually fundamentally linking care for those conditions, that’s a really different model of care. “

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

So far, the program has enrolled nearly 200 seniors. Although the pressures of COVID have put it on temporary hiatus, Trillium plans to reset and improve it in the future.. During enrollment, 64 percent of patients reported moderate to severe depression. That dropped to 26 percent after three to four months of treatment. Anxiety decreased from 52% to 23%.

The program assigns care coordinators who visit patients in 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, an occupational therapist or a nurse, is trained in psychotherapy to provide counseling during your visits, as well as connecting patients with support from the community. Two to four times a month, Trillium geriatricians and psychiatrists hold case conferences about patients enrolled in the program with family physicians and care coordinators to ensure that patients are taking the correct medications and dosages and resolving problems.

To design the program, Richard Schulman, director of Senior Mental Health Services at Trillium Health Partners, looked at collaborative programs in the US to determine what works, such as how often case conferences are scheduled. He then adapted the program for the environment and the local population. Providers said the program should not have rigid requirements on what physical and mental symptoms were included, for example.

“Traditionally, physical and mental health is done independently. And that is not the reality. They are fundamentally linked. “

“We integrate geriatric medicine and geriatric psychiatry, something that nobody had done before”Says Schulman. “There were many examples of success for collaborative models treating depression, but it was usually related to another illness, such as diabetes. We made it more open to make it more realistic. “

But like all new programs, there were drawbacks, especially in the beginning. Community physicians were often unable to attend conferences despite invaluable input. So doctors and researchers took a drastic step – They stopped the show for a few weeks.

They realized that part of the problem was that the family doctors did not understand how the program worked. “They were wondering, ‘How long is this going to last? And what happens when you remove the service? ‘”Says Mansfield.

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

Now, with less stress on the healthcare system and home controls starting over, Trillium Health Partners is considering integrating the program in a sustainable way going forward..

After all, it was a success.. “Families felt, for the first time, that their loved one’s care was integrated,” says Reid.

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