Extending Care to Psychiatric Outpatients

The Institute of Mental Health (IMH) recently won the inaugural Grand Award for the Hospital of the Year at this year’s Asian Hospital Management Awards (AHMA). Besides the Grand Award, IMH also bagged a Winner award and two Excellence awards in different categories (see news in Medical Grapevine, September issue). AHMA was part of the 10th Hospital Management Asia Conference held in Singapore this year. In this exclusive interview with Medical Grapevine, Ms Margaret Hendriks, Head, Case Management Unit, IMH, and Dr Goh Yen Li, consultant at the Department of General Psychiatry and Director of the Mental Health-General Practitioner (MH-GP) Partnership Programme, talk about the management of psychiatric outpatients and how the programme works.

What are the keys to optimal care for mentally ill patients?
Ms Hendriks: The care provided to patients with psychiatric conditions should be seamless, continuous and coordinated. It should meet their needs so that they are continuously engaged in treatment, and not default and suffer relapses and result in frequent admissions to the hospital. IMH has ‘re-engineered’ its mental health service, i.e. case management service.

What led to this and what were the steps taken?
Ms Hendriks: The previous system takes into account only a selected number of patients satisfying a set of predetermined criteria. However there were weaknesses in this process, such as not all high-risk patients were considered, case-tracking system was less effective because there was no partnership with the community, and manual tracking was labour-intensive and not easy to maintain.

In the re-engineered process, by using a case management framework, a case manager is assigned according to the patients’ need for close supervision and care in the community upon their discharge. These patients are kept in close contact by telephone to ensure their compliance with follow-up treatment.

In March last year, MOH supported the programme with funding under the Healthcare Service Development Programme. The hospital was able to expand the team of case managers to the current number of 24 staff from the initial four. The funding also enabled us to procure an IT system that assisted the case managers in the monitoring and care of their patients.

What were the success and challenges IMH encountered along the process?
Ms Hendriks: The initial result shows an increase from a baseline of 78 percent to more than 88 percent of patients adhering to follow-up treatment after discharge, with a highest record of 90.2 percent after 14 months of implementing the system enhancements. The number of patients defaulting treatment dropped from 22 percent to 10 percent in a 14-month period.

All discharged patients were ensured a well-coordinated follow-up, through any of the following sites that are suitable for the patients’ needs:
• IMH’s specialist outpatient clinics.
• Satellite clinics in the community which are nearer the patients’ homes.
• Right-siting of patients to general practitioners (GPs) nearer their homes who are able to provide clinical services beyond office hours. This arrangement provides greater convenience for patients in terms of savings of travelling time and transport costs, as they do not have to travel all the way to IMH.

The difficulties encountered include the time required to train case managers and clinical trackers. We tackled this by block-booking some dates to conduct the training, and making the training well-structured to cover the vital concepts and information. There are also challenges in conceptualising and building up an IT system that will meet the needs of the project. We overcame this by involving a multi-disciplinary team right from the conceptualisation stage up to proof of concept and pilot runs, to ensure we have covered all department-specific requirements.

What constitutes an effective primary care model of psychiatric outpatients?
Dr Goh: Stable patients, who are in the remission and recovery phase of their illnesses, are suitable for primary care treatment by their GPs in the community. Mental illnesses that can be adequately managed by GPs include stable chronic schizophrenia, anxiety disorders and depressive disorders. The MH-GP Partnership Programme, which is a programme under the National Mental Health Blueprint and led by IMH, allows for this model of care.

IMH has developed a strong network of GP partners in the community. We provide training for GPs to enhance their skills and knowledge in psychiatry and work closely with the GPs to support and assist them in the management of patients in the community. There is joint management of patients between primary and tertiary levels, i.e. GPs at primary level are able to contact IMH and refer the patients back to their psychiatrists when they suffer an exacerbation or a relapse of their illness requiring specialist care.

How can GPs contribute to the care and management of psychiatric patients in the community?
Dr Goh: GPs are often the first point of contact for a patient with mental illness at the community level. Hence GPs play an essential role in early detection of patients with mental illness symptoms. Patients with stabilised conditions can be effectively managed by family physicians.

IMH patients are referred to a GP Partnership clinic nearest to their home or workplace for convenience and better access to treatment, usually a GP of their choice. There is flexibility of timing as GP clinics are open after office hours and on Saturday mornings; hence patients need not apply for leave from work to seek medical consultations. Patients get personalised and holistic care from their GPs for the treatment of their psychiatric conditions as well as other medical problems.

The accessibility of GP service and less stigmatising environment encourage patients to go for their regular follow-ups.

How does the MH-GP Partnership Programme support GPs in managing these patients?
Dr Goh: Singapore’s healthcare landscape is moving towards community-based care, with enhanced integration between the tertiary and primary care providers. The MH-GP Partnership Programme supports this national agenda by promoting referral of stabilised patients to primary care providers. Regular training and refresher courses on mental illness topics useful for GPs in patient management are conducted.

The programme liaison coordinators are easily contactable via hotline and email for operational support. GPs can also directly seek advice from IMH psychiatrists for clinical matters, during emergencies and after office consultations.

All GPs are encouraged to sign up for the Graduate Diploma in Mental Health which is jointly offered by IMH and National University Singapore.

Short URL: http://www.medicalgrapevineasia.com/mg/?p=1343

Posted by MG on Nov 6 2011. Filed under Features, Local, Singapore. You can follow any responses to this entry through the RSS 2.0. Responses are currently closed, but you can trackback from your own site.

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Extending Care to Psychiatric Outpatients

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