By Sandeep Dhaliwal
Care manager Lisa Ahmed has a unique and innovative role at Trillium Health Partners (THP) in Mississauga. Working within a new integrated healthcare model currently being piloted at THP, she is responsible for helping patients receive timely and coordinated access to the services they need. Her patients are seniors living with both mental and physical illnesses in a system that has traditionally not been set up to see patients for both areas of care simultaneously.
“When you have an older patient who is being treated for a mental health concern, nine out of 10 times, they will have co-existing physical issues as well,” Lisa says. “That is why it is so important for their health care to be holistic, whereby their health providers look at all of their needs together. As a result, the chances that a patient will be re-admitted to hospital decrease, they adhere to their medications better, and in general experience a better quality of care and life.”
The Medical Psychiatry Alliance (MPA) is an unprecedented healthcare partnership that aims to transform the delivery of mental health services in Ontario. THP, one of the members, is creating a new approach to the healthcare of seniors. In the new pilot program, Lisa is part of an interprofessional health care team working directly with primary care to address both mental and physical health needs of senior patients. The other health providers on the team include a geriatrician, a geriatric psychiatrist, a social worker, the family doctor, and other allied health care providers, as needed. The patient and their family are at the centre of the health team and active members in their health care.
Initially focusing on a small target group of seniors, the new service at THP is providing care to patients like Ernest Coulombe, aged 82, and his wife Laurette, aged 72. Ernest, who has emphysema, started experiencing a decline in his mood and memory functions about two years ago. Laurette, who is legally blind and relies on her husband for daily support, experiences increased anxiety as she watches her husband struggle with issues of mental health. For two years, they attended multiple specialist appointments, where one health issue was dealt with per doctor. They also went back and forth to their family doctor and often made trips to the ER when their medical issues became worse. They felt alone.
Now, the Coulombes, who have been a part of the new pilot program at THP since last October, find a “huge improvement in their health care” compared to a year ago.
“Our healthcare team at THP follows up with one another, and they keep us informed about everything we need. They simplify all our medications, and connect us to helpful resources in our own community, such as additional support programs available to seniors,” says Mr. Coulombe. “We feel the new program is moving forward in the right direction. Sometimes we wish someone had a pill to take away all this frustration we have felt with the health care system – but this is definitely a good start.”
Seniors comprise the fastest growing age-group in the nation (65 years and over) which will result in the health care system serving more patients with multiple chronic conditions who visit the hospital regularly. THP currently receives over 1.6 million patient visits a year; 37 per cent of whom are seniors, many presenting with a combination of mental and physical illness.
“Under the umbrella of the MPA, the new senior’s pilot program at THP will be studied carefully over a five-year period with research and education outcomes used to modify the care program,” says Dr. Rose Geist, MPA Director of Collaborative Care at THP. “If successful, we hope to be able to provide this innovative model of care for more seniors in our community.”
“Traditionally, medicine has not been prepared for mental health, and mental health has not prepared for medicine,” says Lisa. “But this new model of care is an exciting chance to change that.”