A Study of The Rapid Assessment for Psychopharmacologic Treatment (RAPT) Clinic:

A novel, rapid response, collaborative care intervention in mental health Katz MR, Doherty R, Stokl S, and Levac J. Departments of Mental Health

and Family Medicine, Southlake Regional Health Centre

Background-1• Mental Health Commission of Canada, 2010 (strategic direction 3/6): provide access to the

right combination of services, treatments and supports, when and where people need them.• Mental health problems are increasing in Canada and largely go untreated.• 1.6 million people in Ontario have a mood, anxiety, substance abuse or

gambling problem; direct costs are 5.1B; indirect (eg lost productivity) is 28.7 B

• Much of the treatment occurs in primary care, often w/o psychiatric support• A shortage of mental health specialists (especially psychiatrists), and long

waiting lists to see psychiatrists prevent timely care• A lack of timely care means patients get worse, become treatment resistant

or end up in the ED

Background-2• York Region is the fastest growing region in Canada• large population of patients with acute and chronic mental health

needs ( one of the highest densities of psychiatric group homes in Canada; 8 within walking distance of SRHC)

• There is a severe shortage of psychiatrists in the Region with very long wait times up to a year for psychiatric assessment

• Many patients with severe and/or persistent mental illness do not have a psychiatrist (Bipolar Disorder, Treatment Resistant MDD)

• Family MDs try and manage complex patients with multiple comorbidities who often require careful psychiatric assessment and aggressive polypharmacy as well as linkage to other support services

Background-3

• At SRHC over 4000 mental health visits in the ED per year; one of the highest proportion of ED visits per bed ( a reflection of demand vs supply) in the province; ED volumes, admit volumes, admit rates all increasing

• Patients often wait 3-4 days in the ED or longer for a MHU bed• Admissions tend to be short; many patients are sent back to

family doctors from the MHU not fully stabilized, on multiple medications, without psychiatric follow-up

• a significant minority of mental health patients are rehospitalized within 1 month (Lin et al, 2011)

Background-4

• many of these patients could be diverted if there was a rapid outpatient assessment and follow up system to stabilize them ; others could be stabilized before presenting in a state where admission required; discharged patients could be stabilized more fully to prevent readmission

• Urgent Care or Crisis Clinics (such as our own) provide primarily counselling support and is staffed primarily by SW who cannot address med changes, side effects or compliance

• The literature has only one paper on a rapid response type clinic (Kowal

et al, 2011) for urgent mental health needs• Large literature on collaborative care interventions for depression

including a cochrane review demonstrating efficacy vs usual care ( psychiatrist, nurse-clinician, family practitioner) (Angstman and Williams,

2010; Thota et al, 2012; Archer et al, 2012)

Background-5

• Collaborative Care defined by Gunn (2006) as involving 4 key components:

• 1) multi-professional approach to patient care usually involving mental health specialist, a nurse case manager and the family physician

• 2) structured management plan• 3) scheduled patient follow ups• 4) enhanced inter-professional communication• None of studies in Cochrane Review involved heterogeneous

high distress patients with comorbidities and need for rapid assessment

The RAPT Clinic: Key Components of the Model

• Collaborative Care: ( Psychiatrist, Nurse, Family Health Team)• Rapid Access (within 7-10 business days)• Targeted Population: age 18-65, high level of distress, Major Axis 1

Disorder (mood, anxiety or psychotic disorder) and no existing psychiatrist; comorbidity permitted

• Consultation and Structured Follow up visits for 8 weeks with Psychiatrist and a mental health RN who addresses compliance, side effects, basic activity scheduling and problem solving, community linkages and serve as liaison between psychiatrist and family health team

• Enhanced communication with Primary Care Provider• Return of Care to PHP within 8 weeks with a follow-up care plan

RESEARCH PLAN

1. To reduce mental health related visits and admissions for patients referred to the RAPT Clinic from 5 selected FHT and all primary care practitioners affiliated with Southlake,

2. To demonstrate improvement in patient related outcomes (PRO) following the intervention,

3. To capture patient experience of the intervention through qualitative interviews,

4. To conduct an economic evaluation of the intervention

Study Objectives

Primary outcome measured1. Change in ED admission and hospital admission rates comparing 6, 12

and 24 months prior to RAPT with 6 and 12 month rates after RAPT using ICES data.

  Secondary Outcome Measured

2. Patient related outcomes:

Change in Brief Symptom Inventory (BSI), Sheehan Disability Scale (SDS), Clinician Global Impression (CGI), and Patient Global Impression (PGI) scores pre and post intervention.

3. Patient experience: Qualitative data will be obtained via detailed interviews of a subset of patients and primary care providers and via The Satisfaction Index – Mental Health (SI-MH)

4. Economic outcomes: examine healthcare costs of our cohort using data from ICES database. .

. 

RESEARCH PLANMeasuring Outcomes

RESEARCH TIMELINE

WEEK 0 (Baseline)

WEEK 2 WEEK 4 WEEK 6 WEEK 8 (Endpoint)

Psychiatrist Consultation

Informed consent signed and returned

Baseline Measures:•BSI•CGI-S• SDS

Patient seen by RAPT RN*

Measures:•CGI – I/S•PGI – I/C

Follow up with Psychiatrist

Measures:•CGI – I/S•PGI – I/C

Follow up with RAPT RN*

Measures:•CGI – I/S• PGI – I/C

Follow up with RAPT RN*

Measures:•BSI•SDS•CGI – I/S•PGI – I/C•SI-MH

*RN will be available for phone calls between week 0 and week 8*RN will connect patients to community agencies, as neededWeek 8 visit with psychiatrist if necessary

Study Recruitment(July 2013 to January 2015)

• Referrals Received: 521

• Did not meet Inclusion Criteria: 124

• Unavailable for first appt: 75

• Booked first visit: 322

• Seen but not eligible: 30

• Did not consent: 27

• Consented: 265

• Completed study with all follow up measures: 152 (57.4%)

• Did not complete follow up measures: 96 (completed study early or lost to follow up)

• Active: 5

• Withdrawn: 12

• Average time to first appt: 17 business days

Domain of BSI N Pre Post * (n=152)

Change

  Mean (SD) Mean (SD)

Mean (SD)

p-value**

GSI 265 1.88 (0.78) 1.29 (0.81) -0.63(0.72)

<0.0001

PSDI 265 2.50 (0.59) 2.02 (0.67) -0.51 (0.64)

<0.0001

PST 265 38.23 (10.18) 31.54 (13.25) -7.14 (10.4)

<0.0001

Anxiety Sub-scale 265 2.06 (0.99) 1.41 (0.97) -0.70 (0.97)

<0.0001

Depression Sub-scale 265 2.30 (1.04) 1.54 (1.09) -0.83 (0.99)

<0.0001

** Paired t-test

Baseline: 12.2% Mildly Ill or betterFinal: 69.2% Mildly Ill or better

Fre

que

ncy

56.7% reported moderately better or greater

Future Directions

• Expand the referral sources for the Clinic• Expand manpower (especially another nurse and admin support)

as clinic grows• Consider model for a post-MHU discharge clinic and specialized

clinic for the medically ill (eg cardiac and GI programs)• Demonstrate effectiveness via research study and look for LHIN

support to grow clinic• Publish findings and disseminate model if successful to other

sites• Teaching: opportunities for General Psychiatry Residents and

Family Practice Residents on consistent basis

Thank You!

• Alison Comeau RN: RAPT Nurse

• Dawn Nichols: admin support

• Paul Cappuccio and Janet Giannini: our previous and current Outpatient Managers

• My co-PI and co-investigators (Bob, Steve, Jody)

• Dr. Garcia, Stokl, and Mehta my RAPT colleagues

• Bridges and AHRC for ongoing support and help with the research project

• Sharon Futers Jenny Gatov, Lee-Anne Crilley our research assistants

• Pat Clifford, our Director of Research