| 4. In which ways is the initiative creative and innovative?
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In 2003, the MH-GPPP was set up as a pilot project with four pioneer GPs, and a detailed training programme was drawn up to allow the GPs to obtain the skills and knowledge required.
In 2006, the successes of the programme led to its implementation into a hospital-wide initiative. A referral criteria was developed to ensure that patients referred to the GPs were suitable and stabilised. A dedicated team comprising a Programme Director and administrators were set up to ensure a smooth transition of care for the patient from the hospital to the GP, as well as to provide administrative support to the GPs. At the same time, active recruitment of willing GPs was conducted to increase the programme’s pool of GP Partners.
In 2007, MH-GPPP was officially positioned under Singapore’s National Mental Health Blueprint. At the same time a survey was commissioned by MOH, and led by IMH, on GPs to examine their perceptions of managing mental healthcare within the community and to identify their learning or training needs in mental healthcare. The findings from the survey contributed to the development of the Graduate Diploma in Mental Health.
In 2010, for GPs requiring a more structured approach to education, IMH pioneered the GDMH, offered in collaboration with the Division of Graduate Medical Studies, National University of Singapore (NUS). The 1st Cohort saw 17 GPs completing the 12-month program. Case Management was started to improve the quality of care of the patients discharged to the GPs in the community and a dedicated Case Manager was added to the MH-GPPP team. Case-tracking was also initiated to aid management of patients in the community as well as to early detect patient who had defaulted from their treatment with the GPs.
In 2011, MH-GPPP began conducting twice yearly GP Engagement Continuing Medical Education (CME) workshops on various mental health topics to highlight to GPs on the mental conditions that they may come across in their practice and how to manage them. As these CME workshops are opened to all GPs in Singapore, this also provides the MH-GPPP with an additional platform to recruit willing GPs to join the programme as partners. In addition, a MH-GPPP outreach quarterly e-newsletter was started to provide GP Partners with a quick refresher update about the programme.
As of 30 Sep 2014, MH-GPPP has successfully grown its pool of GP Partners to 67 partners and has referred more than 1,400 patients for continued treatment in the community since programme’s inception. In addition, a total of 68 GPs have completed the GDMH and 17 from the 4th Cohort are expected to graduate in Mar 2015. To date, a total of 7 CME workshops have been conducted by MH-GPPP since 2011 and a total of 507 GPs have attended.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The MH-GPPP was developed in 2003 under the Early Psychosis Intervention Programme, as a collaborative idea resulting from discussions between IMH’s Psychiatrist and a GP. When the programme was implemented hospital-wide in 2006, professional involvement for implementation included IMH’s senior management, clinicians from IMH’s Specialist Outpatient Clinics, the GP Partners, as well as the MH-GPPP team which comprised a Programme Director and administrators. It was also during this period that saw the involvement of Integrated Health Services, MOH, and the National Mental Health Blueprint (NMHBP), MOH, in discussions with IMH, as the sole tertiary institute for mental health in Singapore, to explore positioning the MH-GPPP under the NMHBP. As part of the implementation of the NMHBP in 2007, MOH commissioned a survey on GPs to assess their perceptions to managing mental healthcare in the community and their training needs. These findings would later contribute to the development of the Graduate Diploma in Mental Health (GDMH) which has been crucial in providing training for GPs in the community.
Prior to the commencement of GDMH’s 1st Cohort in 2010, there was much discussion and consultation between IMH and NUS to develop and finalise the modules for the programme, as well as consultations between IMH as well as NMHBP on funding to sustain the programme.
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| 6. How was the strategy implemented and what resources were mobilized?
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MH-GPPP has been wholly funded by the National Mental Health Blueprint since its inception as a blueprint programme in 2007. Its manpower funding allowed for a dedicated team comprising a Programme Director, a Deputy Programme Director, three Liaison Coordinators and a Case Manager.
To ensure development of staff within MH-GPPP, funds were allocated to cater for training.
The provision of drugs supply service to the GPs made the bulk of the Other Operating Expenses. This service provided by IMH’s Pharmacy initially and was outsourced to NHG Pharmacy from FY2010 onwards. This service ensure that the programme’s GP Partners were able to procure the psychotropic medication for patients referred by IMH, and more importantly at a cost low enough to maintain comparable costs for patients when they were seeking treatment at IMH.
Other major expenses from the funding included the twice yearly CMEs, as well as for IT equipment for MH-GPPP’s administrative team.
Similarly, the GDMH was wholly funded by the NMHBP. Manpower funding allowed for a dedicated team of administrators to manage the planning of the curriculum for the 12 month programme as well as facilitating the conduct of classes. Other Operating Expenses were used for the development of the learning materials provided to the students during GDMH, as well as to fund the remuneration for the lecturers of each module.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Referral Criteria and Referral Processes
The programme’s established referral criteria ensure that all patients who are referred to GP Partners are clinically stable and are suitable for management within the community. The referral process handled by the programme’s Liaison Coordinators ensure that patients are well informed of what to expect when consulting a GP and that all relevant documentation is handed over to the GPs for a smooth transition.
Case Management
MH-GPPP’s provision of a dedicated case manager to support patients transition of care from IMH to the GP Partners has considerable reduced the stress levels that patients face during the initial change in their treatment routine due to the unfamiliarity of a new environment. The follow up and psychoeducation provided by the case manager has ensured that patients continue with their treatment with the GPs.
Case Tracking
The case tracking conducted quarterly by MH-GPPP with the GP Partners allows the programme to monitor the patients compliance with their treatment with the GPs. It also allows the programme to early detect patients who have defaulted and recall them to IMH, if needed, for closer follow up and monitoring.
Developing MH-GPPP’s GP Partner Network and Continuous Engagement & Training
Since inception, the programme has successfully grown its GP network to 67 GP Partners. This has ensured that stabilized patients are able to receive continued treatment and care for their mental illness within the community. Refresher courses are providing for GP Partners, if needed, and mental health related continuing medical education (CME) workshops are conducted twice yearly to engage with GP Partners as well as recruit more willing GPs as partners with the programme.
Structured Post Graduate Training to Enhance GP’s Competencies
With the introduction of the Graduate Diploma in Mental Health (GDMH) in 2010, conducted in collaboration with the Division of Graduate Medical Studies, National University of Singapore (NUS), a total of 68 GPs have been trained over the last three intakes from 2010 to 2013. GDMH is currently in its 4th intake cohort. A significant number of these GPs who graduate from the GDMH, join the MH-GPPP as GP Partners.
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| 8. What were the most successful outputs and why was the initiative effective?
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Patient and GP Satisfaction Surveys
The programme conducts patient and GP satisfaction surveys annually. The patient satisfaction survey is aimed to survey patients on aspects regarding (1) Knowledge and Skills of GPs, (2) Coordination of Care and, (3) Willingness to Recommend MH-GPPP to others. In addition, information on the patient’s current health state is also collected to provide an update on the patient’s condition following their referral to the GP. The GP satisfaction survey is aim at gathering feedback regarding (1) Programme Objective, (2) Coordination of Care, (3) Level of Support from IMH, (4) Overall Satisfaction and, (5) Willingness to Recommend MH-GPPP to other GPs. These two surveys allows MH-GPPP to identify possible improvements which the programme may need.
Case Tracking
Case tracking has been conducted by the programme every quarter with all GP Partners to ensure that patients right-sited have continued with treatment and to identify patients who have defaulted follow-up with the GPs. Patients who have defaulted treatment are immediately flagged up for monitoring and recalled to IMH to prevent a relapse.
Case Management
Studies (1) have shown that the default rate for mental health treatment was significantly higher than other medical treatments. Many of those who miss appointments drop out of scheduled care and are at risk of further deterioration, relapse and hospital readmission. MH-GPPP employed strategies to support care continuity through case management strategies by monitoring patient’s compliance to appointments. Its Case Manager (CM) identifies first appointment (FA) for GP consultation, provides psycho-education to patient followed by telephonic contact for FA reminder. Thereafter, CM maintains telephonic contact with patient for subsequent three GP visits to ensure compliance with GP visit(s). Overall, patients referred to GP partners under the MH-GPP programme achieve an average 80% compliance to first appointments as compared to 74.5% average recorded at outpatient specialist clinic at IMH.
(1) Why don't patients attend their appointments? Advances in Psychiatric Treatment (2007), vol. 13, 423–434 doi: 10.1192/apt.bp.106.003202
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| 9. What were the main obstacles encountered and how were they overcome?
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During initial implementation of the programme, some of the main problems encountered were: (1) some GPs felt the need for training to enhance their ability to manage certain types of mental illnesses, in particular, psychosis, (2) some psychiatrists were not convinced that their patients could be competently managed by GPs, (3) a consensus had to be reached with regards to the types of patients who could be best managed by GPs, and (4) a system of referral and support including the accessibility of the mental health professionals for consultation and advice, and the availability of psychotropic drugs had to be put in place.
To address the issue of training and to convince the psychiatrists that the GPs were competent, a comprehensive training programme for the GPs was developed. The training programme comprised in-depth lectures on the various mental illnesses as well as attachment to ward rounds in IMH and specialist outpatient clinics. A referral criteria was formally agreed upon for assessment of a patient’s suitability for referral through the programme. To ensure a smooth transition for the patient and the GPs, a framework on the referral process was developed. In addition, a drug supply management system was developed to provide GPs with access to psychotropic drugs at a cost kept low so that the cost to the patient could be as close to that as the hospital as possible.
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