Transforming Primary Health Care of Psychiatric Outpatients in the Community through GP Partnership
Institute of Mental Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Mental disorders are recognized as major public health problems worldwide, and the management of mental illnesses places an enormous burden on a country's health services. In a 2003 report, the World Health Organisation (WHO) estimated that the cost of mental health problems in developed countries to be between 3% and 4% of Gross Domestic Product (GDP). This can come up to several billion dollars in terms of economic impact affecting personal and caregivers’ incomes, loss of contribution to the national economy, as well as utilization of medical support and services. (Investing in Mental Health - World Health Organization, 2003) Locally in Singapore, over and above this deemed difficulty and high costs involved in the management of such patients, there has been a large stigma involved in seeking medical treatment for mental illnesses in Singapore. This is therefore a possible reason for the delay in seeking professional help. A study in 2004 showed that the mean duration of untreated psychosis in Singapore was almost 3 years, which is longer than in the West. (Determinants of duration of untreated psychosis and the pathway to care in Singapore, Chong SA et al 2005). At same time, the Singapore National Mental Health Survey carried out in 1996, revealed that a large portion of the population (63%) would not seek professional help if they are mentally unwell. In addition, 49% of those who do so would choose to go to their GP as a first point of consultation. This finding was similar to that of a strawpoll carried out on patients and their accompanying family members visiting the psychiatric outpatient clinics at the Institute of Mental Health (IMH), the Behavioural Medicine Clinics at Viking Road and in Geylang Polyclinic. The poll showed that 56.7% of patients and 74.5% of their caregivers were comfortable with psychiatric follow-up care provided by their GP. The top 3 reasons cited by both patients and their family members were: 1) convenience, 2) savings on transport costs and 3) care by GPs is perceived to be less costly. It was also revealed that 65% of patients who worked had to take leave or time off from work for their follow-up appointments. Likewise, 75% of family members had to take leave or time off their work to accompany their relatives for their appointments. Also in 2003 and before, patients already on treatment for mental disorders in the hospitals were largely managed by specialists with minimal involvement of community partners such as general practitioners (GPs). Yet, many of these patients with chronic mental illnesses were stable and required only maintenance medications and they could be best managed in the community.

B. Strategic Approach

 2. What was the solution?
The Mental Health – GP Partnership (MH-GPP) Programme was first established at the Institute of Mental Health (IMH) in 2003 to discharge stabilised psychiatric outpatients to GPs in the community. The initial pilot project started, under the Early Psychosis Intervention Programme, with 4 participating GPs. With no similar programmes in Singapore to draw past experiences from, GPPP had to be developed from scratch. The Programme aimed to provide holistic and cost-effective care to psychiatric patients in the community as well as to train and develop a network of GPs to treat mental illness in the community. Its main objectives were to promote, sustain and maintain the right-siting of care for patients with mental illness within the GP Partnership network in the community as well as to recruit, train and establish a network of GPs through our GP Engagement Efforts. To further enhance the capabilities of the GPs and to provide them with a more structure form of training in mental healthcare, the Graduate Diploma in Mental was pioneered by IMH, in collaboration with the Division of Graduate Medical Studies, NUS. It was a 12 month programme that involved in-depth comprehensive lectures, involvement in ward rounds, and attachment to the specialist outpatient clinics.

 3. How did the initiative solve the problem and improve people’s lives?
Improving the Allocation Of Healthcare Resources Through Right-siting of Psychiatric Patients in the Community The programme allowed for stable psychiatric patients to be discharged from IMH and yet enabled them to receive continued treatment for their psychiatric conditions in the community through the GP partnership network. Improving Care Coordination by Enhancing Patient’s Referral to Treatment Pathway Initially, GPs were tentative about accepting psychiatric patients from IMH’s specialist outpatient clinics. Therefore, to provide the assurance that mental health professionals were committed to render support in sustaining collaboration and continuity of patient care, care pathway(s) were subsequently established. Training and Developing a Network of Competent GPs to Manage Mental Illness in the Community Earlier surveys showed that the perceived need for additional knowledge in managing patients with mental illness hindered GP engagement in primary-tertiary partnership programmes. Therefore, to manage such a need, opportunities for continuing medical education and clinic observation sessions to GPs partners were prioritized. Training and education components remain key features of the programme as part of GP engagement strategy. MH-GPP programme continues to train and develop competencies of GPs in the community to identify patients with psychiatric disorders and ensure that these patients seek the right treatment.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
As the programme has progressed, some notable initiatives implemented within the MH-GPPP since inception are: 1. Improving Case Tracking & Compliance to First visits with GPs 2. Improving Patient Satisfaction & Outcomes 3. De-stigmatization of Mental Healthcare 4. Developing GP Network through Continuous Engagement & Training 5. Structured Post-graduate Training through Graduate Diploma in Mental Health (GDMH) The implementation of these has resulted in the following key benefits: 1. Promoting the national healthcare movement towards a policy of right-siting In line with Singapore’s health care policy towards right-siting and ensuring that healthcare is dispensed at a suitable site, MH-GPPP has referred 1,410 patients since its inception till end-FY2013. During this same period, the programme has managed to ensure that more than 93% did not visit IMH’s Emergency Room and more than 95% were not re-admitted to IMH 12 months after being right-sited to the GP Partners. This meant that on average, over the period FY2007 to FY2013, 187 patients did not return to IMH for at least 12 months after being right-sited to the GP Partners. This translated to an average annual workload savings in IMH’s special outpatient clinics of 748 Return Visit Slots or 187 First Visit Slots. This would have meant that more appointment slots were freed up for patients who have not yet stabilized, thus resulting in improved waiting times. 2. Provision of Care in a Cost-Effective, De-stigmatized & Convenient Manner for Improved Quality of Life Just as the national vision for mental healthcare was to “move away from an institutionalized-based healthcare system towards a community based model of psychiatric care”, so was the aim of MH-GPPP. The provision of continued psychiatric treatment within the community at the GPs significantly reduced the stigma faced by patients while seeking treatment at IMH. Continuing treatment for these patients became more convenient as they were referred to GPs whose clinics were situated nearer to their homes. This convenience helped overcome the issue of patients refusing to continue treatment due to the long commute from their homes to IMH. Furthermore, the GP clinics are open in the evenings and weekends, allowing many of those currently working to continue with their treatment without the need to apply for leave. For more holistic care, these right-sited patients were now able to consult the same GP doctor for other chronic illness that they may face. In the latest survey conducted in FY2013, 90% of patients surveyed reported high levels of satisfaction with the GP one year after referral, with 87% scoring at least 80 on the Global Assessment of Functioning (GAF) scale. On a national scale, the MH-GPPP’s provision of continued psychiatric care within the community has helped to significantly destigmatize psychiatric treatment and vastly improve the accessibility of services, attributing to high levels of satisfaction among right-sited patients thus resulting in a likely improved quality of life. 3. Improving the Capabilities of Primary Healthcare Providers in Mental Health Through Training GPs are multi-skilled primary care providers and are also recognized as gate-keepers to healthcare in the community, supporting 83% of all primary care in Singapore. Therefore it is important to acknowledge that GPs can play a significant role in providing services to people with mental health problems in Singapore. Their rapport with their patients and knowledge of the family history, combined with the flexibility of a convenient service (in terms of time and place) will be important in encouraging patient compliance and reducing the default rate in patients. Furthermore, previous studies have shown that a large percentage of Singaporeans who would seek help for their mental illness would choose to go to a GP for a first consult. Therefore, the MH-GPPP’s continued engagement of GPs and twice yearly CME workshops are beneficial in encourage more GPs to take up the role of a community mental healthcare provider. From the inception of MH-GPPP’s CMEs in 2011 till now, a total of 507 GPs have been provided with additional information on mental healthcare. The GDMH has also greatly improved the mental healthcare capabilities of the GPs. A pre-post training survey completed in 2013 shows that GPs completing the GDMH showed an increase in confidence level of up to 53% and 59% in diagnosing and managing mental illness in the community respectively. Since its first cohort in 2010, the GDMH has successfully trained 68 GPs in three cohorts while a further 17 GPs from the 4th cohort are expected to graduate in Mar 2015 and can be expected to play an active role as GP Partners in the MH-GPP network as well as to provide mental healthcare within the community.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
MH-GPPP continues to be funded by the National Mental Health Blueprint and the programme. As of end-FY2013, a total of 1410 patients have been right-sited to the MH-GPPPs since 2007. The programme continues to identify suitable and stabilized patients to be right-sited to the community. More importantly, the programme has focused on sustaining and maintaining the care provided to the patients who have already been referred, through proactive case management and continued engagement with its GP Partners. As at end-FY2013, the MH-GPPP had 746 patients who remained in care with the GPs and had notably reduced its default rate since case-tracking began in 2010. In addition, the programme continues to identify and recruit willing GPs as partners with MH-GPPP so as to enhance its network of GPs. Following the successes of MH-GPPP, several hospitals in Singapore have begun to develop similar GP Partnership Programmes. In addition, the Agency for Integrated Care is looking at replicating this initiative at a national level. Meanwhile the 17 GPs from GDMH’s 4th Cohort are expected to graduate in Mar 2015, and this would bring the total number of GPs trained to 85. More recently, GDMH’s 5th Cohort commenced in Sep 2014 with 19 GPs and intake for the 6th Cohort is expected to begin end-2014.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The unique and innovative MH-GP Partnership Programme has been integral in enhancing mental healthcare in Singapore. Its right-siting of stable psychiatric patients to the GPs has helped in their reintegration to the community and has also reduced the stigma attached with seeking treatment for mental illness. Patient outcomes and satisfaction are prioritized as part of the programme’s key objectives. The continued development of its network of GP partners to detect, treat and refer psychiatric patients, together with the structured and enhanced mental health training provided by GDMH, has raised the level of mental healthcare within Singapore’s community. Lessons learnt and data gathered at individual care and programme development level, will inform practice and primary care policy development for care integration in the next lap.

Contact Information

Institution Name:   Institute of Mental Health
Institution Type:   Other  
Contact Person:   Ziyu Pan
Title:   Ms  
Telephone/ Fax:   63892264
Institution's / Project's Website:  
E-mail:   ziyu_pan@imh.com.sg  
Address:   Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View
Postal Code:   539747
City:  
State/Province:  
Country:  

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