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COOPERATION BETWEEN SPECIALIZED MENTAL HEALTH SERVICES AND GENERAL PRACTITIONERS IN ARKHANGELSK COUNTY: THE POMOR MODEL1
G.G. Rezvy1, E.A. Andreeva2, N.N. Ryzhkova3, V.A. Yashkovich4, E.N. Belaya4, V.V. Popov2, T. S0rlie1
1 University of Troms0 - The Arctic University of Norway, Troms0, Norway
2 Northern State Medical University, Arkhangelsk, Russia
3 Primorsky central district hospital, Arkhangelsk oblast, Russia
4 Arkhangelsk psychoneurological clinic, Arkhangelsk, Russia
The Kirkenes Declaration, which formalized Norwegian-Russian international cooperation in the Euro-Arctic Region, was signed in 1993 [4]. Since 1999, project funding has been available through the Barents Health Programme and collaboration on health between Northern Norway and North-Western Russia dates back to the early 1990s. The first Barents conference in psychiatry with participants from Russia and Norway took place in Troms0 Norway in 1996 and since 2001 there has been regular project based cooperation on psychiatric health care development.
Currently, the Russian-Norwegian project is focusing improvement of mental health care in primary care in the Arkhangelsk County. The relevance of this focus is due to:
• high prevalence of mental disorders and suicidality in the Arkhangelsk County;
• the average consultation load of the specialists (psychiatrists and psychologists) at the Arkhangelsk psychoneurological clinic is above the recommended norms and many of those who are requesting psychiatric treatment cannot not be offered treatment here;
• in one-third of the districts in Arkhangelsk County there are no certified psychiatrists;
• individuals with non-psychotic mental disorders (the most prevalent mental disorders) are usually first encountered by a general practitioner;
• mental health stigma may be less provoked in primary than in specialized care encounters;
1 Название работы на русском языке - «Поморская модель взаимодейст-
вия специализированной психиатрической службы и общей врачебной
практики в Архангельской области».
• poorly developed cooperation between mental health specialists and general practitioners (only 5% of patients who are identified with signs of depression by their general practitioners are referred to psychiatrists; Archangelsk local statistics).
Similar factors motivate improvement of mental health care in the primary health care system in most countries worldwide [1].
The quality of mental health care relates to the providers' communicative, diagnostic and treatment skills, but is also strongly influenced by the quality of professional networks, both in terms of the accessibility of competent coworkers and specialists as well as their support and sharing when the individual provider is caring for individuals with mental health problems [6, 8].
Thus, the project is both aiming to improve general practitioners' diagnostic and treatment skills, as well as to improve the cooperation between general practitioners and specialists in psychiatry.
The general practitioner training has focused improvement of psychiatric diagnostic skills using a structured clinical psychiatric interview for general practitioners (The SPIFA) [3, 5] and psychotherapeutic skills based on principles of cognitive therapy. These aspects will not be further elaborated in the current article.
The «Pomor model»
The systemic aspect of the project has been sought realized by creation and implementation of an integrated model for cooperation between specialized psychiatric services, and primary health care (The Pomor model). The primary health care center Rikasikha (a small district nearby Arkhangelsk city) was selected as a pilot site in 2011.
In order to estimate different psychiatric patients' needs for treatment and care from specialists and general practitioner's, two groups of patients were examined and evaluated by specialists and general practitioners: a) a representative group of patients from the psychiatric dispensary and b) patients in primary care with an identified mental disorder [7].
Based on these evaluations, three groups of patients were identified:
1) patients with severe mental disorders with a need for active treatment (18,2%) were a specialist is their primary therapist. When needed, the general practitioner consults the specialists concerning patients' family relations and social issues;
2) patients with moderate mental disorders (47.7%) where adequate treatment can be provided in cooperation between a specialist and a general practitioner through joint consultations;
3) patients in stable remission following specialized treatment and patients wth mild depression (34.1%) who can primarily be treated and followed up by a general practitioner, if necessary in combination with specialist consultations.
This division into these groups has allowed for redistribution of the responsibilities and tasks of general practitioners and specialists in management and treatment of patients with mental disorders. Consultative support and advice from the specialists increase the competence of the general practitioners and improve the quality of care for patients with mental health problems.
The project activities have been organized in order to increase interaction between general practitioners working at Rikasikha primary health care center and specialists at the psycho-neurological clinic in Arkhangelsk being carried out by multi-professional teams using a biop-sychosocial perspective in the understanding, management and treatment of the patient. The following cooperation methods have been used:
• face to face meetings with patient, general practitioner and specialist being present - allowing for shared decision on treatment goals and approaches,
• face-to-face and telephone consultations between general practitioners and a psychiatrist/psychologist. Early information to the general practitioner about patients who are going to/have been discharged from the regional psychiatric hospital with instructions on initiatives in primary care.
In addition, general practitioners have received consultation/training on how to provide psycho educational relapse prevention to family members of severely mentally ill patients. The general practitioners cooperates with the Department of Social Welfare and NGOs on solving social issues when necessary.
The general practitioners and specialists, who are participating in the project, had a one-week teaching practice at the out-patient unit at a district-psychiatric center and selected primary health care centers in the North Norwegian municipality Fauske. The Department of family medicine at the Northern State Medical University and the University of Troms0 held two-week courses focusing on improvement of general practitioners psychiatric competence.
Evaluation
The experiences with the model were evaluated by a) qualitative interviews with the patients, b) diagnostic statistics from Ricasikha primary health care center, and c) number of patients admitted from the model district to the regional psychiatric hospital [2].
Patient interviews showed that they responded positively to the cooperation between general practitioners and the specialists, including the joint consultations with both a general practitioners and a specialist. It is of particular interest to note that the patients in stable remission following specialized treatment and patients with mild depression who had primarily been treated and followed up by their general practitioner (group 3) expressed high satisfaction with their treatment and care. They also conveyed that the experienced level of stigma was lower when meeting their general practitioner than when meeting a specialist at a specialized clinic.
Between 2012 and 2014 the number of patients with mild and moderate depression at the primary health care center in Rikasikha increased, mainly due to better psychiatric diagnostics by the general practitioner. In addition, the hospitalization rates from this district to the regional psychiatric hospital decreased, probably due to better continuity of care following discharge from the hospital.
Progress and further development of the model
Model development has been delayed by lack of cooperation traditions between the general practitioners and the specialized mental health services, poorly developed financial reimbursement for working with psychiatric patients in primary care as well as lack of professional guidelines for diagnostic and therapeutic work in the primary health care system.
However, despite these limitations, high motivation among the participating health professionals, managers - and especially the active support and recommendation of the Minister of Health, have provided very good progress in the project. The model will now be implemented and evaluated in other districts of Arkhangelsk County.
In scattered populated areas with long geographic distances between local health providers and available specialists such as in Northern Norway and North West Russia, the advantages of web-based networking possibilities are increasing [9].
Specialists who are providing consultations should be trained in consultation approaches respecting the treatment responsibility and autonomy of the local provider.
REFERENCES
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2. Belaya E.N. Model of cooperation between psychiatric services and primary health care in Archangelsk region («Pomor model» from a psychiatrist's point of view). In: Integration of psychiatric care in the primary healthcare system: abstract
book of the sixth Barents Conference on Psychiatry. Arkhangelsk, October 6-7, 2015. Arkhangelsk, 2015, p. 87.
3. Dahl A.A., Krüger M.B., Dahl N.H., Karlsson H., Von Knorring L., Stordal E. SPIFA-A presentation of the Structured Psychiatric Interview for General Practice. Nord. J. Psychiatry. 2009 Nov; 63(6): 443-53. doi: 10.3109/08039480902874769.
4. Declaration. Cooperation in the Barents Euro-Arctic Region. Conference of Foreign Ministers in Kirkenes, 11.01.1993. www.barentsinfo.fi/beac/docs/ 459_doc_KirkenesDeclaration.pdf (20.6.2011) (Accessed 20 January 2015).
5. Rezvy G.G., Popov V.V., Serlie T. Vozmozhnosti okazaniya meditsinskoi pomoshchi bol'nym s psikhicheskimi rasstroistvami vrachami obshchei praktiki [The possibility of providing medical care to patients with mental disorders by general practitioners]. Spra-vochnik vracha obshchei praktiki [Manual of general practitioner], 2014, no. 3, pp. 19-23.
6. Ruud T., Flage K.B., Kolbj0rnsrud O.B., Haugen G.B., S0rlie T. A two-year multidiscipli-nary training program for the frontline workforce in community treatment of severe mental illness. Psychiatr. Serv. 2016 Jan 1; 67(1): 7-9. doi:10.1176/appi.ps.201500199.
7. Ryzhkova N.N. Improving mental health services in Arkhangelsk region by integration of primary and specialized mental health services - development of Pomor model, its implementation and evaluation. In: Integration of psychiatric care in the primary healthcare system: abstract book of the sixth Barents Conference on Psychiatry. Arkhangelsk, October 6-7, 2015. Arkhangelsk, 2015, p. 88.
8. S0rlie T., Borg M., Flage K.B., Kolbj0rnsrud O.B., Haugen G.B., Benth J.S., Ruud T. Training frontline workforce on psychosis management: a prospective study oftraining effects. Int. J. Ment. Health Syst. 2015 Nov 19; 9: 38. doi:10.1186/s13033-015-0029-3.
9. Yashkovich V.A. Experience of international cooperation in the field of interaction of psychiatric service with general practitioners. In: Integration of psychiatric care in the primary healthcare system: abstract book of the sixth Barents Conference on Psychiatry. Arkhangelsk, October 6-7, 2015. Arkhangelsk, 2015, pp. 85-86.
ЛИТЕРАТУРА
1. Atun R. What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? January 2004 (2004). Copenhagen, WHO Regional Office for Europe Health Evidence Network report. http: //www.euro.who.int/document/e82997.pdf (Accessed 20 January 2015).
2. Belaya E.N. Model of cooperation between psychiatric services and primary health care in Archangelsk region ("Pomor model" from a psychiatrist's point of view). In: Integration of psychiatric care in the primary healthcare system: abstract book of the sixth Barents Conference on Psychiatry. Arkhangelsk, October 6-7, 2015. Arkhangelsk, 2015. P. 87.
3. Dahl A.A., Krüger M.B., Dahl N.H., Karlsson H., Von Knorring L., Stordal E. SPIFA-A presentation of the Structured Psychiatric Interview for General Practice. Nord. J. Psychiatry. 2009 Nov; 63(6): 443-53. doi: 10.3109/08039480902874769.
4. Declaration. Cooperation in the Barents Euro-Arctic Region. Conference of Foreign Ministers in Kirkenes, 11.01.1993. www.barentsinfo.fi/beac/docs/ 459_doc_ KirkenesDeclaration.pdf (20.6.2011) (Accessed 20 January 2015).
5. Резвый Г.Г., Попов В.В., Серлие Т. Возможности оказания медицинской помощи больным с психическими расстройствами врачами общей практики // Справочник врача общей практики. 2014. № 3. С. 19-23.
6. Ruud T., Flage K.B., Kolbj0rnsrud O.B., Haugen G.B., S0rlie T. A two-year multidiscipli-nary training program for the frontline workforce in community treatment of severe mental illness. Psychiatr. Serv. 2016 Jan 1; 67(1): 7-9. doi:10.1176/appi.ps.201500199.
7. Ryzhkova N.N. Improving mental health services in Arkhangelsk region by integration of primary and specialized mental health services - development of Pomor model, its implementation and evaluation. In: Integration of psychiatric care in the primary healthcare system: abstract book of the sixth Barents Conference on Psychiatry. Arkhangelsk, October 6-7, 2015. Arkhangelsk, 2015. P. 88.
8. S0rlie T., Borg M., Flage K.B., Kolbj0rnsrud O.B., Haugen G.B., Benth J.S., Ruud T. Training frontline workforce on psychosis management: a prospective study oftraining effects. Int. J. Ment. Health Syst. 2015 Nov 19; 9: 38. doi:10.1186/s13033-015-0029-3.
9. Yashkovich V.A. Experience of international cooperation in the field of interaction of psychiatric service with general practitioners. In: Integration of psychiatric care in the primary healthcare system: abstract book of the sixth Barents Conference on Psychiatry. Arkhangelsk, October 6-7, 2015. Arkhangelsk, 2015. P. 85-86.
Rezvy G.G., Andreeva E.A., Ryzhkova N.N., Yashkovich V.A., Belaya E.N., Popov V.V., S0rlie T. Cooperation between specialized mental health services and general practitioners in Arkhangelsk County - the «Pomor model» (English). Vestnik psikhiatrii i psikhologii Chuvashii [The Bulletin of Chuvash Psychiatry and Psychology], 2016, vol. 12, no. 1, pp. 17-24.
Abstract. The Kirkenes Declaration, which formalized Norwegian-Russian international cooperation in the Euro-Arctic Region, was signed in 1993. The Barents Health Program and collaboration on health between Northern Norway and Northwestern Russia date back to the early 1990s. Currently, the Russian-Norwegian project is focusing improvement of mental health care in primary care in the Arkhangelsk County. The project is aiming to improve GPs' diagnostic and treatment skills and to improve the cooperation between general practitioners (GPs) and specialists in psychiatry. The systemic aspect of the project has been realized by creation and implementation of an integrated model for cooperation between psychiatrists and GPs (the Pomor model). Consultative support from the specialists increases the competence of the GPs and improves the quality of care for patients with mental health problems. The experiences with the model were evaluated by a) qualitative interviews with the patients, b) diagnostic statistics from the primary health care center, and c) number of patients admitted from the district to the regional psychiatric hospital. Model development has been delayed by lack of cooperation traditions between the GPs and the specialized services, poorly developed financial reimbursement for working with psychiatric patients in primary care as well as lack of professional guidelines for diagnostic and therapeutic work in the primary health care system. However, high motivation among the participating health professionals, managers - and active support and recommendation of the Minister of Health, have provided good progress in the project. The model is implemented and evaluated in other districts of the Arkhangelsk County.
Keywords: psychiatry, primary care, general practitioner, international cooperation, Pomor model, Arkhangelsk, Russia, Norway.
Information about authors:
Rezvy Grigory, M.D., Ph.D. in Medicine, Assistant Professor, Institute of Clinical Medicine, The University of Troms0 - The Arctic University of Norway; Troms0, 9037, Norway, tel. +47 77644000. [email protected].
Andreeva Elena, M.D., Ph.D. in Medicine, Associate Professor, Department of Family Medicine, Northern State Medical University; 51, Troitsky pr., Arkhangelsk, 163000, Russia, tel. +7 8182 655194, [email protected].
Ryzhkova Nadezhda, M.D., general practitioner, Rikasikha Health Center, Primorsky central district hospital, Rikasikha; Primorsky district, Arkhangelsk oblast, 163523, Russia, tel. +7 8182 256325, [email protected].
Yashkovich Vera, M.D., doctor-in-chief, Arkhangelsk psychoneurological clinic; 271, Lomonosova pr., Arkhangelsk, 163001, Russia, +7 8182 242907, [email protected].
Belaya Elena, M.D., deputy doctor-in-chief, Arkhangelsk psychoneurological clinic; 271, Lomonosova pr., Arkhangelsk, 163001, Russia, +7 8182 242907, [email protected].
Popov Vladimir, M.D., Doctor of Medical Science, Vice rector for clinical care and postgraduate education, Head of Department of Family Medicine, Northern State Medical University; 51, Troitsky pr., Arkhangelsk, 163000, Russia, tel. +7 8182 285791, [email protected].
S0rlie Tore, M.D., Ph.D. in Medicine, Professor, Institute of Clinical Medicine, The University of Troms0 - The Arctic University of Norway; Troms0, 9037, Norway, tel. +47 77644000.
Rezvy G.G., Andreeva E.A., Ryzhkova N.N., Yashkovich V.A., Belaya E.N., Popov V.V., S0rlie T. Cooperation between specialized mental health services and general practitioners in Arkhangelsk County - the Pomor model [Поморская модель взаимодействия специализированной психиатрической службы и общей врачебной практики в Архангельской области (на англ. яз.)] // Вестник психиатрии и психологии Чувашии. 2016. Т. 12, № 1. С. 17-24.
Аннотация. В 1993 году была подписана Киркенесская Декларация, оформившая норвежско-российское международное сотрудничество в Евро-Арктическом регионе. Развитие сотрудничества в области медицины и здравоохранения между Северной Норвегией и северо-западным регионом России относится к началу 1990-х годов. В настоящее время российско-норвежский проект направлен на улучшение оказания психиатрической помощи в первичном медицинском звене Архангельской области. Целью проекта является совершенствование у врачей общей практики навыков диагностики и лечения, а также развитие взаимодействия между врачами общей практики и врачами-психиатрами. Системный аспект проекта реализован через создание и внедрение интегрированной модели взаимодействия психиатров и врачей общей практики (Поморская модель). Консультационная поддержка от врачей-психиатров повышает компетентность врачей общей практики и улучшает качество медицинской помощи пациентам с психическими расстройствами. Опыт реализации данной модели оценивался посредством: а) формализованного интервью с пациентами, б) данными диагностической статистики, поступавшими из центра первичной медицинской помощи, в) а также количеством пациентов, поступивших из района в областную психиатрическую больницу. Развитие данной модели приостановлено по причине отсутствия тра-
диции взаимодействия между врачами общей практики и психиатрической службой, слабым развитием финансового стимулирования работы врача общей практики с психически больными в первичном звене, а также отсутствием профессиональных руководств для диагностической и терапевтической работы в системе первичной медицинской помощи. Тем не менее высокая мотивация медицинских работников и организаторов здравоохранения, активная поддержка и рекомендации регионального министерства здравоохранения обеспечили значительный прогресс проекта. Данная модель реализуется в нескольких районах Архангельской области.
Ключевые слова: психиатрия, первичная медицинская помощь, врач общей практики, международное сотрудничество, Поморская модель, Архангельск, Россия, Норвегия.
Информация об авторах:
Резвый Григорий Геннадьевич, кандидат медицинских наук, доцент Института клинической медицины, Университет Тромсё - Арктический университет Норвегии, г. Тромсё, Норвегия, тел. +47 77644000. [email protected].
Андреева Елена Александровна, кандидат медицинских наук, доцент кафедры семейной медицины и внутренних болезней ГБОУ вПо «Северный государственный медицинский университет» Минздрава России, Россия, 163000, г. Архангельск, Троицкий пр., 51, тел. +7 8182 655194, [email protected].
Рыжкова Надежда Николаевна, врач общей практики (семейный врач) ГБУЗ АО «Приморская ЦРБ», обособленное структурное подразделение - врачебная амбулатория «Рикасиха», Россия, 163523, Архангельская область, Приморский район, п. Рикасиха. Тел. +7 8182 256325, [email protected].
Яшкович Вера Анатольевна, главный врач ГБУЗ АО «Архангельский психоневрологический диспансер», Россия, 163001 г. Архангельск, пр. Ломоносова, 271, тел. +7 8182 242907, [email protected].
Белая Елена Николаевна, заместитель главного врача ГБУЗ АО «Архангельский психоневрологический диспансер», Россия, 163001 г. Архангельск, пр. Ломоносова, 271, тел. +7 8182 242907, [email protected].
Попов Владимир Викторович, доктор медицинских наук, профессор, проректор по лечебной работе и последипломному образованию, заведующий кафедрой семейной медицины и внутренних болезней ГБОУ ВПО «Северный государственный медицинский университет», Россия, 163000, г. Архангельск, Троицкий пр., 51, тел. +7 8182 285791,[email protected].
Сёрли Туре, доктор философии (медицина), профессор, Институт клинической медицины, Университет Тромсё - Арктический университет Норвегии, Норвегия, 9037, г. Тромсё, тел. +47 77644000.
Поступила: 09.02.2016 Received: 09.02.2016
