Please describe your work setting, sharing with readers the mandate of the program and some detail about the population of focus.
I work in a primary care clinic that was created ten years ago as a demonstration clinic for people with mental health and substance abuse issues. The original goal of the clinic was to create innovative ways to facilitate access for this complex population and their families. The services are targeted to address the gaps in medical health care needs of clients whom are unattached to any clinic or provider and who, for many reasons, cannot access appropriate services. Our clinic is set up in the same building as mental health and substance use services to enhance access and comfort for clients, by getting all their services in familiar surroundings. The partnership and linkages between the clinicians who provide care to those with mental health and substance use issues promotes continuity and enhances access as well as ensures that physical and mental health care are provided jointly rather than separately.
While we are by appointment only, we allow 30 minutes and up to 60 if it is for a physical exam or it is otherwise required to address their complex needs. Clients with diagnosis of mental health or history of substance dependence can self refer to our clinic. We take referrals from community services, mental health and substance use care providers. New referrals are reviewed by RN and NP and assigned appropriate health care provider once a week.
What are some common health conditions you encounter and how do you prioritize to address these health needs?
Chronic diseases are regularly seen in this population, due to their lifestyles and the pharmacological management required of mental illness. Mood disorders, schizophrenia, bipolar disorder, obsessive compulsive disorders, panic disorders and anxiety disorder are all common examples of the diagnoses our patients experience. The medications used to treat some of these conditions, such as antipsychotics, can cause diabetes, dyslipidemia, hypertension (metabolic syndrome) and hypothyroidism. Additionally, other conditions which can be a challenge for this population and that are multifactoral in their causation, include obesity, smoking and chronic pain. It is difficult to treat the medical condition without addressing the mental health issues as well. Because of this, we recognize a team approach may be most effective, with NPs, RNs, psychiatrists, addictions and mental health counsellors all being involved at times. Our Clients are valued and are able to exert their choice on how and which health issue is to be managed first. In our clinic, building relationships and listening to client concerns is recognized as vital in order to have them come back.
Although there is significant prevalence of mental health and addiction issues among the general population, we as health care providers may sometimes feel stumped when working with clients who continue to place themselves at risk due to their mental illness or substance dependence. What practical and philosophical approach do you find helpful in such circumstances?
We look at the whole person, not just the symptoms they are presenting with, recognizing that it is not possible to address only one problem during the visit. Our approach must be flexible, evidence-based, collaborative, comprehensive, complimentary and co-ordinated with expert and appropriate clinical services. The values we emphasize are: participative decision making, respecting personal dignity, individual differences along with choice, safety and security.
Supportive, collaborative and respectful team work is very important when working with these clients. We meet once a month to discuss any issues or concerns. I feel supported in our team and am able to consult with my colleague physicians anytime on any questions or concerns I may have with my clients.
Often this population requires the support of added services, which can include much work on the part of the provider in filling forms, contacting resources and connecting individuals. How do you manage this workload and navigate engagement to address these various requests from clients?
We do not charge extra to fill forms, physicals, or driver’s license exams. The majority of our clients are on temporary or permanent disability and cannot afford to pay. Filling disability forms is a common occurrence and requires extra time. We will often ask clients to go to Advocacy Groups in surrey to assist them in completing their part of the form. The RN in our clinic is involved in helping clients complete their part of the form as well. “No show” time is often used for chart review and extra time may be booked off to complete forms. The emphasis in our clinic is on complete and comprehensive care not the increase in numbers seen. Contacting resources and connecting individuals to services in the community are a very challenging task. Often we end up doing this off the side of our desks, utilizing expertise of other team members as well as mental health counsellors.
Whether clients successfully access specialty services or supports is largely dependent on how much encouragement and coordination we can offer; this is an essential part of what we do in helping our clients meet their primary care needs.
What additional training or practice tools have you found useful in your work? Any bookmarks on your computer which you might recommend to your colleagues?
I have attended the practice support sessions (PSP) offered through Fraser Health Authority to physicians on managing major depression and diabetes. Working in Fraser Health, we are provided with access to resources such as UpToDate, Lexicomp, and diabetes education resources. Resources for mental health and substance use through the intranet are also very useful and effective in increasing my knowledge in order to provide the care required. The uses of guidelines have been effective in providing comprehensive and consistent care, such as the guideline that Fraser Health has created on metabolic monitoring for clients on antipsychotics. This guideline is now being used in our clinic and with assistance of our RN, to monitor clients at risk. This kind of experiential learning is a constant need and goal in my practice.
Karol Ghuman is a Primary Care Nurse Practitioner
Her clinic is located at 13401- 108th Avenue Surrey, 13th floor of the office tower at Gateway Sky Train Station, the same building as Surrey Mental Health and Substance Use Services. Open Mon – Fri from 8:30-5:30.