Integrating Mental Health Services: Principles, Practices, and Possibilities

Abstract

The majority of mental health and addiction problems initially present to a primary care provider, with many being treated only in primary care. Problems in the relationships with mental health services, however, often mean that individuals needing care often do not reach the services they require, while primary care providers do not always receive the support or assistance they are looking for. Increasingly, though, mental health services are recognizing the importance of working more collaboratively with primary care colleagues and an effective way of achieving this is by integrating mental health services within primary care settings. This can improve access and the patient’s experience, and expand the kinds of mental health services that can be delivered within a primary care practice, with new opportunities for earlier detection, relapse prevention, support for self-management, and assistance with system navigation. It opens up novel opportunities for continuing education, improves communication, and leads to better coordinated, less fragmented, and safer care. This chapter summarizes the benefits of collaborative partnerships, the core principles on which collaborative partnerships need to be based, the components and activities of effective collaborative initiatives, and the ways in which these approaches can help to address wider problems facing Canada’s health care systems.

1. Introduction

A high-performing network of primary care services is the foundation of any well-functioning health system, and providing mental health care is integral to their work. A primary care provider is usually the first point of contact for someone struggling with a mental health or substance use problem, and while these problems are not always detected, the majority of those that are will be treated exclusively in primary care. Primary care is also uniquely positioned not only to treat mental health problems but to identify individuals at risk, intervene earlier, prevent relapses, and even prevent or delay the onset of a problem.

But this cannot be done in isolation. Partnerships with mental health and other social services are essential to support and enhance these activities, but family physicians often encounter problems with their relationship with mental health services. These include difficulty in accessing services in a timely manner, poor communication, a lack of support or respect for their work, fragmented transitions, and poorly coordinated care planning [1].

Increasingly, if a little belatedly, mental health services have come to appreciate the key role that primary care plays within a city or region’s mental health system, and have explored different ways in which they can work more collaboratively and better support and assist their primary care colleagues. This has led to a rapid expansion of collaborative initiatives, including the successful integration of mental health services within primary care settings [2].

In the US, this has been accelerated by the Affordable Care Act, which offered incentives for integrating or “bundling” services delivered by different specialties or sectors [3]. Globally, the WHO’s MHGap initiative has promoted the idea that the most effective way of expanding access to mental health care in low- and middle-income countries is to integrate these resources within general medical settings, especially first-level (primary care) [4]. The work of Wayne Katon and colleagues in Seattle has led to the development of the “Collaborative Care Model,” which has provided an evidence-informed underpinning to the introduction of collaborative projects [5], while clinicians and researchers in many other places have adopted this work to local contexts or developed similar models, such as the “Canadian Collaborative Care Model” [6].

Wagners (Chronic) Care model [7] has provided a framework for understanding the elements that need to be in place within a service to support successful collaborative practice while evolving models of collaborative care are increasingly informed by the experiences of individuals with lived experience and families. And programs are increasingly using quality improvement methods and implementation science to guide their implementation and outcome measures [8].

All of this has clearly demonstrated that embedding mental health services and providers within primary care settings has the potential to strengthen communication and co-ordination and continuity of care, improve access to needed services, especially for marginalized and underserved populations, integrate physical and mental health care, facilitate transitions in care, and permit interventions earlier in an episode of illness. These new service alignments can improve health and mental health outcomes and help with treatment adherence, while a wider range of problems can be treated, in a less stigmatizing and more culturally congruent environment. Such programs are also better positioned to respond to the needs of specific populations and provide additional support and education to family physicians and other primary healthcare providers [6].

Collaborative mental health care (CMHC) has also been shown to decrease wait times, and avoidable emergency room visits and hospitalizations, avoiding duplication of services and reducing the likelihood of medical errors while supporting population health. And from a systems perspective, CMHC increases the capacity of both the primary care system—with more people being seen and the skills of primary care providers being augmented—and of the mental health system, as primary care is now seen as being an integral part [6].

This chapter reviews the principles that guide collaborative practice, the key elements of a successful integrated mental health program and its component activities, and the support required to help it succeed. And while CMHC is not a panacea for all the challenges our health systems face, by strengthening the links and partnerships between mental health and primary care services it can potentially assist—to a greater or lesser degree—in addressing many problems facing all of our health services.

2. Definitions

Collaborative mental health care (CMHC) describes situations where primary care and mental health care providers co-ordinate their resources, expertise, knowledge, and decision-making to ensure the patients whose care they are sharing receive the best possible care from the right provider in the most appropriate location when they need it. At the core of these new working relationships are (i) shared goals or purpose (ii) mutual recognition and respect (iii) equitable and effective decision-making making, and (iv) clear and regular communication [6].

Integrated care refers to situations where mental health and primary care providers are located in the same setting and are in regular contact, as part of the same care team. Clinical care can then be reorganized to develop a comprehensive continuum of services to improve access, communication, quality, and user satisfaction, using resources differently and efficiently [6].

3. Underlying assumptions guiding the integration of mental health services in primary care settings

There are six underlying assumptions on which the need for integrating services is based.

1. In most communities, the majority of mental health and addiction problems present and are treated, and will continue to present and be treated, in primary care. Traditional mental health services do not have the capacity to see even a relatively small percentage of these cases, but if the mental health care delivered in primary care (primary mental health care) can be enhanced and better support primary care providers, more individuals can be treated, and secondary and tertiary services can be used in a more targeted manner, for those problems which cannot be managed in primary care.

2. The integration of mental health services within primary care has the potential to reduce or eliminate many of the problems that can bedevil the relationships between the two sectors such as poor communication, a lack of coordinated or continuous care and limited support for primary care providers.

3. Patients prefer being seen in an environment that is likely to be more convenient, comfortable, and culturally congruent and which they perceive as being less stigmatizing.

4. The successful integration of mental health services within primary care settings opens up a myriad of opportunities for prevention, earlier detection and intervention, relapse prevention, health education, and managing populations as well as individuals, something that is beyond the current capability of mental health or primary care services when working in isolation.

5. Each community or practice needs to be able to adapt successful models to meet its own needs and resource base. This is best accomplished by focusing on the principles of collaboration, and adapting these to the local situation, rather than just trying to implement a model that has worked elsewhere.

6. Consistent with the principle of collaboration, if mental health services are to look at ways of improving their relationship with their primary care colleagues, this needs to be done together. A first step toward implementing any of the changes outlined below would be to establish a process whereby primary care providers and mental health staff and leaders can meet to identify the major problems and explore together potential solutions that take into account the local context and also the realities of what can and cannot be changed.

The integration of mental health services aims to build on and complement the care already being delivered in primary care but needs to be supported by other changes in the system. Traditional mental health and substance use services, including in-patient services, need to think differently about how they work with their primary care colleagues, forging stronger partnerships to improve access to care and support and a more timely exchange of information.

And at a wider system level, it needs to be supported by (a) a funding strategy that supports successful ongoing projects and innovations, (b) health care plans at the local, regional, or national level that outline clearly the role of primary care within redesigned mental health and addiction systems and how this can be supported, and (c) a training strategy to prepare all providers for new roles, especially future psychiatry and family physicians.

4. Goals of collaborative or integrated care program

There are a number of ways in which mental health professionals can be integrated within primary care. The mental health clinician could be permanently located within primary care, as their main or sole place of work. It may involve a visit by a single clinician, the frequency often depending on practice size (often the model for psychiatrists working with a practice), or by a team, with a variety of mental health clinicians on-site at the same time. Sometimes specialized hospital or clinic-based services like seniors or child services may utilize a “hub and spoke” model, whereby clinicians will visit a number of different primary care practices in their catchment area, usually less frequently, to provide more specialized consultations and advice.

And whatever the arrangement, programs will share one or more of five possible goals, consistent with IHI’s quadruple aim. These are:

• To improve clinical outcomes.

• To improve access to services.

• To enhance the experience of those receiving care.

• To enhance the experience of providing care.

• To offer sustainable and cost-effective services.

5. Principles to guide collaborative partnerships

Collaborative care is most likely to be successfully implemented and sustained when based upon principles, rather than just trying to implement a program that had been established elsewhere. This allows for the components of the program to be adapted according to local needs and resources.

There are principles that apply to the relationship between services and others that apply to the relationship between frontline providers.

5.1 Between services or systems

• Collaboration is not a single event but a process that changes and evolves over time. Better collaboration is not an end in itself but a means to the goal of better outcomes for people being seen.

• Collaboration is always easier when providers are working in close proximity.

• New care models need to be tailored to meet the needs of each physician or practice—“one size fits one.”

• The foundation of productive collaboration is effective communication, whether in person or electronically. It needs to be clear, avoiding jargon and two-way.

• Organizational support on both sides is important.

• Projects need to consider their sustainability from the outset, so they do not fall apart if the initial champions leave or change roles.

• Resource availability, local culture, geography, and the severity of the individual’s problem can all affect the ability to successfully implement a new program or partnership and need to be taken into consideration.

• Collaborative projects should be planned together from the outset, with clear and mutually agreed upon goals and priorities.

5.2 Between providers

• There should be a single integrated plan, with the patient being a partner in developing these.

• Tasks and roles should be allocated according to respective skills, interests, and resources of each provider and not solely by discipline.

• The person and their family or caregiver should always be at the center of care, with services being adjusted to make sure this remains the focus.

• There should be a regular and unimpeded flow of information (written and verbal) between providers.

• Collaborative care should focus on prevention, wellness promotion, and adaptive functioning, as well as treatment and relapse prevention.

6. Integrating mental health services within primary care settings

Although the clinical care provided by mental health providers working within primary care is similar to those that are delivered in traditional settings, many other opportunities open up for indirect care and case discussions/reviews, screening and pro-active care, and provider education and capacity building. But mental health providers are likely to be asked to see a wider range of cases, or to employ a greater array of assessment and treatment modalities than they would if working in a traditional mental health service. There will, however, always be certain kinds of cases that because of their complexity, or the need for a wider range of resources that primary care can offer will probably be better served by a referral to a mental health program.

Care is usually short-term, and can include consultations and assessments of adults, children, and youth, initiation of treatment and short-term stabilization, brief psychotherapies—CBT, IPT, or solution-focused therapy, case management and system navigation, family and couple assessments or treatment and patient education and self-management support. But working together in primary care changes the way these services can be delivered.

Any referral can be discussed with the family physician to clarify what they are looking for from the consultation and to obtain relevant background information before an assessment is conducted. The EMR can also be reviewed at the same time. All of this leads to a more focused and often briefer consultation. Meanwhile, at the end of an assessment, the findings and plan can be discussed with the family physician before the person leaves, and respective responsibilities negotiated.

As care is shared, the partners can determine who is best positioned to provide which services in each situation, supporting and complementing each other’s roles. In general, the involvement of the MHP is short-term, to avoid the development of waiting lists, and care is returned to the family physician who knows that the MHP will remain involved—the shared care model—and is able to get more actively engaged again at any time in the future, with no fuss or referral procedures. This also means that a person’s progress can be discussed during any visit, and care plans—medications, for example, adjusted without the person necessarily needing to be seen.

Working together in the same setting also enhances communication, with multiple opportunities to discuss cases at any stage of assessment or treatment. A single integrated care plan can be developed, knowledge of local resources and programs exchanged, and assistance provided with system navigation or referrals into the mental health system. The family physician may also use these informal contacts to discuss whether someone they are seeing should be seen for a mental health assessment, or possible treatment options that could be initiated prior to any assessment, and may end up rendering it unnecessary. Occasionally the FP may request assistance with someone they are seeing at the same time as the MHP is in the practice, or can book someone in to be seen at very short notice after such a visit, reducing the need for a trip to an emergency room.

Every consultation or assessment offers opportunities for brief (2–3 min), case-based teaching such as why a specific anti-depressant was suggested, or the difference between a schizoaffective disorder and a bipolar disorder, or depression and dementia. MH Providers can also offer case-based teaching sessions and provide information or links to screening tools, online resources, community programs, and care pathways, as well as updates on new medications or treatments. Ideally, this information can eventually be incorporated within the practice’s electronic health record.

Mental health providers can also assist in developing and populating of patient registries, and proactive screening, especially when this is aimed at preventing relapses. This could be a list of all patients of the practice seen in a mental health facility in the last year, or who are taking an antidepressant can be compiled using an excel spreadsheet. This list can be reviewed by the team monthly, to see who may not be improving, or who has not been seen for a while, so that their care can be managed proactively.

7. What makes integrated care work

To take full advantage of the possibilities that collaborative care can offer, a number of elements need to be in place (as many of the following as possible). Care needs to be:

Team-based: The team composition may vary but will include a family physician, psychiatrist (if one is involved), and other mental health professionals working in that practice. Other primary care staff, including administrative and management staff, may also be involved, depending on their role and involvement.

Information is shared regularly— orally, in writing, or electronically—and all team members should be working within their full scope of practice. Tasks can then be divided up according to skills, rather than professional titles, as a number of aspects of care can be delivered by more than one member of the team (task sharing). Certain clinical and administrative tasks may also be able to be completed by less skilled or qualified members of the team—often supported by medical directives—(task shifting). This can free up time for the family physician or practice nurse to focus on tasks for which only they have the skills, training, or authority.

Shared with both mental health and primary care specialists remaining involved as long as needed. Even though it may just be one provider delivering the majority of care at any moment, other can be re-involved whenever needed.

Stepped: This has two dimensions. One is linking treatments, and their intensity, to the nature and severity of a problem or a person’s needs. The second is sequencing the involvement of different health care professionals, according to their respective skills and the complexity of the problem(s).

Evidence informed: All clinical activities need to be informed by the best available evidence, including the use of proven treatment pathways.

Measured and evaluated: With the individual, it allows for progress to be measured and treatment adjusted according to response, the concept of treatment to target. At a program level, it helps to determine whether the new program is working and which elements may be contributing to its success. Evaluation criteria should be based on the project goals and required data should be easy to collect within the constraints of daily practice.

Proactive and population-focused: This allows individuals who might otherwise be “lost” to treatment to be followed proactively, with particular attention to groups who face barriers in accessing care, or who have an identified problem but are not being seen. Monitoring a population allows for earlier intervention and more continuous care, and can also facilitate relapse prevention, instead of having to wait until symptoms recur before reengaging services.

Person and family centered with the person—and their caregivers if appropriate—participating in the development of the treatment plan and goals. They will also be provided with information, suggestions, and support that can help them better manage their own care. It also provides a reminder that other family members may be struggling and require additional support when a relative is not well.

Equitable and inclusive, recognizing and eliminating the barriers, prejudices, and oppression faced by individuals from marginalized or racialized communities, who may also face other barriers when attempting to access mental health care, and advocating for the eradication of systemic attitudes and biases that contribute to these problems. Addressing external (social) determinants, such as adequate housing or income and cultural factors, should also be considered when developing a management plan.

Recovery focuses, recognizing and building upon an individual’s strengths, supporting their personal goals, instilling realistic hope, and taking into consideration the roles an individual’s physical and social environment can play in the development and management of mental health and addiction problems.

Trauma-informed: As we continue to understand the ways in which previous trauma—during childhood or in later years—can contribute to the development and presentation of many mental health and addiction problems, it becomes even more essential that these issues are identified and explored, and supports or treatment put in place—if the person wishes—to facilitate the resolution or amelioration of the current presenting problem.

8. Other changes to support an integrated program

Changes in the way care is organized within a practice are also required for successful and sustainable collaboration. These can include adequate preparation/training for mental health professionals starting to work in primary care; direct and timely handovers of care, ideally in person; the introduction of treatment protocols or care pathways; charting in a common clinical record; and protected time for collaborative activities. There needs to be an identified champion or lead within the primary care setting and incentives (academic, professional, or financial) to encourage collaborative practice, and these initiatives must be actively and visibly supported by organization leaders.

9. Roles of the mental health team members

When working together and sharing care in a collaborative partnership, the different providers from mental health and primary care will work out which of them is in the best position to provide the care that an individual may require. The family physician will usually continue to deliver care after consultation or brief treatment, with support from the mental health team, but the presence of a psychiatrist or other mental health professional can help them expand their role, knowing that support is readily available, or can offer them a break when seeing complex or demanding patients.

While the psychiatrist will usually give priority to providing consultation and short-term care or stabilization, they will also be available to discuss cases and for case-based education, with every person seen providing an opportunity for brief teaching that can be generalized to other cases the family physician is seeing. They can also facilitate referrals to local mental health services The mental health professional, usually a psychologist, social worker, or nurse, can play many roles, including assessment, care planning and ongoing therapy, monitoring and support, system navigation, and providing information for the team. This usually encompasses a wider range of activities than if they were working in a traditional MH Service, where they may be seeing a narrower range of cases or offering a much more limited series of treatments.

Other primary healthcare providers, especially practice nurses, are well positioned to recognize mental health problems, provide support or advice, and increase a patient’s understanding of the interconnected nature of their physical and mental health care problems, and the presence and support of mental health professionals can increase their skills and comfort in managing these problems (Table 1).

Activity (competency)	Family physician	Psychiatrist	Mental health clinician	Other team member (e.g., nurse, pharmacist, dietitian)
Direct clinical care
Screening & identification	√		√	√
Assessment & consultation individuals	√	√	√
Assessment & consultation families	√	√	√
Initiating medication treatment	√	√
Telephone advice to team		√
Integrating physical and mental health care	√	√		√
Specific psychological treatments (i.e., CBT, IPT, ACT, and MBCBT)	√		√	√
Medication management/reconciliation	√	√		√
Health promotion, health behavior change	√			√
Care management and coordination
Care coordination	√		√	√
Care management	√		√	√
Case discussions	√	√	√
System navigation	√		√	√
Monitoring and relapse prevention	√		√	√
Family and couple interventions	√		√	√
Referral	√	√	√	√
Patient and family education and support for self-management	√	√	√	√
Building system capacity
Staff education and training	√	√	√
Building community partnerships	√	√	√	√
Introducing new tools to extend care	√	√	√
Using care registries/data sets	√	√	√	√
Program evaluation, quality improvement	√	√	√	√
Improving population care
Early detection	√			√
Relapse prevention	√	√	√	√
Eliminating barriers to care	√	√	√	√
Providing culturally sensitive care	√	√	√	√
Advocacy at the community level	√	√	√	√

Table 1.

Potential roles of the mental health team members [6].

10. Competencies and training for health care professionals

To work effectively in these models, mental health professionals need to be flexible, respectful, open to new learning, able to communicate effectively, culturally humble, and aware that they do not always need to be the “expert,” as the learning is multifaceted and interdisciplinary.

They also need to appreciate the central role primary care plays in any health care system, the pace and demands of primary care and how these can affect the way care is delivered. They need to be able to “translate” mental health concepts and terminology into language that primary care providers can understand and apply, and be willing to see a wide variety of cases and problems, which may take them outside of their comfort zone. In many ways they end up working like other primary care providers, seeing people during an acute episode of care, and then being able to get involved again at any point in the future should the need arise.

As collaborative practice becomes accepted more and more as an integral part of mental health care, and becomes an expected part of the practice of all practitioners, it is important that future primary care and mental health professionals learn how to work effectively in collaborative partnerships during their training.

11. Evaluating collaborative initiatives

All projects should build in evaluation from the beginning, based upon the mutually agreed upon goals for the initiative. The purpose of the evaluation and how the results will be used and by whom needs to be clearly spelled out. Evaluation materials should be easy to complete, using validated measurement frameworks and tools wherever possible, and balance quantitative and qualitative data, with people using the service (and their families) should be involved in the design. It should also be framed within a quality framework, with the areas being measured fitting within the domains of quality care.

12. Integration of physical health care into mental health settings

Many individuals living with mental health and addiction problems, particularly those with severe and persistent mental illnesses, are more likely to experience significant health problems, one of the reasons why their life expectancy may be as much as 25 years less than those in the same community who are not living with a SPMI, they can face multiple challenges in accessing continuing medical care. One solution to this has been the integration of family doctors and/or other healthcare professionals (e.g., nurse practitioners) within a mental health program, sometimes referred to as reversed shared care. Working in a collaborative model, they will visit on a regular basis to assess both acute and chronic health problems, initiate treatment where possible, provide health teaching and education, and connect patients with other needed health services (Table 2).

Goal	Activities
Improve communication	Providing useful and timely assessment and discharge summaries, and updates about changes in care. Informing family physicians of programs offered and changes in services. Actively obtaining family physicians’ ideas for improvements through 1:1 discussions, surveys, and focus groups.
Improve timely access to consultation or care	Providing telephone advice or e-consultative services to family physicians. Providing a rapid consultation service, with recommendations going back to the family physician to implement while the patient waits for other services to become available. Assisting with system navigation. Providing more resources and support to assist with self-management.
Improve the coordination of care	Developing and updating patient care plans with the patient and team. Clarifying the respective roles and responsibilities of team members. Discussing possible referrals before they are made. Easing transitions and ensuring face-to-face information exchange.
Increase the capacity of primary care to manage mental health problems	Delivering educational sessions or continuing professional development events for family physicians. Providing relevant screening tools, up-to-date treatment guidelines, and online resources. Providing information on community resources and programs.

Table 2.

Activities any mental health service can consider [6].

13. Potential to address wider challenges facing our health care systems

Once they are located within primary care, mental health providers can assist in addressing mental health problems that face every health care system. These can include:

• Improving access to mental health care and reducing waiting times by increasing the capacity of primary care to see individuals with mental health problems, and using secondary and tertiary mental health services more selectively.

  This may be especially true for populations who have difficulty accessing mental health care but who may have an ongoing relationship with a primary care provider, including recent immigrants and individuals from different ethnic groups, who may find receiving care in their family physician’s office to be more culturally congruent or safe. It can also enhance care for seniors, who may find it much easier, more comfortable, and less confusing to access services in their family physician’s office.

• Reducing avoidable ED visits by providing care at an earlier stage in its evolution, before it requires an emergency visit or intervention.

• Providing additional support for primary care and primary care providers at a time when they are under increased stress. Team-based mental health care can help to deliver a wider range of services to individuals who need them, shifting some of the load carried by primary care providers without overburdening any one provider. It also offers a unique situation where consultant and consultee, specialist, and generalist can work together and learn from one another.

• Improving transitions between services and continuity of care and reducing system fragmentation by better communication between providers, ensuring that all are involved in the development and implementation of a care plan. At the very least, the primary care provider should be informed whenever a patient is transitioning from one service to another.

• Enhance earlier identification and intervention, by identifying and tracking individuals or sub-populations who may be at greater risk of developing a mental health or addiction problem.

• In particular, there are opportunities to support children in the earliest years by building a list of children born in a single year, and known risk factors to this list and then proactively following these children after the 18-month well-baby visit, to try to ensure that no child gets left behind. This may be one of the best chances we have to change the trajectory of children at risk.

• Promoting relapse prevention by identifying and monitoring (in person or by phone) individuals who have an identified mental health or addictions problem, that is, everyone in the practice discharged from a mental health service, or who has been started on an anti-depressant in the previous 12 months.

• Reducing errors and increasing patient safety, as communication between providers/sectors is quicker, clearer, and can be explained in person and confusion about roles resolved.

14. Challenges

Despite the progress that has been made, challenges can arise, although these will vary from community to community. Insufficient resources may limit what a program can accomplish and expectations, services, and priorities need to be adapted accordingly. Space is often at a premium and this will require flexibility on the part of all concerned, with mental health professionals needing to adjust to working under different conditions from those they are used to.

Time constraints are often a factor and this requires compromises on the part of everyone. Mental health professionals need to respect the multiple demands on family physicians, while the family physician needs to be willing to try and find time for case discussions and other related activities. It is also a style of practice that may not suit everyone, so assessing aptitude for this work and adequate preparation before starting is important (Table 3).

Effective	Timely	Efficient	Patient-Centered	Equitable	Safe	Provider experience
Care follows evidence-informed guidelines; Clinical outcomes (symptom rating scales, functioning, quality of life, recovery); Percentage of patients who respond to, remit with treatment	Early identification of problems; Waiting time from referral to initiation of treatment; Triage process; Waiting time from query to receipt of advice (indirect consultation)	Amount of service delivered; Team members working to scope; Utilization of outside services	Patients as involved in goal setting and care planning as they wish; Patient has a copy of their plan; Patient experience of care; Patient & family involvement in program planning and evaluation	Elimination of barriers to access; Collection & management of population data for planning & monitoring; Equity in health service utilization; Equity in health outcomes; Patient experience care as culturally competent	Medication reconciliation; at every visit; Elimination of preventable adverse events	Provider satisfaction; Provider retention; Team functioning; Providers/practices involved in local planning

Table 3.

Quality domains and potential targets for measurement in program evaluation [6].

15. Conclusions

One very effective way of strengthening the relationship between primary care and mental health providers, improving both access to care and the patient experience is to integrate mental health service within primary care settings.

Evidence has shown that in addition to improving access, especially for individuals from underserved or isolated communities, when the mental health professional and family physician are working side by side it creates many opportunities for “indirect” services, whether these be case discussions, system navigation, and assistance with referrals. Every case provides opportunities for a brief educational component, thereby building the capacity of primary care.

Collaborative approaches also have the potential to address wider problems facing our health care systems both in identifying and assisting particular populations who have difficulty reaching traditional services and also improving the coordination of mental health services and reducing fragmentation and duplication.

Above all, being seen for mental health care in their family physicians’ office is very popular not only with people using these services but also with providers who appreciate the extra dimension it brings to their practice and the additional support. And this is an approach that has the potential to be expanded to many other medical specialties, especially those that are not reliant on high-tech equipment.