Transition Into Primary-care Psychiatry (TIPP)
Condition: Mental Disorders
MeSH terms: Mental Disorders
Study type: Interventional
Phase: Phase 2/Phase 3

Summary: 
      The objective of the Transition into Primary-care Psychiatry (TIPP) project is to determine
      how feasible it is to conduct a study to evaluate a new primary-care focused program of
      mental health care delivery for people with chronic mental illness. This will be done by
      comparing a primary-care based collaborative, interdisciplinary model to care-as-usual on
      health related quality of life, client symptomatology, client's perceived need of care,
      participant satisfaction and cost-effectiveness.
    

Detailed description: 
      The TIPP service will consist, at both the London and Thunder bay sites, of: (i) a mental
      health care nurse (B.Sc.N.) with at least several years experience as an outpatient mental
      health service clinician, and (ii) a psychiatrist with a license to practice medicine in the
      Province of Ontario and sensitivity to the issues of family physicians providing mental
      health services in the community

      The TIPP intervention will involve a service delivery that is a modification of the
      Consultation Liaison in Primary-care Psychiatry (CLIPP) program

      Four elements will act in synthesis and enable collaboration between the primary care and
      TIPP teams:

      (i) Co-location of mental health services staff will involve the psychiatric nurse and
      psychiatrist visiting the family physicians' office at 1 and 3-month intervals, respectively.
      During these visits they will review and document the client's progress. This empowers the
      family physician as clinical manager. Treatment plans will be developed for family physicians
      that can be easily implemented. The family physician will monitor the client's status between
      the psychiatric nurse and psychiatrist's visits. At times of greater need, and/or impending
      crisis, increase in contact to every 14 days, with weekly or more from the family physician,
      and contacts with all providers adjusted to accommodate client needs. By developing linkages
      with area mental health services the psychiatric nurse will assist the family physician in
      co-coordinating access, while minimizing redundant use, to these services.

      (ii) The TIPP nurse will select, prepare, and facilitate appropriate clients from the
      outpatient department for transfer to the family physician. The initial transfer process
      includes a face-to-face meeting with the client, TIPP nurse and family physician in family
      physician's office. Warning signs and symptoms of an impending relapse will allow for an
      opportunity for intervention to prevent or lessen the severity of a relapse. For each client
      a "relapse signature" strategy will be developed by the TIPP nurse to assist the family
      physician in detecting clients at high risk of mental illness relapse. Having obtained the
      client's permission significant caregivers will be routinely involved in the development and
      implementation of a clinical management plan. Standardized CLIPP based contact sheets\data
      sheets will promote efficient and effective communication between clinical care providers.

      (iii) Client monitoring will be maintained by administrative staff support procedures
      targeted at ensuring a high level of retention and effective client follow up. The family
      physician will complete a Clinical Global Impression Scale (CGIS) (severity and change
      scores) every 3 months in the first year then at each visit for the remainder of the project.
      The CGIS will not add time to the clinical time with the clients. An administrative member of
      the project receiving these scales will alert the appropriate clinical providers for clients
      whose condition is not improving as judged by the family physician.

      (iv) Telephone back up for the family physicians' whose clients are involved in the project
      will be provided by a project psychiatrist and/or psychiatric nurse.

      The outcomes of the TIPP intervention clients will be compared to those who receive post
      outpatient service transfer care-as-usual from their family physician. The clients in this
      group will obtain any and all services normally available inside or outside their primary
      care service, including re-referral to specialty mental health care. No additional services
      will be provided for the care-as-usual group, but no usual services will be limited or
      withheld. Design features to ensure the interests of the control group are considered include
      outcomes assessment for both groups at 6, and 12 months, as well as at the projects end
      point. Should significant clinical concerns be noted by the rater during the assessment a
      systematic process will allow for the family physician to be notified so as to minimize the
      risk of compromised care.
    

Intervention name(s): program of care delivery
Intervention type(s): Procedure
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single
Primary purpose: Treatment
Keywords: chronic mental illness