management of depression in primary care dr carole mcilrath senior professional officer northern...
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Management of Depression in Management of Depression in Primary CarePrimary Care
Dr Carole McIlrathDr Carole McIlrathSenior Professional OfficerSenior Professional Officer
Northern Ireland Practice & Education CouncilNorthern Ireland Practice & Education Council
BACKGROUNDBACKGROUND
DEPRESSIONDEPRESSION
• many mood disorders with varying severity, many mood disorders with varying severity, symptoms and persistencesymptoms and persistence
• dysthymia, major depressive disorder, bipolar dysthymia, major depressive disorder, bipolar disorder, psychotic depression, post-partum disorder, psychotic depression, post-partum depression & seasonal affective disorderdepression & seasonal affective disorder
• leading cause of disability worldwide (121 million)leading cause of disability worldwide (121 million)• 70% of recorded suicides70% of recorded suicides• psychiatric disorder 90% of suicide victimspsychiatric disorder 90% of suicide victims
INCIDENCEINCIDENCE
• Taiwan - 0.8 cases per 100 adultsTaiwan - 0.8 cases per 100 adults• 5.8 - New Zealand5.8 - New Zealand• 6% - Australia6% - Australia• 5% - 10% - UK 5% - 10% - UK • 10% - USA 10% - USA • 23.5% - Japan23.5% - Japan
NORTHERN IRELANDNORTHERN IRELAND
• 21% aged over 16 21% aged over 16 • 24% women & 17% men24% women & 17% men• mental health needs 25% mental health needs 25% than England than England• Prescriptions – Prescriptions –
– anti-depressants 37% anti-depressants 37% , ,
– psychosis & related disorders 66% psychosis & related disorders 66%
– hypnotics & anxiolytics 75% hypnotics & anxiolytics 75%
CO-MORBIDITYCO-MORBIDITY
• cancers cancers • 4.5% to 58% 4.5% to 58%
• cardiovascular disorders cardiovascular disorders • myocardial infarction 20-30% myocardial infarction 20-30%
• chronic conditions chronic conditions • asthma & diabetes – 50%asthma & diabetes – 50%
• neurological disorders neurological disorders • Parkinson’s Disease 40-50%Parkinson’s Disease 40-50%• Stoke 16-60% Stoke 16-60%
• GPs – GPs – three times more likely to miss major depression in minor physical illnessthree times more likely to miss major depression in minor physical illness
& five times more likely to miss major depression in serious physical& five times more likely to miss major depression in serious physical
illnessillness
POLICY CONTEXTPOLICY CONTEXT
• increasing recognition of mental illnessincreasing recognition of mental illness• major public health issuemajor public health issue
• emphasis on promotion of mental & emotional health emphasis on promotion of mental & emotional health
• 30 years refocusing of service provision away from 30 years refocusing of service provision away from hospital settings towards community carehospital settings towards community care
• Greater understanding of mental illnessesGreater understanding of mental illnesses
• developments in psychopharmacologydevelopments in psychopharmacology
• changes in social policychanges in social policy
• vast array of legislative change vast array of legislative change
• Sex Discrimination Act 1975; Race Relations Act, 1976; Mental Health Sex Discrimination Act 1975; Race Relations Act, 1976; Mental Health Act, 1983; Disabled Persons Act, 1999; NHS & Community Care Act, Act, 1983; Disabled Persons Act, 1999; NHS & Community Care Act, 19901990
PRIMARY CAREPRIMARY CARE
•early 1990s - the development of primary careearly 1990s - the development of primary care•support mental health services support mental health services
•improve collaboration between secondary care & primary care improve collaboration between secondary care & primary care professionals professionals
•potential for early detection, intervention, utilisation of voluntary potential for early detection, intervention, utilisation of voluntary sector organisations and mental health promotion sector organisations and mental health promotion
•to support this - NSF for Mental Healthto support this - NSF for Mental Health•set national standards and defined service modelsset national standards and defined service models
•seven standards - first three relevant to and promote the seven standards - first three relevant to and promote the development of primary care mental health servicesdevelopment of primary care mental health services
•NI has lagged significantly behind developments NI has lagged significantly behind developments
NORTHERN IRELANDNORTHERN IRELAND
• regional strategic objectives highlighted mental health regional strategic objectives highlighted mental health as a priority for action:as a priority for action:
• Health and Well-Being into the Millennium (97-02)Health and Well-Being into the Millennium (97-02)
• Health and Social Well Being Survey (02)Health and Social Well Being Survey (02)
• Programme for Government (NIE, 02)Programme for Government (NIE, 02)
• Investing for Health Strategy (02) Investing for Health Strategy (02)
• Promoting Mental Health Strategy & Action Plan (03)Promoting Mental Health Strategy & Action Plan (03)
• Bamford Review of Mental Health (05 &06)Bamford Review of Mental Health (05 &06)
• ““each individual with a mental health problem should be given each individual with a mental health problem should be given the opportunity to have their mental health needs understood the opportunity to have their mental health needs understood and addressed promptly within primary care settings, taking and addressed promptly within primary care settings, taking into account biological, psychological and social dimensions”into account biological, psychological and social dimensions”
PRIMARY CAREPRIMARY CARE
““It is the first level of contact of individuals, the familyIt is the first level of contact of individuals, the family
and community with the national health system bringingand community with the national health system bringing
health care as close as possible to where people live andhealth care as close as possible to where people live and
work, and constitutes the first element of a continuingwork, and constitutes the first element of a continuing
health care process” health care process”
(WHO, 1978)(WHO, 1978)
Membership of the primary care teamMembership of the primary care team
Medical Paramedical Administrative Therapists Social
General practitioner Community nurse Practice manager Physiotherapist Social worker
Dentist Practice nurse Receptionist Chiropodist Community psychiatrist
Community geriatrician
Ophthalmic optician Assistant Speech therapist Psychologist
School medical officer
Midwife Secretary Osteopaths Counsellor
Health visitor Dietician Domiciliary aid
Pharmacist
Almost 20,000 people actively involved in the provisionAlmost 20,000 people actively involved in the provision
of primary care services:of primary care services:– 1,200 GPs;1,200 GPs;– 5,000 Nurses;5,000 Nurses;– 250 Midwives;250 Midwives;– 700 Dentists;700 Dentists;– 1,000 Community Pharmacists;1,000 Community Pharmacists;– 1,000 Allied Health Professionals;1,000 Allied Health Professionals;– 500 Optometrists;500 Optometrists;– 4,000 Social Workers; and4,000 Social Workers; and– 6,000 Home-helps.6,000 Home-helps.
Source: DHSSPS (2005) Source: DHSSPS (2005)
PRIMARY CAREPRIMARY CARE
90% 90% cared for and managedcared for and managed
• 50%50% of attendees from depression of attendees from depression
• patients present with patients present with somatised medical problems somatised medical problems
• nearly three times the consultation ratesnearly three times the consultation rates
• suicide linksuicide link
• variationsvariations
• 50% ‘missed’50% ‘missed’
10% spent 10% spent
PROFESSIONAL ISSUESPROFESSIONAL ISSUES
•Primary care nurses increasingly involved in identifying, Primary care nurses increasingly involved in identifying, assessing and caring for people with depression:assessing and caring for people with depression:
•little time allocated little time allocated
•often untrained & unsupportedoften untrained & unsupported
•CMHNs - “mild” or “moderate” mental illnessCMHNs - “mild” or “moderate” mental illness•widely accepted in April 1993 - GP fund-holderswidely accepted in April 1993 - GP fund-holders
•CMHNs well regardedCMHNs well regarded
•many GPs favour closer liaisonmany GPs favour closer liaison
•much criticism howevermuch criticism however•at risk of abandoning most vulnerable – SMIat risk of abandoning most vulnerable – SMI
•little attention paid to their selection & preparationlittle attention paid to their selection & preparation
•many torn between the demands of GPs and their employing Trustmany torn between the demands of GPs and their employing Trust
RESEARCHRESEARCH
• Recommendations from: Recommendations from: • Bamford Review of MH & LD (DHSSPS, 2005)Bamford Review of MH & LD (DHSSPS, 2005)
• New GP Contract (BMA & NHS Confederation, 2004) New GP Contract (BMA & NHS Confederation, 2004)
• ideal vehicles for developing primary care depression services, ideal vehicles for developing primary care depression services, some nurse-led. some nurse-led.
• Nonetheless, Nonetheless, • clarity of roles & responsibilities clarity of roles & responsibilities
• gaps in the knowledge & training of primary care nurses gaps in the knowledge & training of primary care nurses
• no consensus on what standards, guidelines or benchmarks constitute an effective primary no consensus on what standards, guidelines or benchmarks constitute an effective primary care based nursing service for adults with depression. care based nursing service for adults with depression.
• develop, support and guide their practicedevelop, support and guide their practice
• benchmark – a standard to judge or measure something benchmark – a standard to judge or measure something against against
Research QuestionsResearch Questions
1. 1. What are the most appropriate benchmarks for an effectiveWhat are the most appropriate benchmarks for an effective
primary care based nursing service for adults (18-64 years) primary care based nursing service for adults (18-64 years)
with depression? with depression?
2. To what extent do existing primary care based nursing2. To what extent do existing primary care based nursing
services for adults with depression in Northern Ireland conformservices for adults with depression in Northern Ireland conform
to these benchmarks?to these benchmarks?
3. What are the best strategies for enhancing existing primary3. What are the best strategies for enhancing existing primary
care based nursing services for adults with depression? care based nursing services for adults with depression?
Design & MethodologyDesign & Methodology
•Exploratory survey designExploratory survey design
•Qualitative approach multiple Qualitative approach multiple methodsmethods
•Two phasesTwo phases
•Ethical IssuesEthical Issues
Phase OnePhase One
•Delphi techniqueDelphi technique•Purposive Sampling Purposive Sampling •Inclusion criteriaInclusion criteria•84 potential experts84 potential experts•67 (80%)67 (80%)
•Mental Health Nurses (n=36)Mental Health Nurses (n=36)
•Health Visitors (n=9)Health Visitors (n=9)
•Practice Nurses (n=2)Practice Nurses (n=2)
•GPs (n=16) GPs (n=16)
•Psychiatrists (n=4)Psychiatrists (n=4)
Pilot StudyPilot Study
• Questionnaire Questionnaire • Content and face validityContent and face validity• 10 professionals 10 professionals • 100% response100% response• Minor adjustmentsMinor adjustments
– LayoutLayout– DesignDesign– Content Content
FindingsFindings
• Round One QuestionnaireRound One Questionnaire
•96% response rate96% response rate•53% post / 47% email53% post / 47% email•1216 statements1216 statements•239 benchmarks239 benchmarks•3 categories 3 categories
BenchmarksBenchmarks
Structures – 126Structures – 126
• aa primary care based depression service should support and primary care based depression service should support and utilise utilise guidelinesguidelines which have been modified for local which have been modified for local circumstances (NICE)circumstances (NICE)
• protected timeprotected time should be provided to primary care should be provided to primary care practitioners to manage depression, attend reviews, practitioners to manage depression, attend reviews, supervision sessions and education programmes related to supervision sessions and education programmes related to depression servicesdepression services
• all all practice nursespractice nurses should have attended at least a one day should have attended at least a one day training course on depressiontraining course on depression
BenchmarksBenchmarks
Processes – 70Processes – 70
• Structured assessments should be completed by primary care Structured assessments should be completed by primary care practitioners using practitioners using validated rating scalesvalidated rating scales to diagnose to diagnose depression (PHQ-9, HADS, EPNS)depression (PHQ-9, HADS, EPNS)
• Clients with depression should have access to and choice of a Clients with depression should have access to and choice of a range of support/treatments following a clear range of support/treatments following a clear stepped care stepped care modelmodel
• InterventionsInterventions provided in primary care should be structured, provided in primary care should be structured, time limited, time limited, evidenced based and adapted for use in a busy evidenced based and adapted for use in a busy primary care setting (CBT)primary care setting (CBT)
BenchmarksBenchmarks
Outcomes – 43Outcomes – 43
• There should be an increase in the number of There should be an increase in the number of primary care primary care nursesnurses with the training and skills to assist in the management with the training and skills to assist in the management of clients with depressionof clients with depression
• There should be a reduction in the There should be a reduction in the amount of timeamount of time clients with clients with
depression have to wait for psychotherapeutic interventionsdepression have to wait for psychotherapeutic interventions
• There should be a reduction in the number of episodes of There should be a reduction in the number of episodes of relapserelapse of depression of depression
• Round Two QuestionnaireRound Two Questionnaire
•95% response rate95% response rate•26% post / 74% email26% post / 74% email•consensus 70%consensus 70%•descriptive statisticsdescriptive statistics•22 benchmarks22 benchmarks
• Round Three QuestionnaireRound Three Questionnaire
• 95% response rate95% response rate• 10% post / 90% email10% post / 90% email• consensus 70% consensus 70% • descriptive statisticsdescriptive statistics• consensus - 22 + 51 consensus - 22 + 51
benchmarksbenchmarks» 45 (61%) structures45 (61%) structures» 18 (25%) processes 18 (25%) processes » 10 (14%) outcomes10 (14%) outcomes
PHASE TWOPHASE TWO
• Multiple Methods - Multiple Methods - triangulationtriangulation• InterviewsInterviews• ObservationObservation• Document analysisDocument analysis
• Stratified purposive Stratified purposive
• Content AnalysisContent Analysis
BENCHMARKING TOOLKITBENCHMARKING TOOLKIT
• Practice ManagerPractice Manager
NoNo BenchmarkBenchmark EvidenceEvidence GuidanceGuidance1.21.2 Enhanced depression services Enhanced depression services
should be provided by all should be provided by all primary care teams and primary care teams and rewarded within the Quality rewarded within the Quality Outcomes FrameworkOutcomes Framework
QOF Contract for QOF Contract for enhanced servicesenhanced services
Inspect Inspect specification. specification. Check Check register, register, annual annual reviews, reviews, relevant relevant auditsaudits
2.22.2 Primary care depression Primary care depression services should support and services should support and utilise guidelines which have utilise guidelines which have been modified for local been modified for local circumstances (NICE)circumstances (NICE)
Guidelines & Guidelines & ProtocolsProtocols
Inspect Inspect guidelines & guidelines & protocols protocols followed to followed to identify, identify, manage, manage, treat and treat and referrefer
BENCHMARKING TOOLKITBENCHMARKING TOOLKIT
• GPs, Nurses, Health VisitorsGPs, Nurses, Health Visitors
NoNo BenchmarkBenchmark EvidenceEvidence GuidanceGuidance8.7 8.7 Protected study time Protected study time
should be available to should be available to primary care primary care practitioners to allow for practitioners to allow for training and updates in training and updates in managing depressionmanaging depression
Courses & updatesCourses & updates
Training& education Training& education records records
Interview pc Interview pc practitionerspractitioners
Describe any Describe any protected study protected study time for time for depression depression management. If management. If none, what are none, what are the main the main barriers? barriers?
15.215.2 Structured assessments Structured assessments should be completed by should be completed by primary care primary care practitioners using practitioners using validated rating validated rating scales/tools to diagnose scales/tools to diagnose depression (PHQ-9, HAD, depression (PHQ-9, HAD, EPNS)EPNS)
Assessment Assessment policy/protocolspolicy/protocols
Interview pc Interview pc practitionerspractitioners
Describe how Describe how you carry out an you carry out an assessment?assessment?
What screening What screening tools do you use?tools do you use?
FINDINGSFINDINGS
• 42 primary care professionals 42 primary care professionals • eight primary care practiceseight primary care practices• 2 from each of the Board areas. 2 from each of the Board areas. • This included This included • GPs (n=8), practice managers (n=8), practice GPs (n=8), practice managers (n=8), practice
nurses (n=8), nurse practitioners (n=2), nurses (n=8), nurse practitioners (n=2), health visitors (n=8) & CMHNs (n=8)health visitors (n=8) & CMHNs (n=8)
Primary care nurses view the provision of depression care as part ofPrimary care nurses view the provision of depression care as part of
their role:their role:
• all practice nurses (87.5%, n=7) and one nurse practitioner (50%) reported all practice nurses (87.5%, n=7) and one nurse practitioner (50%) reported that they provided a limited role in the care of patients with depression and did that they provided a limited role in the care of patients with depression and did not view further depression care as part of their current rolenot view further depression care as part of their current role
• These views reflected the responses from three quarters of the GPs (n=6) These views reflected the responses from three quarters of the GPs (n=6) interviewed. They also viewed practice nurses and nurse practitioners as interviewed. They also viewed practice nurses and nurse practitioners as having a limited role in the care of patients with depression. They suggested having a limited role in the care of patients with depression. They suggested that mental health nursing services should be provided by the Trusts rather that mental health nursing services should be provided by the Trusts rather that GPs. that GPs.
• Potential barriers perceived by practice nurses and nurse practitioners Potential barriers perceived by practice nurses and nurse practitioners preventing greater involvement in depression care included insufficient time preventing greater involvement in depression care included insufficient time (70%, n=7); a lack of knowledge and confidence (70%, n=7) and a lack of GP (70%, n=7); a lack of knowledge and confidence (70%, n=7) and a lack of GP support (80%, n=8). support (80%, n=8).
There are adequate levels of primary care nurses to enable effectiveThere are adequate levels of primary care nurses to enable effective
involvement in depression services:involvement in depression services:• Three quarters of health visitors (n=6) reported that they felt current levels were Three quarters of health visitors (n=6) reported that they felt current levels were
inadequate to deal with post natal depression due to current work pressures.inadequate to deal with post natal depression due to current work pressures.• All practice nurses (n=8) and nurse practitioners (n=2) interviewed reported All practice nurses (n=8) and nurse practitioners (n=2) interviewed reported
inadequate numbers to enable them to take on new roles in depression care. inadequate numbers to enable them to take on new roles in depression care. • All CMHNs (n=8) suggested that current levels of primary care nurses were All CMHNs (n=8) suggested that current levels of primary care nurses were
inadequate to deal with the high prevalence of depression in primary care. Six inadequate to deal with the high prevalence of depression in primary care. Six (75%) CMHNs indicated that they were being referred patients with less serious (75%) CMHNs indicated that they were being referred patients with less serious levels of depression who they thought should be managed by practice nurses. Five levels of depression who they thought should be managed by practice nurses. Five (62.5%) reported that more CMHNs or mental health nurses dedicated to primary (62.5%) reported that more CMHNs or mental health nurses dedicated to primary care were needed to ensure patients were treated as early as possible following a care were needed to ensure patients were treated as early as possible following a diagnosis of depression. Concerns were expressed relating to a possible dilution of diagnosis of depression. Concerns were expressed relating to a possible dilution of the CMHN role and diversion of resources for the care of people with severe the CMHN role and diversion of resources for the care of people with severe mental illness due to the demands of a group of people described as less seriously mental illness due to the demands of a group of people described as less seriously ill. ill.
Alternative service delivery models are used by primary Alternative service delivery models are used by primary care nurses to support patients with depression:care nurses to support patients with depression:Most practice nurses (75%, n=6) and all nurses practitioners (n=2) interviewed Most practice nurses (75%, n=6) and all nurses practitioners (n=2) interviewed referred to face-to-face consultations at the practice. Services provided within referred to face-to-face consultations at the practice. Services provided within these consultations included, health promotion, basic screening, provision of these consultations included, health promotion, basic screening, provision of information and advice and referral to the GP for follow up if appropriate. The information and advice and referral to the GP for follow up if appropriate. The two practice nurses (25%) reported using telephone follow up, but this was only two practice nurses (25%) reported using telephone follow up, but this was only provided occasionally. provided occasionally.
Six (75%) CMHNs reported that their main method of service delivery involved Six (75%) CMHNs reported that their main method of service delivery involved outpatient appointments or home visits. However, the CMHN attached to outpatient appointments or home visits. However, the CMHN attached to primary care and one other CMHN, who was employed by a community mental primary care and one other CMHN, who was employed by a community mental health trust, reported that they provided mental health triage as an alternative health trust, reported that they provided mental health triage as an alternative method of service delivery.method of service delivery.
• The main barriers perceived by participants preventing the use The main barriers perceived by participants preventing the use of alternative service delivery models include the following: a of alternative service delivery models include the following: a lack of opportunity for primary care nurses to be involved in lack of opportunity for primary care nurses to be involved in depression care (26.9% n=7); a lack of knowledge of available depression care (26.9% n=7); a lack of knowledge of available models (69.2%, n=18); funding and resources to lead and models (69.2%, n=18); funding and resources to lead and develop new models within primary care (80.7%, n=21); develop new models within primary care (80.7%, n=21); support from GPs and managers (88.4%, n=23); and a lack of support from GPs and managers (88.4%, n=23); and a lack of relevant personnel to supervise specific programmes, for relevant personnel to supervise specific programmes, for example, computer based therapy programmes (46.1%, n=12). example, computer based therapy programmes (46.1%, n=12).
• Primary care nurses are able to carry out a basic Primary care nurses are able to carry out a basic assessment to detect depressionassessment to detect depression
• Primary care nurses have knowledge of the causes, Primary care nurses have knowledge of the causes, symptoms of depression and influences of co-morbiditysymptoms of depression and influences of co-morbidity
• Primary care nurses have knowledge of relevant local Primary care nurses have knowledge of relevant local statutory, voluntary and private services for patients statutory, voluntary and private services for patients with depressionwith depression
• Primary care nurses have knowledge of local Primary care nurses have knowledge of local guidelines/protocols for drug treatments and guidelines/protocols for drug treatments and therapeutic doses/side effectstherapeutic doses/side effects
• Primary care nurses are competent at assessing suicide Primary care nurses are competent at assessing suicide risk risk
• Primary care nurses have an identified level of Primary care nurses have an identified level of depression training and competencydepression training and competency
• There is regular continuous professional development There is regular continuous professional development (CPD) for primary care nurses on the recognition and (CPD) for primary care nurses on the recognition and management of depressionmanagement of depression
• most practice nurses (87.5%, n=7), nurse practitioners (100%, n=2), health most practice nurses (87.5%, n=7), nurse practitioners (100%, n=2), health visitors (63%, n=5) and CMHNs (75%, n=6) reported a lack of regular visitors (63%, n=5) and CMHNs (75%, n=6) reported a lack of regular CPD on the recognition and management of depression. Barriers identified CPD on the recognition and management of depression. Barriers identified included lack of time, support from management and availability of included lack of time, support from management and availability of courses. courses.
• Protocols for the recognition, treatment, management Protocols for the recognition, treatment, management and referral of patients with depression are used by and referral of patients with depression are used by primary care nursesprimary care nurses
A range of evidence based treatment interventions areA range of evidence based treatment interventions are
provided by primary care nurses to patients withprovided by primary care nurses to patients with
depressiondepression• Three quarters of practice nurses (n=6) and all nurse practitioners Three quarters of practice nurses (n=6) and all nurse practitioners
(n=2) saw their most important treatment intervention as listening (n=2) saw their most important treatment intervention as listening to patients and letting them discuss their worries or problems. The to patients and letting them discuss their worries or problems. The other relevant treatment interventions most commonly reported other relevant treatment interventions most commonly reported included basic counselling (40%, n=4) and referral to the GP (90%, included basic counselling (40%, n=4) and referral to the GP (90%, n=9). n=9).
• The treatment interventions CMHNs reported using included case The treatment interventions CMHNs reported using included case management (62.5%, n=5); marital, bereavement and general management (62.5%, n=5); marital, bereavement and general counselling (75%, n=6); psychosocial interventions (50%, n=4); counselling (75%, n=6); psychosocial interventions (50%, n=4); anxiety management (50%, n=4) and CBT (25%, n=2). anxiety management (50%, n=4) and CBT (25%, n=2).
Summary of benchmarks met by each practiceSummary of benchmarks met by each practice
Practice Benchmarks Met Benchmarks Not Met
Practice A 42(58%) 31 (42%)
Practice B39 (53%) 34 (47%)
Practice C45 (61%) 28 (39%)
Practice D37 (51%) 36 (49%)
Practice E36 (49%) 37 (51%)
Practice F37 (51%) 36 (49%)
Practice G41 (56%) 32 (44%)
Practice H47 (64%) 26 (36%)
RecommendationsRecommendations
Investment/enhancedInvestment/enhanced
Priority Priority
Primary care team/leadPrimary care team/lead
All practitioners All practitioners
Early interventionEarly intervention
Training/timeTraining/time
Partnerships/protocolsPartnerships/protocols
SERVICE MODELSERVICE MODEL
PR IM AR Y C AR E TEAM W O R KER S
S E LF H E LP
GRO U PS
VO LU N T A RY
GRO U PS
G ap s - E arly D e tec tion /Trea tm en t/M an ag em en t
C h ild & A d o lescen t P sych ia try E a tin g D isord ers
SEC O N D AR Y C AR E TEAM W O R KER S
P R A C TIC EN U R S E S
C O M M U N ITYM ID W IV E S
C H IL D & A D O L E S C E N TTE A M
P S Y C H O L O G IS T/P S Y C H O TH E R A P IS T
O U TR E A C HC P N
P S Y C H IA TR IS T O U TR E A C HS O C IA L W O R K E R
A D D IC TIO NU N IT
R E F E R R A L TOS E C O N D A R Y TE A M
A S S E S S M E N T
G P 'S H E A L THV IS ITO R S
D IS TR IC TN U R S E S
NEW MODELNEW MODELPR IM AR Y C AR E TEAM W O R KER S
S E L F H E L P
GRO U PS
V O L U N T A RY
GRO U PS
SEC O N D AR Y C AR E TEAM W O R KER S
P R A C TIC EN U R S E S
C O M M U N ITYM ID W IV E S
O U T O F H O U R S D O CA & E L IA S O N
C H IL D & A D O L E S C E N TTE A M
P S Y C H O L O G IS T/P S Y C H O TH E R A P IS T
C P N P S Y C H IA TR IS T S O C IA L W O R K E R A D D IC TIO NU N IT
R E F E R R A L
M A N A G E D B Y P R IM A R YC A R E TE A M
O U TR E A C HP S W
A S S E S S M E N T
P R IM A R Y M E N TA LH E A L TH N U R S E
G P 's H E A L THV IS ITO R S
D IS TR IC TN U R S E S
