Applying a Bauhaus design approach to conceptualize an integrated system of mental health care: Lessons from a large urban hospital

The bottom tier of the pyramid illustrates the high percentage of mental health issues and needs that are cared for with lower intensity services. Models of care for this tier include self-care and self-management. Peer support is also an emerging model of care and is available in some regions.

Within Canada, a large proportion of mental health issues are treated within a primary care setting. In fact, it has been found that over 50% of Canadians use healthcare services with their primary care physician for issues related to mental health (Kates et al. 2016). The WHO recently released a report entitled “Integrating mental health into primary care: A global perspective” (Greenhalgh 2009), which highlighted reasons for mental health being treated in primary care facilities. These include frequent co-occurrence of mental and physical difficulties; increased availability of access to primary care for mental health; and primary care being less expensive than specialized care within a hospital system. For most people, a primary care physician is their first point of contact for health care. Strikingly, it has been found that between 20% and 76% of patients who commit suicide had visited their primary care physician the month before (Luoma et al. 2002; Carrigan and Lynch 2003).

Loeb et al. (2012) investigated the viewpoints of primary care physicians regarding patient, physician, and system factors impacting care for patients presenting with mental health and medical issues. Physicians indicated that the type of mental illness, acuity of presentation, and patient communication style are all important issues. Primary care physicians also wanted enhanced training regarding mental health issues and to take part in collaborative care models (Loeb et al. 2012). Patients described frustration regarding issues such as inadequate resources and disjointed care. Given the high incidence of mental illness within primary care, this study provides a compelling narrative of areas for improvement to enable enhanced provision of mental health services within primary care settings.

Different primary care models have been well established, including the traditional roles of general practitioners and family physicians (i.e., primary care physicians in the USA), and paediatricians for children and adolescents. In 2005, 184 Family Health Teams (FHTs) were created in Ontario to broaden family healthcare delivery (Ontario Ministry of Health and Long-Term Care 2016b). As described by the Ontario Ministry of Health and Long-Term Care (2016b), FHTs include family physicians, nurse practitioners, registered nurses, social workers, dietitians, and occasionally other specialized professionals. Currently, over three million Ontarians receive care through FHTs in 200 communities (Ontario Ministry of Health and Long-Term Care 2016b). Integrating mental health within primary care also de-stigmatizes mental illness by preventing the segregation that may emerge from treatment in a standalone mental hospital model (Falk and Allebeck 2002; WHO 2003). Thus, FHT models play an important role within a Bauhaus model of health care, as patient needs can be met along the continuum of services that are provided.

We have also listed specialists in the primary care tier based on their clinical functioning and activity rather than on their level of training. Specialists fulfilling mid- or highest-needs clinical roles are listed again in tier 2 or 3, although we use the term “consultant” or “hospitalist” to distinguish their level of functionality within those tiers. Solo practitioner (i.e., often community office-based) specialists, such as psychiatrists, private practice psychologists, and other allied health therapists treat individuals presenting with a variety of mental health issues that are often lower acuity, currently stable, or optimized. Many solo practitioner psychiatrists are providing psychotherapy and low intensity services to a fairly stable, less acute patient population. In this regard, despite training and certification as medical specialists, they are meeting patient clinical needs at the lower end of their initial clinical training potential and functioning more in a primary mental health care capacity. We recognize that this statement is likely controversial and possibly upsetting to the profession. But, based on the principles of Bauhaus design, this reflects the current clinical function of these physicians relative to the broader health system and population. Within a Bauhaus-designed healthcare system, specialists would be working at the top level of their skill set (Grumbach 2009). This would allow for better matching of the needs of patients to services available.

Transitional care services can bridge between the highest-level involvement of acute hospital emergency, inpatient and complex specialized care for severe mental illness (SMI), and lower needs services (e.g., primary care). Tier 2 models include acute ambulatory programs as well as partial hospitalization programs (Granello et al. 1999; Yanos et al. 2009; Thatte et al. 2013; Association for Ambulatory Behavioral Healthcare 2014; Lenz et al. 2014). Partial hospitalization programs were created in the 1930s and, since that time, have conventionally been viewed as an alternative to inpatient hospitalization for individuals presenting with acute psychiatric symptoms not requiring overnight stay or 24-hour safety monitoring (Marshall 2003). These services are very much in keeping with the Bauhaus philosophy of patient needs being matched by appropriate care.

Typically, transitional care services are delivered to a more acute patient population than individuals treated within our lower models of service tier. At NYGH, we have used the name Acute Ambulatory Integrated Transitional Care to describe our tier 2 moderate needs models of care. When conceptualizing this tier of service, we moved from the dominant (but limited) binomial planning conceptual model (i.e., hospital vs. community) to a three-tier model. These services were developed as a response to the need to articulate the function of outpatient mental health services within an acute general hospital and differentiate them from the lower level tier 1. Central health planners believed that only inpatient care should be provided by a hospital with other services divested and provided in “the community.” These types of transitional services are geared towards patient needs that are no longer emergent or most acute, but sub-acute or post-acute, as the individual has not fully stabilized. These services exceed those provided in primary care settings.

The services aggregated and co-located within NYGH include the following: telemedicine consultation (Hilty et al. 2013); collaborative shared care (Kates et al. 2011); reversed shared care (Ungar et al. 2013); outpatient psychiatry; Partial Hospitalization Day Programs; mental health and justice treatment and support services; and community legal aid services and addiction program for adults and transitional aged youth. Low-intensity case management for individuals receiving these services is also depicted in tier 2 of our model (see Fig. 1).

Although our move from a binomial to a trinomial model might be interpreted as being conceptualized from an institutional perspective, we still believe that it holds true to the philosophy of Bauhaus design. Given that patient needs were not being met in our organization (where options were either inpatient services or community resources), a service needed to be created that better addressed patient needs (i.e., form follows function). Many individuals with psychiatric issues require something that is “in between” higher and lower acuity. This type of model can be applied within other acute ambulatory hospitals as well, taking into account the patient profile and overarching needs.

As stated earlier, we acknowledge the role of psychiatrists as medical specialists. However, to better differentiate their functional roles within the healthcare system, we use a novel term “psychiatric hospitalist” (Society of Hospital Medicine 2016) to describe those who provide care to patients with more complex and acute care needs, such as those seen within tier 2 ambulatory outpatient care, consultation-liaison services, partial hospitalization, and (or) tier 3 inpatient care. Psychiatrists functioning as hospitalists in this mid-tier often perform multiple clinical roles. These practitioners often have privileges at a hospital and have on-call duties, allowing them to more seamlessly meet patient care needs, such as facilitating inpatient admission. This is all in keeping with the continuum of services required by patients presenting with more acute conditions.

The top of our pyramid reflects services devoted to patients with the highest acuity and intensity of needs. As illustrated in Fig. 1, we believe that both acute care general hospitals (both “community” hospitals and academic health science centres) and specialty/tertiary care hospitals are providing care within this peak tier, with the latter assuming a greater role with SMI and residential care needs. One such model of care within this tier is assertive community treatment (ACT) teams. These teams can be part of the hospital but provide high-intensity specialized services to patients with long-term needs in the community (including home visits) (Ziguras and Stuart 2000; Falk and Allebeck 2002; Nelson et al. 2007; Franx et al. 2008; Canadian Mental Health Association Toronto 2015) given that this is where the need resides. Other models and service care delivery in this tier include psychiatric emergency room services, inpatient services, medically supported substance detoxification, and long-term care and support for SMI.

We invite the reader to reflect on how our Bauhaus approach may differ from the current organization of mental health services. For example, general hospitals are often categorized as “secondary” care and specialty mental hospitals as “tertiary” or “quaternary” care. Yet, functionally, we believe that they are both providing services of high acuity, intensity, and risk. Given that the services delivered within these types of institutions can sometimes blur, we have depicted a broken diagonal line in the model of services delivered to patients functioning in the high complex tier (Fig. 1). Of course, some services are only offered in specialized tertiary care facilities, such as forensic services or those for individuals with developmental disabilities. Therefore, although both general hospitals and specialized hospitals are providing care to acute high-risk patients, specialized hospitals and services are likely targeting a different degree of complexity. Patients that are highly acute presenting to a general hospital may at times be equally or more resource demanding than patients at specialized tertiary care services. Thus, both general hospitals and specialized services participate and are likely working at the top of their skill set when treating patients in tier 3—another illustration of a Bauhaus principle.

With each tier and for each model of care, enablers must be in place to deliver services. For example, all tiers require skilled professionals, supporting legislation and policy, adequate physical infrastructure, and equitable outcome-based remuneration and funding models. More specifically, for the low-needs models of care, enablers might include self-management tools for patients and families, continuing education, and updated clinical tools. For the moderate transitional needs models of care, enablers might include a multidisciplinary allied ambulatory health team to provide care and the facilities to co-locate these services (Curran et al. 2006), telehealth infrastructure, resources for partial hospitalization programs, and professional and hospital credentialing to support the functioning of health providers. For the high complex needs tier, enablers would include the following: acute general hospital emergency care with adequate patient care areas; acute care psychiatric inpatient beds; medically supported substance detoxification; longer term care inpatient beds and care teams; resources such as housing, finances and vocational rehabilitation; policy and legislation for disability and involuntary care; and high-intensity case management. Health informatics is an important means of enabling widespread access to patient information and collaborative integrated communication within all tiers and has been described within each section.

For each of these forms of service delivery, remuneration models and support for providers should recognize differences in training, skill set, and risk incurred in keeping with the principles of interprofessional education (IPE) in clarifying roles and responsibilities (Curran et al. 2006). Unfortunately, the current physician and health system funding and remuneration models inequitably under-resource neuropsychiatric conditions (Patel et al. 2016). Furthermore, current remuneration models within the Ontario Health Insurance Plan (OHIP) fee structure often fail to proportionally recognize differences between tier 1 and tier 3 care provision, and low-needs service providers often earn the same income or very close to that of high-intensity providers as part of a historical fee structure. This might be an area of re-evaluation for future service planners.

Within each tier and model of care, we propose the development of provider accountabilities. Our intention is not to negate healthcare provider professional judgement or autonomy. However, professional freedoms are not absolute, and principles of social responsibility within a publicly funded health system with limited resources require culpability. For lower needs providers, such as primary care physicians, this might include initiating a treatment trial for low-complex conditions before referring to mid-tier providers. In addition, primary care providers should resume the ongoing care of a person with a mental health condition once adequately stabilized or recovered from moderate- or high-intensity models of care. As described, collaborative care models can help facilitate ongoing consultation, as needed. Specialist physicians providing low-acuity services to a small number of patients in an ongoing long-term manner may need to be challenged given extensive wait lists and burgeoning demands on access to mental health services. Similarly, moderate-tier care providers, such as psychiatric hospitalists, need to ensure timely access to consultation and urgent assessment, and they need to be available for rapid backup and support to primary care providers. In addition, ensuring a timely transition of patients to a lower level of care is also important to avoid patients being seen for an extended period of time within a hospital or unnecessarily under the care of a specialist. Interestingly, the role of primary care versus specialty care in terms of provision and transition of care is clear for most areas of medicine but less clear in mental health. Thus, clarifying interprofessional and interorganizational roles and responsibilities is a best practice of interprofessional education/interprofessional care (IPE/IPC) and effective collaborative care.

Quality-of-care initiatives also, of course, align with accountabilities. The Institute of Medicine’s (IOM) six principles of quality of care can guide the development of accountabilities for providers and health organizations (Institute of Medicine Committee on Quality of Health Care in America 2001). These principles stipulate that delivery of care must be safe, effective, patient centred, timely, efficient, and equitable. We would argue that equitable care is key to overcoming hidden curriculum human factors, such as stigma regarding mental illness that may impede a rational mental health care system or assumption of accountabilities by providers (Knaak et al. 2015; Ungar and Knaak 2013). Implementation of international quality-of-care metrics across mental health services would allow for a better understanding of outcome and recovery. A recent Canadian study found that “mental health high-cost patients”, defined as those that acquire 50% or more of their total healthcare costs within the mental health domain, use 30% more healthcare expenses per capita compared with non-mental health high-cost patients (de Oliveira et al. 2016). Furthermore, these health costs primarily resulted from psychiatric hospitalizations (de Oliveira et al. 2016). Between 2003 and 2004, it was found that 37% of patients with a mental illness were readmitted to an acute care hospital within 1 year of being discharged in Canada as compared to 27.3% of patients with no mental illness (Canadian Institute for Health Information 2006; Madi et al. 2007). Similarly, within the USA one study cited a 22.3% rate of readmission for individuals with schizophrenia and other psychotic disorders within 1 year of discharge (Elixhauser and Steiner 2013). Implementation of quality-of-care metrics across psychiatric care internationally has been suggested to aid with these difficulties (Hermann et al. 2006; Fisher et al. 2013). Fisher et al. (2013) describe the frequency of outcome metrics as compared with recovery metrics—possibly due to the dearth of measurable indicators within the latter domain. Nevertheless, understanding what contributes to long-term recovery is essential to improving the mental health system and ensuring individuals achieve periods of wellness for as long as possible. Overall, we believe that the purpose of accountabilities is to improve the system and ensure best practice models of care.