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5 |
Continuity |
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Development of a discharge plan addressing monitoring and follow-up actions for adults with low prevalence psychiatric disorders (e.g., schizophrenia) who have received specialist mental care and have been transferred back to primary health care.
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Display Detailed
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7 |
Continuity |
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For individuals being treated with antidepressants, establish and maintain follow-up contact (e.g. office visits, phone calls, or other) at intervals tailored to their mental health status.
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Display Detailed
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14 |
Patients with Mood Disorders |
Continuity, Patient-Centeredness
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Frequency of contact for people with major depression should be weekly for severe depressive symptoms; every 2-4 weeks if mild or moderate symptoms are present.
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Display Detailed
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15 |
Children |
Continuity, Family Involvement
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One or more visits with adult caregiver of child (13 years old or younger) within 3 months of the child being treated for a psychiatric or substance-related disorder.
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Display Detailed
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24 |
Continuity |
Comprehensiveness, Efficiency
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Practice participates in a network (including memorandum of understanding) with other services to provide integrated care to clients.
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Display Detailed
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29 |
Continuity |
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For mental health or substance abuse hospital discharges: average number of days between hospital discharge and follow-up with a primary health care provider.
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Display Detailed
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30 |
Patients with Psychosis |
Continuity, Prevention
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Relapse monitoring plan for people in a stable phase of schizophrenia.
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Display Detailed
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33 |
Shared Care |
Continuity, Emergency Services
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Liaison protocols/memorandum of understanding exist to coordinate emergency service provision between primary mental health care services, specialized mental health services, crisis lines, hospital emergency departments, and the police.
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Display Detailed
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36 |
Emergency Services |
Accessibility, Continuity
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Systematic assessment of gaps in service delivery for patients requiring mental health care out of standard office hours.
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Display Detailed
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52 |
Patients with Mood Disorders |
Continuity
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Use of evidence-based relapse prevention interventions (e.g., depression prevention specialist follow-up phone calls) for patients who have recovered from major depression.
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Display Detailed
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56 |
Psychotherapy |
Patients with Mood Disorders, Continuity
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Where patients have responded to a course of individual cognitive behavioural therapy (CBT), consideration should be given to follow-up sessions, which typically consist of 2 to 4 sessions over 12 months.
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Display Detailed
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62 |
Competence |
Continuity, Accessibility
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The provision of telephone support by appropriately trained members of the primary health care team - informed by clear treatment protocols - should be considered for all patients, in particular for the monitoring of anti depressant medication regimes.
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Display Detailed
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69 |
Outreach Services |
Continuity, Accessibility
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Referrals to community supports are accepted from multiple sources including professionals, nonprofit and other service agencies, homeless shelters, employment services and self-referrals. Pro-active outreach/referral finding is part of this process.
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Display Detailed
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72 |
Patient-Centeredness |
Quality and Safety, Continuity
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Percentage of all patients with a comprehensive and current treatment plan on the health record with major review occurring no less frequently than at 6 month intervals.
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Display Detailed
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73 |
Psychotherapy |
Continuity, Patient-Centeredness
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Consider early referral for psychotherapy if psychological and psychosocial issues are prominent and/or patient requests it. Referral for psychotherapy may have maximum benefit as symptom severity diminishes.
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Display Detailed
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82 |
Outreach Services |
Patients with Acute Conditions, Continuity
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The primary mental health care team works jointly with local agencies to ensure home-based crisis services are available on a 24/7 basis (e.g. through PMHC staff providing some portion of clinical coverage for the service)
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Display Detailed
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83 |
Outreach Services |
Patients with Acute Conditions, Continuity
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Crisis resolution and home treatment teams should be used as a means to manage crises for service users to augment the services provided by early intervention services and assertive outreach teams to individuals with severe mental illnesses, as well as a means of delivering high-quality acute care.
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Display Detailed
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86 |
Patients with Psychosis |
Shared Care, Continuity
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The decision to refer a service user from primary health care to specialized mental health services should take into account the views of the service user and consider: treatment adherence problems, a poor response to treatment, co-morbid substance misuse, increased level of risk to self or others, a person with schizophrenia first joining a general practitioner practice list, rehabilitation assessment is required.
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Display Detailed
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89 |
Patients with Acute Conditions |
Comprehensiveness, Continuity
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Acute day hospitals should be considered as a clinical and cost-effective option for the provision of acute care, both as an alternative to acute admission to inpatient care and to facilitate early discharge from inpatient care.
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Display Detailed
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90 |
Continuity |
Health Behaviors
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Mental health appointment no show rate.
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Display Detailed
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91 |
Equity |
Continuity, Acceptability
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Mental health follow-up rates (e.g., repeat visit after initial visit) across racial/ethnic groups.
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Display Detailed
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99 |
Health Conditions |
Continuity
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Use of a brief scale (i.e., the Threshold Assessment Grid (TAG)) to determine immediacy and intensity of specialized mental health services needed by a patient in primary health care based on their current mental status.
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Display Detailed
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110 |
Continuity |
Accessibility, Financial Management
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Existence of a fee-item within the fee-for-service schedule that reimburses physicians for case consultation/case management activities.
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Display Detailed
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115 |
Patients with Comorbid Conditions |
Service Outputs, Continuity
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Percentage of people discharged from hospital with a dual diagnosis (psychiatric and substance abuse) who receive 4 or more mental health visits and 4 or more substance misuse visits in a 12-month period post-discharge.
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Display Detailed
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119 |
Accessibility |
Acceptability, Continuity
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Use of a standardized but brief scale (i.e., the Primary Care Assessment Tool (PCAT) access subscale) to measure access to primary health care.
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Display Detailed
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120 |
Shared Care |
Continuity
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Percent of total primary health care physician and secondary mental health care physician Full Time Equivalents in a region involved in collaborative care.
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Display Detailed
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127 |
Accessibility |
Continuity, Patients with Chronic Conditions
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Percentage of patients who have received reminders a few days before their next appointment.
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Display Detailed
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131 |
Community Health Care Centre |
Shared Care, Continuity
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Perception of other community organizations regarding presence and effectiveness of collaboration with CHC.
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Display Detailed
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135 |
Rehabilitation |
Continuity, Human Function
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Percentage of individuals receiving a comprehensive assessment of occupational status/vocational potential and aspirations at least annually.
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Display Detailed
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137 |
Shared Care |
Continuity, Quality and Safety
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Use of the Primary Health Care Team questionnaire, to evaluate the effectiveness of teamwork amongst providers in collaborative primary health care.
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Display Detailed
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146 |
Continuity |
Accessibility, Information Management
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Percent of services used by patients captured on a common Electronic Health Record.
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Display Detailed
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158 |
Continuity |
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Use of common administrative data based measures of concentration of care with different providers (e.g., Known provider continuity (K index), Modified Continuity Index (MMCI)).
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Display Detailed
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