Nadiya Sunderji

A framework for telepsychiatric training and e-health: Competency-based education, evaluation and implications

Abstract Telepsychiatry (TP; video; synchronous) is effective, well received and a standard way to practice. Best practices in TP education, but not its desired outcomes, have been published. This paper proposes competencies for trainees and clinicians, with TP situated within the broader landscape of e-mental health (e-MH) care. TP competencies are organized using the US Accreditation Council of Graduate Medical Education framework, with input from the CanMEDS framework. Teaching and assessment methods are aligned with target competencies, learning contexts, and evaluation options. Case examples help to apply concepts to clinical and institutional contexts. Competencies can be identified, measured and evaluated. Novice or advanced beginner, competent/proficient, and expert levels were outlined. Andragogical (i.e. pedagogical) methods are used in clinical care, seminar, and other educational contexts. Cross-sectional and longitudinal evaluation using quantitative and qualitative measures promotes skills development via iterative feedback from patients, trainees, and faculty staff. TP and e-MH care significantly overlap, such that institutional leaders may use a common approach for change management and an e-platform to prioritize resources. TP training and assessment methods need to be implemented and evaluated. Institutional approaches to patient care, education, faculty development, and funding also need to be studied.

Telepsychiatry in Graduate Medical Education: A Narrative Review

ObjectiveTelepsychiatry is an innovation that addresses disparities in access to care. Despite rigorous clinical research demonstrating its equivalence and effectiveness relative to face-to-face care, many providers are unfamiliar with this technology. Training residents in telepsychiatry is critical to building mental health care capacity in rural and underserviced communities. However, many questions remain regarding the competencies that future psychiatrists require with respect to telepsychiatry, and technology generally, and regarding pedagogical approaches that will promote their attainment. This literature review aims to elucidate evidence-based approaches to developing residents’ competence to practice telepsychiatry.MethodsThe authors conducted a literature search of telepsychiatry training for psychiatry residents. The authors searched MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane, and ERIC using subject headings and keywords; and hand searched reference lists, forward citations of relevant articles, and tables of contents of relevant journals. Articles were included if they were in English, discussed teaching psychiatry residents to provide direct or indirect clinical care via real-time videoconferencing technology, and were published by January 2014.ResultsIn total, 215 unique references yielded 20 relevant publications. The literature on graduate training in telepsychiatry is sparse, heterogeneous, and primarily descriptive. Even brief learning experiences may increase the likelihood that residents will incorporate telepsychiatry into their future practice. Training should address competencies that are (1) technical, (2) collaborative/interprofessional, and (3) administrative. Training typically consists of supervised provision of clinical care to build modality-specific clinical skills and may also include didactic teaching to provide health systems and transcultural and medicolegal perspectives.ConclusionsA more evidence-based approach to telepsychiatry training is needed, including an assessment of residents’ learning needs, use of multiple learning modalities, and evaluations of educational curricula. Pedagogically sound curriculum development and evaluation of postgraduate education in telepsychiatry could promote social accountability, cultural competence, interprofessional care, and, ultimately, improve clinical outcomes.

Integrated Care Training in Canada: Challenges and Future Directions

To the Editor: The August 2015 series of articles on educating residents for the practice of integrated care is timely and important [1, 2]. In Canada, all psychiatry residents are exposed to an integrated care rotation (also known as “shared care” or “collaborative care”) during their senior years as a result of a mandatory training requirement by the Royal College of Physicians and Surgeons of Canada (RCPSC) in effect since 2011 [3]. This is congruent with broader shifts in medical education that aim to increase physicians’ responsiveness to population and community health needs and contribution to healthcare system sustainability [4]. However, Canadian psychiatry residency programs have faced challenges in interpreting and implementing the new training requirement. We conducted a national survey of Canadian psychiatry residency program directors in Spring 2011 (n=13, a 81 % response rate) [5]. They identified a lack of guidance regarding the intended outcomes of integrated care training and implementation barriers, including lack of training sites (70 %), lack of supervisors (70 %), and the need for faculty development (62 %). Unsurprisingly, a 2013 curriculum evaluation at one residency program revealed substantial discordance between the curricula planned by educators, implemented by teachers, and experienced by residents. The RCPSC responded to the program directors’ concerns in 2014 by reducing the training requirement from a minimum of 2 months to 1 month (or longitudinal equivalent). Although the revision may alleviate program directors’ concerns about maintaining their programs’ accreditation, a time-based requirement was and still is merely an outcome of convenience, and there remains a gap in guiding programs on how best to promote resident attainment of competence in integrated care. At present, programs offer experiences that vary widely in duration, format, and setting, based on idiosyncratic interpretations of the goals of training and local feasibility considerations. Given the identified challenges in implementing nationwide training, the RCPSC is now questioning the quality and consistency of integrated training in Canada in its current forms. However, integrated care models are complex, inherently context sensitive, and evolving over time—traits that do not lend themselves well to standardization of training. If we are to continue with this important innovation in psychiatric education, then we will need to clearly define the purpose and intended outcomes of integrated care training and suitable settings for a workplace curriculum in integrated care. Indeed, this may facilitate resident training in diverse settings while still demonstrating a common standard of competence. Canada has a publicly funded healthcare system with a strong foundation of primary care and public health. Residents require exposure to community and primary care settings during training in order to understand the continuum of acute and community-based services. Integrated care training affords an ideal opportunity for such exposure in a variety of settings, through which residents can contribute to mental health care delivery and capacity building beyond academic hospitals. Residents may attain competencies in multiple domains concurrently, for example, through working with nursing homes, schools, child protection services, hospices, or case management agencies. Such experiences enable residents to learn how to communicate effectively and form collaborative interprofessional relationships to support co-management of patients. Residents will develop skills in knowledge * Nadiya Sunderji sunderjin@smh.ca

Group Day: Experiential Learning About Group Psychotherapy for Psychiatry Residents at University of Toronto

Experiential learning of group therapy training has historically been widely accepted; however, there are few contemporary reports in the literature regarding experiential training groups for mental health professionals (1–6). There are no recent data evaluating such training groups for psychiatry residents. In the absence of such data, residency program directors may view training groups as negative experiences of little value and may believe that residents are disinterested in or opposed to such groups (4). The current article addresses this gap in the literature by examining residents’ experiences of, and considering the potential relevance of, the University of Toronto Department of Psychiatry’s annual experiential “Group Day,” based on 3 years of evaluations completed by participants (N5149).

Can Collaborative Care Cure the Mediocrity of Usual Care for Common Mental Disorders

Despite a 3to 4-fold increase in the use of antidepressant medications, the prevalence of depression and anxiety disorders in Australia, Canada, the United Kingdom, and the United States has remained unchanged over the past 20 years. In the absence of compelling evidence that the incidence of these disorders is on the rise, a natural conclusion is that depressed or anxious patients who could benefit from treatment are still not identified and treated, or that the duration of illness has remained unchanged in those who are treated. This is a striking and troubling finding, considering the known efficacy of antidepressants and psychotherapies. It emphasizes both a well-delineated treatment gap, whereby many patients with depression or anxiety do not receive treatment, and a quality gap whereby those who are treated either do not need to be treated or do not receive effective treatment. Several factors contribute to these gaps. Even knowledgeable and well-intentioned physicians face competing demands, including the need to concurrently address medical comorbidities and social determinants of health, making identification and management of common mental disorders challenging. ‘Usual care’ for these disorders requires both a patient-initiated encounter and the clinician’s subjective impression of the presence of a treatment-responsive condition, leading to delays in the initiation and titration of treatments, high treatment dropout rates, and low recovery rates. A better integration of the care provided by primary care providers and specialists has been advanced as one solution to improve access to care and the quality of the care delivered. Integrated care encompasses models ranging from colocation (mental health providers delivering care within the primary care setting), to shared care (with increased coordination of care through provider-toprovider communication and shared health records), to the collaborative care model (CCM) (also known as ‘chronic care model’). The CCM is a well-established and effective approach to both mental and physical disease management that includes several key elements: 1) teambased care that includes patients as active member of the treatment team and establishes patient-centred goals and care plans; 2) measurement-based care where patient-reported outcomes are monitored using rating scales and treatments are regularly adjusted to reach predefined targets (e.g., a specific depression score corresponding to remission); 3) treatment selection and adjustments based on evidence (encapsulated in algorithms or care pathways) or, in the absence of evidence, expert opinion; and 4) population-based care whereby patients with a target condition are identified via systematic screening, tracked in a clinical registry, and reached proactively if they are disengaging from treatment. In primary care, where most common mental disorders are treated, more than 80 randomized controlled trials (RCTs) have shown that collaborative care is more effective than usual care to improve quality of care processes, clinical outcomes, patient and provider experience, health disparities, and cost-effectiveness. A recent commentary on collaborative care suggested that further RCTs on collaborative care were unnecessary and possibly unethical given the existing body of evidence supporting its implementation.

Using real-time Delphi to develop a consensus on competencies

cross-section of programmes, and developing an oversight committee of cross-disciplinary residents and faculty members to ensure the content remains germane to all incoming residents. Collaborative teamworking by residents and faculty members is the lifeblood of the programme. However, our resident and faculty development teams varied in their work styles. We observed that the teams in which all participants contributed equally produced the most fluid and seamless presentations. Planning styles tended to translate into teaching styles; the most collaborative planning groups admirably modelled interdisciplinary professionalism and teamwork during their sessions. Our challenge will be to maintain effective collaborative strategies with an ever-changing group of resident teachers.

Advancing Integrated Care through Psychiatric Workforce Development: A Systematic Review of Educational Interventions to Train Psychiatrists in Integrated Care

Objective: Integrated or collaborative care is a well-evidenced and widely practiced approach to improve access to high-quality mental health care in primary care and other settings. Psychiatrists require preparation for this emerging type of practice, and such training is now mandatory for Canadian psychiatry residents. However, it is not known how best to mount such training, and in the absence of such knowledge, the quality of training across Canada has suffered. To guide integrated care education nationally, we conducted a systematic review of published and unpublished training programs. Method: We searched journal databases and web-based ‘grey’ literature and contacted all North American psychiatry residency programs known to provide integrated care training. We included educational interventions targeting practicing psychiatrists or psychiatry residents as learners. We critically appraised literature using the Medical Education Research Study Quality Instrument (MERSQI). We described the goals, content, and format of training, as well as outcomes categorized according to Kirkpatrick level of impact. Results: We included 9 published and 5 unpublished educational interventions. Studies were of low to moderate quality and reflected possible publication bias toward favourable outcomes. Programs commonly involved longitudinal clinical experiences for residents, mentoring networks for practicing physicians, or brief didactic experiences and were rarely oriented toward the most empirically supported models of integrated care. Implementation challenges were widespread. Conclusions: Similar to integrated care clinical interventions, integrated care training is important yet difficult to achieve. Educational initiatives could benefit from faculty development, quality improvement to synergistically improve care and training, and stronger evaluation. Systematic review registration number: PROSPERO 2014:CRD42014010295.

Tele-Behavioral Health, Collaborative Care, and Integrated Care: Learning to Leverage Scarce Psychiatric Resources over Distance, Populations, and Time

With significant unmet population health needs for mental health care and a continued shortage of psychiatric providers, future psychiatrists will increasingly need education in new care delivery approaches that address these problems, especially for individual patient care delivery such as telebehavioral health and integrated care. These educational needs can be conceptualized as clinical skills for different modalities of individual patient care and leadership abilities to use systematic approaches to provide population-based care. In this column, we review key learning needs, educational strategies, and available resources to support educators in their curriculum development and implementation activities for the delivery of these emerging approaches to psychiatric care. While there is a growing need to train graduate learners in integrated care(IC)/collaborative care model (CoCM) and tele-behavioral health (TBH), one significant and often overlooked challenge is that faculty members who are called upon to supervise may not themselves have experience or training working in this area. Faculty members require not only the ability to provide these types of care but also the ability to teach, supervise, and assess trainee performance in these areas. Many of the resources we identify as relevant for trainees could also be useful for faculty members starting out in this area. Faculty members could also consider creatively pursuing different professional development opportunities with transferable competencies relevant to new care delivery models based on their individual learning needs and the available educational opportunities in their setting, for example training in the areas of public health, leadership, quality improvement, and/or education scholarship. In this article, we also aim to identify some practical, readily available teaching and assessment resources so that newer faculty can use and/or adapt them without having to “reinvent the wheel.”

Building eHealth and Telepsychiatry Capabilities: Three Educational Reports Across the Learning Continuum

Telepsychiatry and eHealth are evidence-based, cost-effective health care delivery methods that increase access to specialist care, particularly for rural and remote populations [1–3]. Yet, the penetrance of telepsychiatry is uneven and the health system organization to support it is generally underdeveloped [4]. Inadequate postgraduate training in telehealth and eHealth may contribute to this lag. Such training and exposure has the potential to increase interest and skills in telepsychiatry and normalize it as a modality of clinical care. Recent reviews describe the status of telepsychiatry in postgraduate training and highlight the scarcity of literature on the topic and the lack of evaluation of these training programs [ 5–7]. Building on these reviews, and a study assessing resident learning needs in telepsychiatry [8], frameworks have been proposed to delineate competencies in telepsychiatry and eHealth at different stages of training [8–10]. Although these frameworks help define learner competencies, they do not describe teaching and evaluation methods for achieving these competencies. Sunderji, Crawford, and Jovanovic [6] and Glover et al. [7] provide descriptions of programs, but predate the literature on competency development. To address these gaps, we present a pedagogical caseseries across a continuum of skills development, from novice learner to intermediate learner to continuing professional development, drawn from our recent experiences within the University of Toronto, Department of Psychiatry and its residency program, located in Toronto, Ontario, Canada. These experiences align with our Department’s efforts to respond to community needs, build capacity for improved access and quality of mental health care, and prepare future psychiatrists for a rapidly evolving health care system. Each case describes the instructional methods, the rationale and objectives for the activity, the outcomes and evaluation modalities, and considers lessons learned through the implementation process. Pertinent faculty development needs will be addressed throughout the paper given the importance of faculty trained and experienced in the delivery and teaching environment of telehealth. Our aim is to provide a concrete and feasible approach to building eHealth and telepsychiatry capabilities within the context of postgraduate psychiatric training and continuing professional development, as a complement to existing standardized competency frameworks.

Evaluating the Implementation of Integrated Mental Health Care: A Systematic Review to Guide the Development of Quality Measures

OBJECTIVE Although the effectiveness of integrated mental health care has been demonstrated, its implementation in real-world settings is highly variable, may not conform to evidence-based practice, and has rarely been evaluated. Quality indicators can guide improvements in integrated care implementation. However, the literature on indicators for this purpose is limited. This article reports findings from a systematic review of existing measures by which to evaluate integrated care models in primary care settings. METHODS Bibliographic databases and gray literature sources, including academic conference proceedings, were searched to July 2014. Measures used or proposed to evaluate integrated care implementation or outcomes were extracted and critically appraised. A qualitative synthesis was conducted to generate a panel of unique measures and to group these measures into broad domains and specific dimensions of integrated care program performance. RESULTS From 172 literature sources, 1,255 measures were extracted, which were distilled into 148 unique measures. Existing literature frequently reports integrated care program effectiveness vis-à-vis evidence-based care processes and individual clinical outcomes, as well as efficiency (cost-effectiveness) and client satisfaction. No measures of safety of care and few measures of equitability, accessibility, or timeliness of care were located, despite the known benefits of integrated care in several of these areas. CONCLUSIONS To realize the potential for quality measurement to improve integrated care implementation, future measures will need to incorporate domains of quality that are presently unaddressed; microprocesses of care that influence effectiveness, sustainability, and transferability of models of care; and client and health care provider perspectives on meaningful measures of quality.