Introduction: Roughly 30% of the South African population will suffer from a mental disorder in their lifetime (1). Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle-income countries (2), such as South Africa. The bulk of mental health care delivery in South Africa has historically been separated from general health care and centered on specialist care provided at psychiatric hospitals, with little attention to mental health care in the primary setting (3). This is currently perpetuated by the hospicentric Prescribed Minimum Benefits, a legislated private sector funding package with inadequate coverage for mental health care in community-based settings. With only 1.2 psychiatrists to every 100 000 people (4) in South Africa, and fewer than 400 psychiatrists practicing in the private health care sector which services nearly 9 million people, specialist care is not a viable solution to this growing problem with far-reaching health and social consequences. The lack of access to good quality ambulatory mental health care ultimately leads to complications, poorly controlled comorbidities, and costly hospitalisations, which increase the strain on health care funding resources.
Short Description of Practice Change Implemented: The Medscheme Mental Health Programme follows an internationally successful model of integrating mental health care into the primary care setting through effective collaboration between general practitioners, specialists, and auxiliary caregivers, and the introduction of a care manager to help coordinate the process. This, along with general practitioner training, decision support, an alternative reimbursement model, and additional insured benefits for ambulatory care, creates the necessary structure to allow the busy general practitioner to deliver and coordinate good quality, patient-centered care, which includes mental health care. Often the first port of call for sufferers of mental illness who do present for care, the general practitioner is ideally placed at the coalface of primary care delivery to promote the integration of mental health care. There is, however, under-recognition of mental illness in the primary care setting (5) (6), and a general inertia to objectively review and change treatment plans in general practice (7) (8). The concept of treatment-to-target in mental health care employs the use of validated symptom score trackers to monitor response to treatment in order to help identify suboptimal treatment plans timeously. The Medscheme Care Manager communicates regularly with the general practitioner regarding potential new cases and treatment response as measured by validated symptom scores. When treatment targets are not met, the general practitioner is alerted and encouraged to review the current treatment plan, and offered specialist advice from the Medscheme Psychiatrist Decision Support service. In addition, general practitioners will be trained through online and face-to-face initiatives, and have access to standardised care pathways to guide treatment decisions.
Adherence to and active participation in treatment is required from patients to achieve desired clinical outcomes. Patient activation and support for self-care are other key components of the model. These are promoted through education of patients and their families, the facilitation of behavioural activation by care managers during telephonic interventions, “Ask-Your-Mental-Health-Care-Practitioner” checklists, relapse prevention plans, integration with workplace wellness initiatives, and accessing community support groups. As one of the largest managed care organisations in South Africa and the custodian of valuable relationships with both patients and health care providers, Medscheme is ideally positioned to be the first to establish this model in the South African private health care industry.
Timeline & Target Population: Implementation started in early 2016 for Polmed, the medical insurance scheme serving South African Police Service members and their dependants (comprising of roughly 500 000 individuals), and was soon followed by implementation for several other South African private medical insurance schemes. More are expected to follow in 2017.
Highlights: (Innovation, Impact and Outcomes) This programme is the first of its kind in the South African private health care industry. It is also the first time that mental health symptom data are collected on this scale in this country. Combined with claims data for the same population, there is ample opportunity for in-depth analysis and understanding of the mental health landscape in the South African private health care sector, as well as the impact of this intervention.
Comments on Sustainability & Transferability: This presentation will focus on describing the model and its adaptation for the South African private health care environment, which may find application in other, similar scenarios. Rigorous measurement of outcomes will help inform future adjustments and scalability. Outcomes will be measured against the strategic objectives, which are to:
Shift care from the tertiary to primary care level
Curb the rise in overall health care expenditure for programme enrollees in the medium to long term
Improve clinical outcomes
Improve workplace productivity
Promote access to primary care/decentralized care
Promote balanced care, i.e. promote non-pharmacological care where appropriate
Promote good quality care
Integrate care (with care for other chronic illnesses)
The findings and analysis from such measurement may contribute to the academic and industry discourse around improving mental health both locally and internationally. While outcomes are only expected in the medium- to -long term, initial findings such as enrolment rates will be presented. The model of integrated, primary mental health care facilitated through managed care could be replicated in settings other than the private health care sector of South Africa.
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2- World Health Organisation. Mental Health Action Plan 2013 -- 2020. 2013.
3- World Health Organisation and World Organisation of Family Doctors (WONCA). Integrating mental health into primary care: A global perspective. Geneva; 2008.
4- Jack H, Wagner RG, Petersen I. Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness. Global Health Action. 2014;7:23431.
5- Mash B. How to design education on mental disorders for general practitioners in South Africa. South African Family Practice. 2002; 25(5):4-10.
6- Petersen I, Lund C. Mental health service delivery in South Africa from 2000 to 2010: One step forward, one step back. South African Medical Journal. 2011 September; 101(10):751-757.
7- Milani R, Lavie CJ. Health Care 2020: Reengineering Health Care Delivery to Combat Chronic Disease. American Journal of Medicine. 2015 April; 128(4):337-343.
8- AIMS Centre, University of Washington, Psychiatry and Behavioural Sciences Division of Integrated Care and Public Health. Measurement Based Treatment-to-Target. [Online].; 2016 [cited 2016 January 12. Available from: http://aims.uw.edu/resource-library/measurement-based-treatment-target.