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Tiered models of care 

From: Submission to the Select Committee on Mental Health and Addictions. Presented by Paul Garfinkel, June 3, 2009.

Tiered models of care seek to match intensity and acuity of the problem to the intensity and acuity of the treatment; primary care plays a key role in these models.

There are examples of other jurisdictions that have more explicitly articulated a tiered approach to care. Tiered models typically provide better definition of the role that primary care clinicians play relative to other system players. They also shape the information and other needs that must be met in order for primary care to play this key role.

The New Zealand Guidelines Group (2008), for example, presents a tiered model or a ’stepped care’ approach for the treatment of depression, which is grounded in a few guiding principles. First, most people with depression can be managed within primary care and a good outcome depends on partnerships between the patient and practitioner and on provision of active treatment and support for a sufficient length of time. Second, the use of self-management strategies for depression is encouraged and supported by primary care physicians. Finally, brief psychological interventions such as structured problem-solving therapy should be available in the primary care setting. Progression through levels of care is determined on the basis of patient response with support for self-management a major feature.

In order to support such a tiered model of stepped care in Ontario, structural change to the organization of care should be made. As Kates and Mach (2007) summarize, the prevalence of depression in primary care is high; however, the detection, treatment and referral rates are low and if treatment is initiated, most patients do not receive adequate follow-up. This is not so much due to oversights by individuals or ineffective treatments as it is due to problems in the way systems of care are organized. Kates and Mach (2007) stress that central to all models of improved systems of care for individuals with depression in primary care is a redesign of the way services are organized and delivered. This includes the incorporation of mental health care managers or coordinators, visits by psychiatrists in stepped care model and changes in treatment protocols to include screening and follow-up for patients.

Within Canada, a National Treatment Strategy entitled A Systems Approach to Substance Use in Canada, 2008, has been developed which utilizes a tiered model. This approach recommends different levels of services and supports corresponding to the acuity, chronicity and complexity of risks and harms associated with substance use. Services and supports in the lower tiers are open to all and are intended to meet the needs of many, while those in the upper tiers are designed to meet the needs of smaller numbers of people and in many cases, are specialized for people with more severe substance use problems. This model matches the level and kind of services and supports to the specific nature of a person’s substance use problem as well as promoting efficient use of resources.

The National Treatment Strategy is based on common principles; most importantly, people must be able to access the continuum of services and supports at any tier and at any time, and be linked to the appropriate services and supports that they need. Such a continuum requires an integrated system in which services and supports are linked, both within and between tiers, and in which different jurisdictions and systems must be able to easily share information to coordinate services and supports. Primary care is one of the foundations of any tiered system of care, since primary care plays a role in identifying problems and navigating systems of care.


 In Submission to the Select Committee on Mental Health and Addictions:

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