Abstract
Objective To further understand and optimize primary care provider (PCP) referrals to a 1-time psychiatric consultation service by developing profiles of PCP referrers, assessing PCP satisfaction with the service, and determining intervention opportunities.
Design Secondary analysis of a referral database and subsequent cross-sectional survey of referrers.
Setting Winnipeg, Man.
Participants All family physicians who had made at least 1 referral in 2017 to the Centralized Psychiatric Consultation Service for Adults, a 1-time consultation service.
Main outcome measures Referral frequency, individual and practice characteristics, satisfaction with the Centralized Psychiatric Consultation Service for Adults, and subjective drivers of referral activity were assessed. Interest in a range of intervention opportunities to increase mental health knowledge and support were also examined.
Results Of the 403 family physicians who referred patients to the consultation service in 2017, a total of 111 (27.5%) responded to the survey. Among all referrers, 287 (71.2%) were low referrers (1 to 4 referrals), 65 (16.1%) were moderate referrers (5 to 9 referrals), and 51 (12.7%) were high referrers (≥10 referrals). Solo practice (P=.04) and no access to collaborative mental health services (P<.001) were significantly associated with being a high referrer. Roughly 26.3% of low referrers, 29.2% of moderate referrers, and 15.4% of high referrers were satisfied with wait times for the service. Higher referrers did not identify a lack of comfort with providing psychiatric care as a driver of referrals; more indicated that they had a high volume of patients with mental health needs, that there was a lack of access to alternative services, and that patients sometimes requested referral. Overall, more than 40% of respondents expressed interest in a mental health care navigator, hard-copy resource information, and rapid access to consultation advice via telephone or an electronic platform. There was less interest in other proposed interventions.
Conclusion We found referrers to the Centralized Psychiatric Consultation Service for Adults to be clustered based on specific practice characteristics, as well as provider-patient factors. Overall, satisfaction with the service was fair and PCPs were not highly interested in a variety of proposed interventions. Future studies should explore how useful 1-time consultation services are for solo-practising PCPs and how best to support these and other PCPs in their management of patients with mental health needs.
Mental illness is one of the leading causes of disability worldwide.1,2 Often primary care providers (PCPs) are the first point of contact for individuals with mental health needs.3 However, there are many barriers to comprehensive mental health treatment provided by PCPs, including provider-level factors (eg, lack of training or confidence, competing demands), patient-level factors (eg, comorbidities, treatment non-engagement), and systemic factors (eg, few monetary incentives, time constraints, limited access to supporting mental health services).4-7
In Canada, psychiatry is consistently rated by PCPs as being one of the most difficult specialties to access.8-11 Collaborative care initiatives involving coordinated partnerships between PCPs, psychiatrists, and other mental health professionals are potential solutions to improving accessibility to mental health care, as well as enhancing efficiency and clinical outcomes.12-14 Although these strategies are evidence based,14,15 the availability of collaborative care services is an issue for many PCPs owing to factors such as program funding, differences in remuneration models between providers, provider shortages, lack of training or experience in collaborative practice, and geographic barriers.12,16 To facilitate access to psychiatric assessment and treatment recommendations, a possible solution—a 1-time psychiatric consultation service accessible through a central registry—has been implemented.17 Sved-Williams and colleagues evaluated an example of such a psychiatric consultation service in Australia, reporting that both psychiatrists and general practitioners were satisfied with this approach.17,18 Overall, however, there has been little evaluation of these 1-time consultation services with respect to their effectiveness in supporting PCPs and improving patient outcomes.17,18
Additionally, PCPs demonstrate high variation in their practices for referral to specialists.19-22 A Cochrane review of interventions implemented to alter referral rates or improve referral appropriateness included studies of referrals to a range of specialists.23 This review found few studies overall and none on referrals to psychiatrists. A recent study examining referral practices among PCPs to child and adolescent psychiatry in rural and remote areas of Canada focused primarily on reasons for referral, but not actual referral volumes and patterns.19
In our region (Winnipeg, Man) wait-list reduction and management are key considerations in the quality of patient care and optimization of resources. The Centralized Psychiatric Consultation Service for Adults provides a 1-time psychiatric consultation for individuals referred to a central registry by PCPs. This study surveyed PCPs referring to the Centralized Psychiatric Consultation Service for Adults based on their referral frequencies, with the objective of examining referrer characteristics, understanding referrer satisfaction with the service, and determining intervention opportunities that would better support high-referring PCPs and ultimately improve patient care.
METHODS
Design
This study consisted of a secondary analysis of PCP referral volumes to the Winnipeg Centralized Psychiatric Consultation Service for Adults in 2017, followed by a survey study of all family physicians who made at least 1 referral that year. This study was approved by the University of Manitoba Research Ethics Board.
Study population and setting
Winnipeg has a population of approximately 749,500 people.24 The Centralized Psychiatric Consultation Service for Adults started in 2010 to address challenges in accessing psychiatric consultation among PCPs in the city. The service accepts referrals from all PCPs and provides a 1-time consultation with the next available psychiatrist. Treatment recommendations and additional referrals for specialized programs (where appropriate) are discussed with patients at the end of the assessment, and a letter summarizing the assessment is sent to the referring provider. In 2017, there were 14 psychiatrists offering consultations. There were 2170 referrals, with wait times ranging from 20 to 23 weeks. There is also a telephone-based Rapid Access to Consultative Expertise (RACE) service available to PCPs in Winnipeg during daytime hours, Monday to Friday for nonurgent consultations. The RACE service offers a call back from a psychiatrist within a maximum of 2 hours.
Data collection procedures
A list of providers and referral counts for all PCPs who had referred to the Centralized Psychiatric Consultation Service for Adults at least once in 2017 was obtained from the Manitoba Health Seniors and Active Living clinical database. Institutional policy when releasing administrative data is to suppress small cells (count <5); as a result, this was the minimum detectable referral rate. Although nurse practitioners and a small number of specialists also referred to the service in 2017, only family physicians were surveyed. Nurse practitioners could not be individually identified in the database, and specialists were considered outside the study target. The referral distribution among providers was visually examined to determine useful cut-offs to distinguish low, moderate, and high referrers.
Surveys were sent by mail to all eligible PCPs. Contact information was obtained from a publicly available practitioner directory published by the College of Physicians and Surgeons of Manitoba. Completed surveys could be returned by mail or fax, or could be completed online via a provided SurveyMonkey link. All surveys returned by mail or fax were manually inputted into the SurveyMonkey Web-based survey by a research assistant to facilitate data output. There were no returned surveys that were excluded from the study. To increase response rates among moderate and high referrers, a second survey was mailed if a survey was not returned within 1 month of being distributed. Repeat mailing was not done for low referrers owing to budget constraints and lower interest in this subset of referrers. Participation was voluntary but not anonymous. Respondents were provided with a short description of the study summarizing intended use of data, and consent was implied based on survey completion. The survey introduction highlighted that participation could lead to an opportunity to improve mental health care support; no other incentives were offered.
Survey description
The survey consisted of 3 sections: practice characteristics, satisfaction with the Centralized Psychiatric Consultation Service for Adults, and audit and feedback. The sections on practice characteristics and satisfaction with the service were identical for all categories of referrers. The audit and feedback section differed between moderate to high referrers and low referrers.
The practice characteristics section included the following areas: years in practice, main type of practice (eg, group practice, solo practice), access to co-located collaborative care psychiatry or involvement with a My Health Team (team-based practice that provides access to various allied health professionals, such as dietitians, pharmacists, and social workers), use of RACE, estimated average percentage of patients seen per week with mental health as a primary concern, estimated average percentage of clinical time spent per week providing mental health care, and comfort with managing various mental health presentations. These descriptions were chosen in consultation with a primary care researcher (A.G.S) based on the known practice characteristics in our region. Comfort was assessed on a Likert scale: no comfort, moderately comfortable, and very comfortable. This was assessed separately for patients in an emotional or situational crisis; common mental disorders like depression or anxiety; psychotic disorders like schizophrenia; less common mental disorders like posttraumatic stress disorder, eating disorders, and attention deficit hyperactivity disorder; and complex patients who are refractory to treatment or have multiple diagnoses.
The satisfaction with the Centralized Psychiatric Consultation Service for Adults section included the following areas: self-reported satisfaction with various outcomes (referral process, time from referral to appointment, time from appointment to consultation report, overall service), agreement with and helpfulness of recommendations, and suggestions for improvement. Responses were collected on Likert scales, with suggestions for improvement recorded as open text.
The audit and feedback section informed each provider about their referral pattern relative to their PCP colleagues (ie, moderate, high, or low), and asked for self-reported reasons as to why this might be the case. Additionally, survey respondents were asked about interest in various additional services (urgent requests via telephone or electronic consultation, access to allied health support for assessment and service navigation, mental health community resources, and continuing professional development for managing common mental disorders).
Statistical analyses
Descriptive statistics were generated for PCP characteristics, stratified by referrer type. Associations between PCP characteristics and referrer type were compared using 2-sided 
2 tests of independence (or Fisher exact tests for low cell counts) for categorical variables and ANOVA (analysis of variance) for continuous variables, with α=.05 used to define statistical significance. For PCP comfort with managing mental health presentations, we clustered presentations such as patients in an emotional or situational crisis and common mental disorders like depression and anxiety as “common presentations”; whereas psychotic disorders like schizophrenia; mental disorders like posttraumatic stress disorder, eating disorders, and attention deficit hyperactivity disorder; and patients who are refractory to treatment or have multiple diagnoses were grouped as “less common presentations.” A comfort score was derived by assigning a score of 1 to “little to no comfort,” 2 to “moderately comfortable,” and 3 to “very comfortable” to each response and calculating the mean for each category. For responses to items concerning satisfaction with the service, we plotted positive responses (ie, satisfied or extremely satisfied) and compared across referrer type with 2-sided 
2 tests of independence. Descriptive statistics were generated for the audit and feedback portion of the survey, overall and by referrer type. All quantitative data were analyzed using SPSS, version 25.
Open text responses to the satisfaction section of the survey regarding suggestions for improvement were reviewed by 2 authors (D.Y., J.H.), individually coded, and categorized into areas perceived to need improvement.
RESULTS
A total of 403 family physicians referred patients to the consultation service at least once in 2017. This represented 50.2% of the 802 family physicians registered with Manitoba Health and based in Winnipeg that year. The PCPs were categorized as low referrers (1 to 4 referrals; n=287, 71.2%), moderate referrers (5 to 9 referrals; n=65, 16.1%), or high referrers (≥10 referrals; n=51, 12.7%).
Survey respondents
Of the 403 surveys mailed out, a total of 111 (27.5%) surveys were completed and eligible for analysis. There were 71 returned via fax, 14 returned by mail, and 26 completed online. Response rates were 21.3% (61 of 287) for low referrers, 36.9% (24 of 65) for moderate referrers, and 51.0% (26 of 51) for high referrers. Characteristics of PCP survey respondents and their practices are summarized in Table 1. Respondents were most commonly in practice for more than 10 years, working in fee-for-service solo or group practices, and spending between 25% and 50% of their time in a week managing mental health needs of their patients. A minority of respondents reported having access to collaborative mental health services or health teams, with low referrers having the highest rate of access to these services.
Characteristics of PCP survey respondents classified by number of referrals to the Centralized Psychiatric Consultation Service for Adults in 2017
Reasons for referral
Among moderate and high referrers (5 or more referrals in 2017), the most often cited reasons for high rates of referral were high volumes of patients in need, lack of access to alternative services, and patients requesting referral (Figure 1).
Reasons for referral to the Centralized Psychiatric Consultation Service for Adults among moderate and high referrers (≥5 referrals): Numbers in parentheses represent the absolute numbers of respondents. Responses were not mutually exclusive (n=50).
Satisfaction with the service
Rates of satisfaction with the referral process, time to appointment, time to report, and overall service are shown in Table 2, stratified by referrer type. Lowest satisfaction was for time to appointment, with less than 30% satisfied with this metric.
Percentage of low, moderate, and high referrers who were satisfied or very satisfied with the overall service, time to receiving the consultation report, time to appointment, and referral process for the Centralized Psychiatric Consultation Service for Adults
No significant association was found between referrer type and satisfaction with the overall service (
=0.15, P=.93), satisfaction with time to consult (
=0.90, P=.64), satisfaction with time to appointment (
=1.56, P=.46), or satisfaction with the referral process (
=3.56, P=.17). The majority of referrers agreed with recommendations provided by the service “most of the time” or “always,” but 6.8% of low, 16.7% of moderate, and 11.5% of high referrers reported that they agreed “sometimes.” No respondents said they “rarely” or “never” agreed. No significant association was found between referrer type and agreement with recommendations (
=4.52, P=.34). Similarly, most referrers found recommendations to be helpful “most of the time” or “always.” Of importance, 3.8% of high referrers reported that they “rarely” found recommendations to be helpful and 23.1% of high, 20.8% of moderate, and 20.3% of low referrers reported that they “sometimes” found recommendations to be helpful. Two low referrers did not answer this question. No significant association was found between referrer type and finding the recommendations helpful (
=4.41, P=.62).
The open-ended feedback identified perceived areas for improvement, comprising the referral process, wait times, and outcomes. The referral process (particularly the referral form) was perceived to be unnecessarily onerous and was often delayed for seemingly small omissions, with patients sent for repeated consultation often seeing a different provider each time. The wait times were perceived to be too long. Outcomes included the perception that recommendations were generic and not particularly helpful, and that there was a lack of follow-up care for complex patients. There was also concern about how to manage cases where initial recommendations were ineffective and could lead to negative impacts on patients experiencing mental illness.
Interventions
Respondents varied in terms of their interest in interventions, although there was not a lot of difference between low versus moderate and high referrer groups (Table 3). The most popular interventions were access to a mental health service navigator, and information about regional mental health services. A preference for hard-copy resources was expressed over online. Fewer than half were interested in access to psychiatrists through other rapid means (eg, telephone or electronic consultation, with a slightly higher percentage of low referrers interested in these interventions).
Respondent self-reported interest in interventions to aid in management of patients with mental health needs
DISCUSSION
This study aimed to describe PCP referral patterns to psychiatrists through a 1-time psychiatric consultation service. This is not a highly investigated topic and it is not well known how these 1-time consultation services are perceived. We identified some PCP characteristics associated with referral behaviour and found that overall satisfaction with the 1-time consultation model was fair. Some particular aspects of the model were criticized—notably, excessive wait times and lack of follow-up. Interventions that could potentially support PCPs to better manage patients in their practice or direct patients to other resources were not as highly rated as hoped. These findings can help primary care and mental health services better align to improve community mental health outcomes.
We identified that referrers differed in their use of the consultation service and could be clustered as low, moderate, and high referrers. Most PCPs who used the service were low referrers, with fewer than 30% referring 5 or more times in the year. Low referrers were more likely to be part of a My Health Team or have access to collaborative care, and less likely to be in fee-for-service solo practice. This is consistent with the most prominent self-perceived reasons for higher referral: high volume of patients with mental health issues, lack of access to other services, and patient request. However, although more higher referrers perceived they had a high volume of patients with mental health issues, they did not report significantly higher percentages of patients seen for or time spent assessing and managing mental health issues. Experience as measured by years in practice and self-assessed comfort with both common and less common mental health presentations did not differ significantly between referrer types. This is consistent with previous studies indicating that variance in referral rates is best explained at the patient rather than the provider level.20,25-28 Higher referrers also tended to be more satisfied with the Centralized Psychiatric Consultation Service for Adults, although this was not statistically significant. This may be a factor in subsequent re-referrals to the service.
Satisfaction rates with the 1-time consultation service were mostly less than 50%. Sved-Williams et al18 piloted a 1-time consultation service; data were qualitative but satisfaction was reported as being high among both PCPs and psychiatrists. However, there was extensive training provided to the psychiatrists, and rapid feedback was provided to referrers along with telephone advice. Our data are also low compared with those of a study of a collaborative care psychiatry model by Kates et al, which yielded high satisfaction ratings from both participating PCPs and psychiatrists.29 This model did offer follow-up care and embedded the psychiatrist in the primary care setting. Although Kushner et al demonstrated that PCPs prefer referral with treatment as opposed to a 1-time consultation,30 only 21% of the patients in Kates and colleagues’ study were seen for follow-up. It is possible that the availability of follow-up, even though not often required, produced higher satisfaction and improved communication and collaboration between providers. This would be consistent with studies that correlate higher care coordination between referring physicians and specialists with higher satisfaction among PCPs29 and patients.31 A study by Starfield et al32 indicated that family physicians, more than any other medical specialty, desired long-term follow-up care from psychiatrists. However, if and how satisfaction itself impacts treatment outcomes remains unclear.
In particular, satisfaction with the referral process itself was poor. This was especially true for time to appointment, where the percentage of referrers who were satisfied was less than 30%. This is unsurprising given that at the time of survey time to triage was 9 weeks, and time from triage to consultation was 13 weeks, for a total of 22 weeks. This is much longer than the 4-week recommended benchmark set by the Canadian Psychiatric Association33 for nonurgent assessments. Since this study was done, a number of changes were made: the referral form was modified, more psychiatrists joined the service (there are now 20 psychiatrists, compared with 14 in 2017 when the study was done), and RACE and eConsult have been encouraged as an alternative resource. As well, more attention was given to improving efficiency in the referral and triage process; a nurse clinician now does a patient intake to determine the need for and fit of the service, redirecting those referrals that are not appropriate. These changes have drastically decreased wait times; now, time to triage is 2 weeks, and time from triage to consultation is 2 weeks, totalling 4 weeks. We hope to evaluate whether this has had an impact on satisfaction with the service and understand more about which types of patients and providers this model is most effective for.
Interest in a variety of proposed interventions was lower than expected. Although both electronic34-37 and telephone38,39 consultation models have been shown to be well received by PCPs, with potential to provide timely access to specialist advice, interest in these services among our survey respondents was not very high. A minority of our survey respondents reported prior use of the RACE telephone-based service, however, and interest was expressed by less than half. Additionally, interest in this service was slightly higher among low referrers, which may be owing to differences in practice and patient characteristics, and this service may have limited utility to affect referral rates among the highest referrers. A previous study on the use of an electronic consultation service indicated that PCPs believe psychiatry is uniquely complex, limiting the usefulness of electronic consultation services compared with other specialties (other than for psychopharmacology advice).40
Information about regional mental health services was desired, and the highest interest was in access to a navigator—an intervention that can be patient-facing and offered virtually to assist in timely support and direction to the most appropriate services.41 There was less interest in practice tools and continuing professional development; this was in keeping with the finding that providers do not consider lack of comfort to be a primary reason for referral. Apart from indirect support and capacity building, it is clear from our qualitative responses that access to follow-up care is an area that PCPs feel needs to be addressed. While recommendations from 1-time assessment may be initially helpful, the lack of opportunity for follow-up if they do not work is frustrating, and PCPs feel uncomfortable managing more complex patients without follow-up.
Limitations
Limitations of this study include those inherent to a non-anonymous survey study, such as self-report. Response bias is a common limitation in physician survey research, although mailed surveys are typically the most preferred and successful survey strategy.42,43 In this study, response rate was low among infrequent referrers, with a rate closer to expected among moderate and high referrers who received a second mailing. We also had a high number of PCPs in practice more than 10 years; this may represent a response bias or may relate to practice characteristics of PCPs over time. It is possible that newer graduates enter practices with access to more collaborative mental health services or fewer patients with mental health needs. Similarly, although this study identifies a number of reasons for referral, we did not study reasons for not referring. We did not evaluate factors contributing to absence of repeated referral in 1-time referrers. In terms of treatment outcomes, we did not assess for how often treatment recommendations were actually implemented, nor were there any measures assessing patient experience or satisfaction. Certainly the consultation model works for a proportion of individuals with mental health needs managed in primary care, but we do not know who those people are, nor do we have data on what percentage of individuals seen in consultation end up being re-referred or access other services including emergency departments and mental health crisis services. Given high referrers tended to work in solo practice, without access to allied health or shared health care, it is also possible some referrals were sent for patients in need of psychosocial intervention and not necessarily psychiatric care. These are all important variables that could help to inform which patients are best served by this type of model. Whether PCPs have access to the right services is an area of study that should be explored in the future.
Conclusion
We found referrers to the Centralized Psychiatric Consultation Service for Adults to be clustered based on specific practice characteristics, as well as provider-patient factors. Overall, satisfaction was fair and PCPs were not very interested in a variety of proposed interventions to supplement the consultation service. Based on our survey results and the complexity of our local mental health system, we used our results to develop and distribute a hard-copy package consisting of a patient self-help handout and a referral guide to help direct PCPs to the most appropriate services, and we are currently exploring how to offer some follow-up services. Future studies should explore what types of questions PCPs ask, what kinds of assistance they require, and how 1-time consultation services impact patient outcomes. As well, further studies should consider how 1-time consultation services fit into the range of options for psychiatric care (such as RACE, eConsult, and ongoing psychiatric care and follow-up). In the absence of collaborative care services for all PCPs, we need to better understand how to best support PCPs in their management of patients with mental health needs, particularly PCPs in solo practice.
Acknowledgment
We thank the primary care providers who participated in this study, as well as the research assistants and administrative supports who provided data support and assisted with survey dissemination and data entry. Specifically, the study team thanks Breanne Berg, Gabrielle Wilson, and Aimee Schwager. This study was supported by an academic project grant from the Department of Psychiatry at the University of Manitoba in Winnipeg.
Notes
Editor’s key points
▸ The Centralized Psychiatric Consultation Service for Adults provides a 1-time psychiatric consultation for individuals referred to a central registry by primary care providers (PCPs). This study surveyed PCPs referring patients to the service about referral frequencies, characteristics, and satisfaction with the service to determine intervention opportunities that would better support high-referring PCPs and improve patient care.
▸ The authors identified some PCP characteristics associated with referral behaviour and found that overall satisfaction with the 1-time consultation model was fair. Some particular aspects of the model were criticized—notably, excessive wait times and lack of follow-up.
▸ Interventions that could potentially support PCPs to better manage patients in their practice or direct patients to other resources were not as highly rated as hoped. These findings can help primary care and mental health services better align to improve community mental health outcomes.
Points de repère du rédacteur
▸ Le Service centralisé de consultations en psychiatrie pour les adultes offre une consultation ponctuelle en psychiatrie aux personnes pour qui un professionnel des soins primaires (PSP) a demandé une consultation au moyen d’un registre central. Cette étude effectuait un sondage auprès des PSP qui avaient demandé ce service pour leurs patients, et portait sur la fréquence des demandes, leurs caractéristiques et la satisfaction à l’endroit du service, dans le but de déterminer des possibilités d’interventions susceptibles de mieux soutenir les PSP dont les demandes étaient nombreuses et d’améliorer les soins aux patients.
▸ Les auteurs ont cerné certaines caractéristiques des PSP associées au comportement en matière de références et ont observé que la satisfaction à l’égard du modèle de consultation ponctuelle était acceptable. Certains aspects particuliers du modèle ont été critiqués, notamment les temps d’attente trop longs et le manque de suivi.
▸ Les interventions qui pourraient éventuellement soutenir les PSP dans la prise en charge des patients dans leur pratique ou diriger les patients vers d’autres ressources n’ont pas reçu des cotes aussi élevées qu’on l’avait espéré. Ces constatations peuvent aider les services de soins primaires et de santé mentale à mieux s’harmoniser pour améliorer les résultats en santé mentale dans la communauté.
Footnotes
Contributors
Dr Dorothy Yu supported data analysis and interpretation and drafted the manuscript, including the creation of tables and figures. Drs Jennifer Hensel, Jane Moody, Alexander G. Singer, and Jitender Sareen supported study design, analysis and interpretation of results, and reviewed the manuscript draft. Drs Jennifer Hensel and Jane Moody obtained study funding.
Competing interests
Dr Jitender Sareen does consulting work for UpToDate. None of the other authors have anything to declare.
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © 2023 the College of Family Physicians of Canada
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