Among mental health teams that care for patients with severe and persistent mental illness, a growing concern is patients' limited access to psychiatric support. One contributing factor is a shortage of psychiatrists, especially in community-based and outpatient settings.
Physician assistants (PAs) historically have been used in settings with physician shortages. The role of PAs in psychiatric care in the United States is evolving, and examples described in the literature include community mental health clinics, after-hours care in inpatient or long-term-care settings, and mental healthcare under the provision of family physicians.1 In Canada, this method of delivering psychiatric care with PAs is less common despite similar physician shortages. This is likely attributable to the smaller cohort of civilian PAs practicing in Canada and more recent introduction of civilian PAs to the Canadian system in 2006; civilian PAs were introduced to the US healthcare system in the 1970s. Despite the well-established role of psychiatric PAs in the United States, little research exists on the use of PAs in psychiatric care, despite calls for additional research on this topic.2 In particular, no research has examined the role of PAs in the care of patients with severe and persistent mental illness. Using an exploratory qualitative analysis, we examined the effect of this clinical model.
METHODS
The setting of this study was an Ontario-based assertive community treatment (ACT) team, a common model of providing comprehensive multidisciplinary care to patients with severe and persistent mental illness. Due to limited access to psychiatric and primary care, a PA was hired to assist with intake psychiatric assessments, physical examinations, preventive care, and follow-up of psychiatric and medical complaints. A qualitative analysis of this new model was undertaken.
Information was collected from key informant interviews and semistructured focus interviews. An open-ended thematic topic guide was used to ensure common themes were explored in interviews. Study participants were chosen by purposive sampling and included the ACT team members (three social workers, one psychiatrist, two psychiatric nurses, one occupational therapist, one recreational therapist, and the PA). Questions focused on the perceived effect and challenges of delivering psychiatric care in this model (that is, frontline PA supervised by psychiatrist). Transcripts were generated from audio recordings and conceptualized and indexed by an independent researcher.
RESULTS
The following themes emerged from the exploratory descriptive analysis:
Improved access to primary care
Participants described improved access to primary medical care for their patients. The PA was able to assess semiurgent medical concerns more rapidly when they arose. One nurse reported: “When we see UTIs, we can deal with things before it gets full-blown for the consumer.” Another participant described the PA service as “one-stop shopping” for the patient. Participants felt that the PA helped them to coordinate care more efficiently with family physicians. Additionally, the PA's former training in primary care enabled the ACT team to provide more preventive health services, with an emphasis on smoking cessation, diabetes management, and women's health.
Improved access and quality of psychiatric care
Participants described more timely access when managing patient mental health complaints, as well as “longer and more collaborative appointments.” The PA let the team conduct more home visits and assessments than previously. Participants described increased opportunities for medication reviews, and improved continuity of care during physician absences. Though quantitative data were not collected, this model let the ACT team expand its roster from 75 to 85 patients. In terms of team cohesion, participants reported equal levels of satisfaction between the PA and psychiatrist.
Effect on health system navigation
Participants described decreased wait times and ease of referrals to tertiary care treatment, especially when preadmission physical examinations were required. They also noted improved liaison with community specialists and improved access to publicly funded screening programs.
Implementation challenges
Participants warned against the risk of developing a “triage” hierarchy, in which the PA merely relays patient complaints to the psychiatrist. Consideration must also be given to the psychiatrist's scope of practice, especially as primary care treatment is undertaken. Participants cautioned about the need for educating patients about the term physician assistant and the PA's role in the team.
DISCUSSION
This represents the first study to explore the role of PAs in comprehensive psychiatric care. Our results suggest there are several benefits, including improved quality and access to primary and psychiatric care. These early results support the increased use of PAs in care for patients with severe and persistent mental illness, and highlight the need for further health systems research in this domain.
REFERENCES
1. Shanks CS. PAs in psychiatry: improving care for the underserved.
JAAPA. 2007;20(4):14.
2. Miller JG, Peterson DJ. Employing nurse practitioners and physician assistants to provide access to care as the psychiatrist shortage continues.
Acad Psychiatry. 2015;39(6):685–686.
