This paper reports patient satisfaction and clinical course from a 7-year follow-up study of a cohort of service users with severe mental illness (SMI) who received collaborating services from primary care (including general practitioners, GPs) and a community mental health center (CMHC) in a rural area on the west coast of Norway. As large-scale development of community mental health care is still in an early phase in many countries [
1,
2], experiences related to the close collaboration of primary care services and a pioneering CMHC in Norway 1992–2000 may be of interest for others who are currently developing local mental health services in rural areas.
Most studies of community mental health services for individuals with SMI have been performed in cities. Studies of shared care by collaboration of primary care including GPs and specialized mental health care have been performed primarily for patients with depression, and few studies are available concerning the experience of combined treatment from primary care and CMHC for individuals with SMI [
3,
4]. This type of combined treatment may be the most common type of services for this target group, especially in rural areas.
According to patients and health professionals, GPs are important for patients with SMI [
5]. The engagement of GPs in the treatment of individuals with SMI depends on their interest in mental health and other factors like the support available from collaborating mental health services [
6]. Good communication between services is important for the quality of the services [
7]. In addition, mental health nurses, primary care mental health teams and social services are important collaborators for the GP and the CMHC.
In Norway, the development of CMHCs with outpatient clinics and inpatient wards was one of the main strategies in a national plan for mental health 1999–2008 [
8]. Much of the country consists of rural areas, and during the ten-year plan, resources were increased for CMHCs and for primary care in the municipalities. However, a report on all of the CMHCs in the country in 2013 revealed that there is still great variation in the available resources and the degree of implementation of the different types of community mental health services [
9]. In rural areas the number of psychiatrists is one of the critical factors for capacity and quality of outpatient and local inpatient treatment at CMHCs for persons with SMI. In two recent national surveys of GPs’ assessment of the local CMHC showed that many CMHCs still have great potential for the improvement of their services [
10,
11].
Countries and areas that are developing community mental health services based on collaboration by primary care and CMHCs may take into account the experiences from similar processes during the last three decades in Norway. Studies describing the content of shared care and patient satisfaction with this care over time may be especially valuable. However, recent Norwegian studies have been primarily cross-sectional studies describing the types of services provided, but not following the patients over time and reporting course and outcome. One 6-year study followed a group of patients who were receiving long-term inpatient care at the time of the baseline evaluation [
12,
13], but this study reported limited information concerning the content of the treatment provided in the communities after discharge from institutions, and it had no measures of patient satisfaction.
The local area and the collaborating services
Nordfjord is a rural area surrounding a fjord on the west coast of Norway. There are six small municipalities in the area, with a total population of 30,000. An epidemiological study found a lower prevalence of affective disorders but a similar prevalence of non-affective psychoses in this rural county in comparison to the Norwegian capital Oslo [
14]. The CMHC is located in the middle of the area, with a 1 hour drive to most of the municipality centers. At the time of the follow-up study, 20 GPs were in the area and each municipality provided primary care by mental health workers, social services and supported housing for persons with SMI. In the small municipalities, the GPs and other primary care workers had a good knowledge of the population and the local community. High stability and low turnover among GPs and health workers contributed to high continuity of care and long-term personal contact with patients. Most GPs were highly engaged in serving patients with SMI and other mental disorders, and the GPs expressed that the close collaboration with the CMHC encouraged them to take more active responsibility for these patients.
Nordfjord CMHC was one of the first CMHCs in Norway to provide the full range of outpatient, day patient, mobile and inpatient services, as intended in national plans. The CMHC became fully operational in 1992 and has subsequently provided treatment in close collaboration with GPs and other municipal primary health and social services in the catchment area. At the time of the follow-up study, the CMHC had an outpatient clinic with seven clinicians, a mobile rehabilitation team with a staff of four individuals, a day unit with a staff of three individuals, and two nine-bed inpatient wards with a staff-patient ratio 1.5:1.0. One of these wards was for patients with SMI, and the other unit was for all other patient groups.
Four psychiatrists were available at the CMHC. The staffing was considered to be fairly good for a small CMHC, and the CMHC has been rated highest in quality in two national surveys of GPs’ ratings of the local CMHC [
10,
11]. This indicates that the quality of local mental health care and collaboration in our area was considered to be fairly good.
Most of the needs for psychiatric inpatient services and all of the needs for psychiatric outpatient services in the local area were covered by the CMHC. The CMHC also collaborated closely with the mental health clinic at the county central hospital 2–3 h from Nordfjord, which had acute and closed inpatient psychiatric wards. On average, four inpatients from Nordfjord were present in these wards. Involuntary admissions could only be processed at the mental health clinic at the county central hospital, but involuntary treatment could be transferred to the CMHC and continued there.
A major component of the care available from the CMHC for people with SMI was clinical case management by the staff of the mobile rehabilitation team, as well as of outpatient and inpatients units. Building and maintaining relationships and alliances with the patients and continuity of care were emphasized. Primary care or CMHC staff met SMI patients weekly or more often in their homes, in the community or in localities of the services. Important treatment components included help and support in everyday living, meaningful activities, training in practical and social skills, medication, supportive psychotherapy and meeting the family [
15]. During the years of the follow-up study, clinical guidelines and evidence-based treatments were emerging and began to influence clinical practice, but specific models and fidelity measures were still scarce and not implemented in the services.
The shared care provided by the primary care and mental health care services was implemented partly as joint service delivery and partly by close coordination of the services provided by each agency. The psychiatrists and other clinicians from the CMHC spent 1 day every week working in the municipalities with the GPs and primary care. This service included joint consultations, home visits, family sessions and supervision. The close collaboration led to good working relationships based on mutual knowledge and respect and increased the overall competence of the shared care. The coordination of the total services for each patient was accomplished in meetings every 6–8 weeks for all professionals involved with the patient, with one case manager from the primary care or the CMHC as coordinator. The CMHC also had close contact with the psychiatric inpatient department at the central hospital, facilitating early discharge to the community or transfer to the CMHC inpatient ward.
In 1996–1998, more than thirty health professionals from the CMHC and municipality primary care services participated in a comprehensive 2-year local training program in community mental health care for people with SMI. This program was arranged in collaboration with the Center for Psychotherapy and Psychosocial Rehabilitation of Psychoses (SEPREP), which is a national network of clinicians, service users and caregivers. The participants received supervision every second week in joint supervision groups for health workers from both the CMHC and primary care, attended 1 day of lectures every month, and met in groups to discuss clinical literature every month [
16]. The training was part-time and completed in parallel to clinical work and aimed to increase the competency of clinical practice during the training. From 1999, SEPREP was commissioned by the government to build a national program with local training programs based on this model. This national program has been widely disseminated and is still running with strong impacts throughout Norway.