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Monthly Archives: February 2014

NMHP becomes part of NCD.

With the cabinet decision today to prune centrally sponsored schemes (CSS), NMHP becomes part of NCD. The noncommunicable diseases program (NCD) will include the following programs as per Planning Commissions draft document. 1. Cancer control program. 2. NMHP 3. National program for Diabetes, Cardiovascular diseases and Stroke 4. Health care of elderly. 5. Assistance for states in capacity building in Trauma. 6. 8 pilot projects. (Official communication awaited)

However as per this document the entire CSS under the health sector will be collapsed into one “National Health Mission including NRHM”

Report of committee on restructuring of CSS. An interesting excerpt

The monitoring by Ministries and independent evaluation of schemes is generally poor in CSS due to gaps in design of scheme, lack of ownership amongst States. No emphasis is being laid on outcomes or impact of these schemes through independent assessment/evaluation

12th plan document for health.

Research Proposal From CMHP-Kottayam.

The following intent for research activity at CMHP-kottayam was submitted to the state-level Nodal officer. Suggestions and comments are welcome

Covering Letter

Ramkumar G S
Field Psychiatrist.
Community Mental Health Program.
Kottayam District.

State-level Nodal Officer.
NMHP.
KeralaState.

Sub: Submission of a proposal for research study in Kottayam district under the Community Mental Health program.

Sir,

It is heartening to understand that conducting research activities is also very much a part of the DMHP/CMHP programmic architecture. The monthly reports which are being furnished from the district have explicit instructions to furnish details of the research activities done during the month. As you are aware research activities cannot be planned on a monthly basis as it involves discussion on research design, ethical approval and funding support. Therefore I submit the following research proposal as an abridged statement of interest for conducting research in my district.

Kindly advice me on the specifics of moving forward with this proposal with respect to

  1. Procedure for getting ethics approval for conducting research as part of DMHP/CMHP activities.
  2. The funding head of account for research based activities.
  3. What other procedures need to be followed.

Thanking you

Yours truly
[Sign]
Ramkumar G S

Place: Kottayam
Date:  17.02.2014

_________________________________________________________________

General Introduction:

As per draft policy document for the DMHP 12th plan, regarding research activities it is explicitly mentioned that

The primary role of research in the context of DMHP is to….reduce the treatment gap. As the ICMR already supports clinical and epidemiological research and the DBT supports aetiology and basic sciences research, it is recommended that the DMHP (or NMHP) conduct health policy and systems research in order to provide guidance about how to increase access to cost-effective treatments. In particular, the emphasis in these priorities is to better understand how to deliver what we know works in an affordable manner, which has been referred to as ‘implementation’ science.
Research questions include……To develop and evaluate mental health interventions for delivery by non-specialist health workers, a strategy referred to as ‘task shifting’

Research-Proposal-Proper as an abridged statement of interest.
 
In keeping with the mandate of NMHP I have selected an operational research question which aims to test the implementation of primary care integration of mental health care by trained GPs in the health department via an incentive augmented task-shifting paradigm.
 
Title
General Practitioner run outpatient clinic for mental health: Exploring the feasibility and role of monetary incentive as a motivational factor.
 
Principal Investigator:
Idea put forward by Ramkumar G. S. MD, Field Psychiatrist, Community Mental Health Program, Kottayam District.
Investigators: Negotiable

Duration of Study
One year

Background
With many years of experience with the training of General Practitioners (GPs) in Mental Health service delivery ever since the conceptualization of the National Mental Health Program (NMHP) in 1983, it has become clear that training is not correlated to service roll out in the periphery. The ICMR –DST study on severe mental morbidity (1987 Report) had forewarned that even though General practitioners gained knowledge after training their actual performance over a one year period was not good.

Based on certain anecdotal reports it is possible to believe that DMHP Thiruvananthapuram may have had some success in GP delivered mental health care, however we have report from northern Kerala and other parts of India that training alone does not translate to practice. The reasons may be due to include lack of motivation and not being adequately incentivised  for taking up this work, rather than just skill or confidence deficit.

Incentives have a major role in motivating health care professionals in running various public health programs. In a Cochrane systematic review (1) it was noted that financial incentives are being increasingly utilized for bettering health care delivery, though convincing research evidence is not available to support it unequivocally. In the review which evaluated seven studies it was found that there were positive outcomes of modest sizes in some, if not all, outcome measures like quality of care.

In the Indian context GPs working in facilities designated as rural areas are awarded rural service incentives (Rs 3000 per month), those working in difficult rural areas with special health packages are awarded (Rs 20,000 per month in addition to regular salary), those enhancing IP and lab facilities in their facility under the RSBYN scheme are awarded patient care allowances. Health workers involved in facilitating hospital delivery in Janani Suraksha Yojana (JSY) is another example of performance based financial incentive practice.

AIM of this study:
1. To explore whether a modest financial incentive will motivate a trained GP in running a mental health OP in a peripheral health centre and thus increase access to care to patients in the periphery.

2. To quantify the financial burden of this initiative for purpose of policy prescription.

Methodology

Design
Comparison of study group with the control group.

Control group
Status quo situation which is that no GP have come forward for delivering mental health care in the periphery even after providing training for some of them about six months back.

Study Group (n=10) see flow chart
DMHPstudy

 

Primary Outcome measure
Groups compared based on
1. No of mental health clinics in the periphery managed independently by trained GPs.
2. No of patients who received mental health care in GP run clinics as a reflection of increased access to care.

Secondary Outcome measures
1. Percentage of response to request for participation in this research work as a measure of interest in financial incentive based care.
2. Number of GPs who completes one year of running mental health clinics.
3. Assess GP comfort level in running mental health clinic and willingness to continue it if it becomes a policy decision.
4. Patient satisfaction levels with GP run mental health clinics.

Ethical approval:
Ethical clearance by the appropriate review committee as research participants are

(1) The Field Psychiatrist who is employed on contract under NRHM,
(2) Trained GPs working under the Health Department and
(3) The Nodal office which handles the finances is attached to the medical education department.

Expenses

Postage and paper work Rs 6000
Incentive money for research participants Rs 30000
Writing and publication costs Rs 4000
Miscellaneous Rs 5000
Training Rs Nil
Total expenses Rs 45,000.00

 Policy Implication

If a performance based financial incentive is found to work, the financial implication to the exchequer may be duly ascertained for a possible scale up of primary care integration of mental health care in the NMHP via a sustainable performance based financial incentive model.

 Reference:

1. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane database Syst. Rev. 2011;(9):CD008451. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21901722. Accessed January 27, 2014.

INCREASING PATIENTS IN CMHP/DMHP CLINICS..WHERE ARE WE HEADING TO..???

Post by Dr Anoop, Medical officer in charge of CHMP Palakkad district.

The progressive rise in number of patients attending CMHP clinics leads to a concern as to where are we heading towards and what is the limit??? (for in Palakkad within one year of functioning a few clinics have as high as 100+ patients every month with 5-6 new cases/month adding on…..So a natural question is, it being a government program can we restrict the patients attending the clinic??? and if not will it be possible to give quality care to such large number of  patients within a limited time span???

Even if we advise once in 2 or 3 months visit for few patients, we have a limitation to administer them medicine for total 2 or 3 months in one go (because of drug shortage) and hence the patients  invariably turn up every month at the  clinic……

It is high time to train and shift the clinical load to trained medical officers…………………….else NMHP outreach clinics may well turn out to be nothing more than a glorified pharmacy service!!

“Counselling room” opened at extension clinics of CMHP-Kottayam.

Counselling rooms were opened as part of the Community Mental Health Programme (CMHP) Kottayam at its monthly outreach clinics.

IMG_0003Note the portable stand-ease board  which is can be rolled down and packed into a carry bag for the next clinic.

Services offered are

  • Psycho-eduction about illness behavior
  • Drug Compliance therapy.
  • Care giver support
  • IDEAS Disability assessment
  • MET interviewing for Alocohol using patients
  • Brief supportive psychotherapy for Common Mental health issues.
  • Assessment of children with behavioral problems
  • Assessment of women and elderly who need intensive case management needs.
  • Case management of dementia and mentally retarded children.
  • Linking home based care by collaboration with field staff ( (JHI/JPHN) who have started attending the clinic. (Patronage for the same received from the deputy DMO-Kottayam).

IMG_0001

“SEIZURE CLINIC” at CMHP, Palakkad.

anoop gInvited Contribution: Dr.ANOOP.G, Medical Officer, Community mental Health program (CMHP) at Palakkad, reports about a seizure clinic  organised at Pallakad and  also answers three questions on the CMHP experience.

The  Community Mental Health Program (CMHP) of Palakkad district conducted a “SEIZURE CLINIC” at the district hospital on January 5, 2014 (Sunday). It was a joint venture with doctors from Neurology department of Amritha Institute of Medical Science (AIMS), Ernakulam.

From a total of  884 patients who are registered and on regular follow up with the CMHP at its 20 mental health outreach clinics, a separately compiled SEIZURE REGISTRY  revealed about 78 cases who suffered from seizure disorder.

It included cases like Juvenile Myoclonic Epilepsy, Landau-Klefner Syndrome and focal seizure disorder cases that are potential candidates for curative surgery. The reason behind the idea of setting up such a one day clinic was mainly to create awareness and alleviate  stigma associated with seizure disorder which hampered the marital life and occupational life of many .Depressive symptoms were evident in many and often led to social isolation.DSC06481

The concept of curability of focal seizures by advanced yet easily carried out epileptic surgery was an eye opener (Thanks to Dr. Siby Gopinath mam of AIMS for her special enthusiasm). A 3 tesla MRI with high quality video EEG monitoring can presurgically evaluate possible cases and can locate the exact focus….which if removed surgically …can lead to permanant cure…)

About 19 patients from the  40 who attended the clinic were identified  as potential candidates for surgical cure of which four people who were found to be the most needy were recruited for surgery. It is hoped that the quality of life of these  identified patients will dramatically improve after surgery. Optimisation of epileptic medications was done for all patients.

The clinic was coordinated by myself and was attended by three doctors from AIMS -Dr. Siby Gopinath (Epileptologist)  ,Dr. Ashok ( Neurosurgeon) ,Dr.Sharath  Menon (my friend& senior at Kottayam  and presently DM resident in Neurology)

Q & A

1. Dr Anoop , as the MO trained in mental health you have been running the outreach activities  of CMHP Pallakad over the last one year. How did this attention towards seizure disorders come into the picture.

Seizure management/epilepsy was initially not under consideration as the major focus is on psychiatric disorders. But considering into account the increasing number of patients turning up at each clinic every month with the hope of free availability of their seizure medications (Valproate, Carbamazepine), we started thinking of including a SEIZURE REGISTRY  to access the disease burden. Besides the interaction with Dr.Siby Gopinath, who is currently working in surgical care for refractory focal seizures and her reports regarding permanent cure in such cases led me to think of conducting such a one day clinic. I screened all the 78 seizure patients and those identified as focal seizures (38 cases) were brought to the clinic.

 2.  I understand that you are in charge of the CMHP as a deputed officer from the health department. I remember you telling something about hardships of being in a deputed  post. Can you elaborate…

A medical officer in health service will be receiving his salary in the 2nd working day itself. The deductions like SLI, GI, Provident fund will be duly deducted and net pay will be easily processed by SPARK software. Moreover updates regarding annual increment, increased DA etc will be naturally processed by SPARK and no issues regarding this. I also had charge allowance of Rs.360/-(ok leave it)..but also rural allowance of 3000/- per month…

But when i joined on deputation, i found it shocking……in spite of  all other good things…  I receive only Rs 40,103/- which was my gross pay as per my LPC then…regarding by subsequent increase in DA / Increment , I had to keep writing to AGs office and wait…..it has been just processed and i expect it will come only by February… increase in HRA is not released, pending  reply from the AG. Under NRHM, I should call myself really lucky if I could receive my salary before 9th or 10th of month! From this gross pay, I will have to find myself time to go to treasury to remit all my deductions which were previously through SPARK and now i have to fill up chalans .

I am posted at District Hospital under NRHM with overall control by nodal office at Thrissur medical college…Now during the hectic continuous clinics…..20 clinics per month….I was equally worried about the red line in attendance register and late markings by District Hospital authority… it was often frustrating…. the busy schedule where u have to leave early morning on all days.

The post of team psychiatrist is vacant…..that leads to increased work load with often no breaks…but special thanks to my authorities at Nodal office for providing special arrangements to ease my work in 10+ clinics. We have 1029 registered patients by January 2014…3 clinics out of 20 have more than 100 hits every time…

I HOPE THE WORK LOAD WILL NOT BE AN ISSUE IN COMING YEARS..WHEN TRAINING AND SHIFT TO MEDICAL OFFICERS STARTS…..BUT REGARDING PAY/ALLOWANCES AND SERVICE MATTERS OF DOCTORS…SOME ARRANGEMENT SHOULD BE MADE…ELSE DEPUTATION WILL TURN OUT TO BE A NIGHTMARE AND AT THE SAME TIME DISCOURAGING FOR DOCTORS…THE ISSUE SHOULD BE TAKEN UP AT THE EARLIEST BY STATE MENTAL HEALTH AUTHORITY..is my request…

3.  I am sure you will continue to offer mental health services to your clientele once you return to general medical care after your deputation. Any personal reflections on the CMHP experience. Thank you for contributing to the blog and best wishes in your future endeavours especially for the forthcoming All India PG counselling 🙂

Infact I should first thank my teacher at medical college Kottayam Dr. Varghese Punnose sir for kindling the spark of interest, a solid base in undergraduate life… and with Dr. Sumesh T P, my friend and brotherly figure and the same time, my PG then at Kottayam and presently my Nodal Officer for carrying me through with the momentum…

A turning point at Palakkad was the substance abuse screening project (see link) and meeting with a giant in the field, Dr.Shaji sir, HOD, Thrissur medical college who intoduced me to the concept of research and practical management. Working under him so far was a real blessing…It was he who introduced me to use of mhGAP IP guide for management.

I am sure graduate level doctors can really do a lot in this field…..a lot in IEC activities, basic management of several conditions and effective follow up….

The ironical aspect is graduate doctors (who) express fear over prescription of antipsychotics and mood stabilisers and often refer for “evaluation ” to me, who is no more than a MBBS doctor like them but with 3 months training at Thrisur medical college…so I would like to point out that if a graduate doctor with training can do basic management in this field.. that is simply possible with any other  doctor…

Now after returning to health service  from march 5, 2014………..planning to continue basic psychiatric management in  patients if detected in routine general practice and to work along with concerned DMHP/CMHP  in district where I may be posted as a support to the team. Also plan to continue with the IEC activities.

Some plans still remains unfinished…….like Ashwasakiranam project Rs 525/- per month to care giver of all dependent MR patients…we have already made MR register…….program for caregivers of Dementia patients…..we have dementia register…seizure management……………………

……after 2 yrs of no exams, no reading….don’t know how I qualified for All India (PG Entrance)  and waiting if I can get DPM at least, by my score…even if not….life has much more for someone in health services….Thank u.