THE BRITISH COLUMBIA NEUROPSYCHIATRY PROGRAM

THE PROVINCIAL CLINICAL-ACADEMIC NEUROPSYCHIATRY PROGRAM

BASED IN VANCOUVER, CANADA

SEPTEMBER 16, 2016

Dr. Islam Hassan, MBChB, MMedSc, MRCP(UK), MRCPsych, FRANZCP, FRCP(C) Clinical Assistant Professor, Dept. of Psychiatry, University of British Columbia

Professor Trevor Hurwitz, MBChB, MRCP(UK), FRCP(C) (Psychiatry & Neurology)

Clinical Professor, Dept. of Psychiatry, University of British Columbia

DECLARATION STATEMENT

THE PRESENTERS HAVE NO COMPETING INTERESTS TO DECLARE.

LEARNING OBJECTIVES

AT THE END OF THIS SEMINAR, PARTICIPANTS WILL HAVE AN UNDERSTANDING OF:

1. THE HISTORY OF THE PROGRAM

2. THE MODEL OF CLINICAL SERVICE DELIVERY

3. THE LEVEL OF CLINICAL-ACADEMIC SUBSPECIALIZATION WITHIN THE PROGRAM

4. THE CLINICAL EDUCATION ROLE INCLUDING THE TWO-YEAR FELLOWSHIP

§  SETTING: DEMOGRAPHICS AND HEALTHCARE SYSTEM §  ORIGINS OF THE PROGRAM §  PROGRAM FLOWCHART §  CLINICAL-ACADEMIC SPECIALIZATION WITHIN THE PROGRAM §  CLINICAL EDUCATION ROLE

OUTLINE

§  SETTING: DEMOGRAPHICS AND HEALTHCARE SYSTEM §  ORIGINS OF THE PROGRAM §  PROGRAM FLOWCHART §  CLINICAL-ACADEMIC SPECIALIZATION WITHIN THE PROGRAM §  CLINICAL EDUCATION ROLE

OUTLINE

§  AREA 944,735 KM2 §  POPULATION 4,720,932 §  POPULATION (METRO VANCOUVER) 2,313,328

SETTING: DEMOGRAPHICS

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CANADA

§  AREA 944,735 KM2 §  POPULATION 4,720,932 §  POPULATION (METRO VANCOUVER) 2,313,328

SETTING: DEMOGRAPHICS

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PROVINCE OF BRITISH COLUMBIA

§  AREA 944,735 KM2 §  POPULATION 4,720,932 §  POPULATION (METRO VANCOUVER) 2,313,328

SETTING: DEMOGRAPHICS

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CITY OF VANCOUVER

PROVINCE OF BRITISH COLUMBIA

§  AREA 944,735 KM2 §  POPULATION 4,720,932 §  POPULATION (METRO VANCOUVER) 2,313,328

SETTING: DEMOGRAPHICS

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POPULATION DENSITY

SETTING: DEMOGRAPHICS

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POPULATION PYRAMID

SETTING: DEMOGRAPHICS

BCStats2016

POPULATION GROWTH

SETTING: DEMOGRAPHICS

KnowBC.com2016

CULTURAL DIVERSITY IN METRO VANCOUVER

SETTING: DEMOGRAPHICS

EUROPE 57%

CHINA/SE ASIA 28%

INDIA/SUBCONTINENT

11%

MIDDLE EAST 2%

SOUTH AMERICA 1% AFRICA

1%

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§  PRACTICALLY A SINGLE-TIER SYSTEM

§  PUBLIC HEALTH INSURANCE FUNDS HOSPITAL STAYS AND CLINICIAN FEE-FOR-SERVICE

§  MOST CLINICIANS ARE INCORPORATED SERVICE PROVIDERS

SETTING: HEALTHCARE SYSTEM

REGIONAL HEALTH AUTHORITIES

SETTING: HEALTHCARE SYSTEM

www2.gov.bc.ca2016

§  SETTING: DEMOGRAPHICS AND HEALTHCARE SYSTEM §  ORIGINS OF THE PROGRAM §  PROGRAM FLOWCHART §  CLINICAL-ACADEMIC SPECIALIZATION WITHIN THE PROGRAM §  CLINICAL EDUCATION ROLE

OUTLINE

§  1987: DE-INSTITUTIONALIZATION (DRAFT PLAN TO REPLACE RIVERVIEW HOSPITAL)

§  2002: TRANSITION FROM 800 BEDS AT RIVERVIEW

TO 920 MENTAL HEALTH BEDS THROUGHOUT GENERAL HOSPITALS

ORIGINS OF THE PROGRAM

§  2000: BC NEUROPSYCHIATRY PROGRAM CREATED §  PARTNERSHIP BETWEEN RIVERVIEW HOSPITAL AND UBC HOSPITAL §  TERTIARY CARE

ORIGINS OF THE PROGRAM

PRIMARY CARE (FAMILY PHYSICIAN)

SECONDARY CARE (GENERAL PSYCHIATRIST)

TERTIARY CARE (NEUROPSYCHIATRIST)

GOALS

§  COORDINATE PROVINCIAL NEUROPSYCHIATRY SERVICES

§  DEVELOP COST-EFFECTIVE SERVICES THAT MEET THE NEEDS OF THE

PROVINCE

§  IMPROVE NEUROPSYCHIATRY CARE THROUGH RESEARCH & EDUCATION,

INCLUDING A FELLOWSHIP PROGRAM, SPECIALIZED ROUNDS &

CONFERENCES

§  SUPPORT & PROMOTE THE CONTINUUM OF CARE FOR NEUROPSYCHIATRY

PATIENTS

ORIGINS OF THE PROGRAM

MEMBERS OF THE TERTIARY NEUROPSYCHIATRY PROGRAM

§  10 PHYSICIANS (ALL FRCP(C) & CLINICAL FACULTY AT UBC):

7 FELLOWSHIP-TRAINED NEUROPSYCHIATRISTS

2 PHYSICIANS DOUBLE-CERTIFIED IN BOTH PSYCHIATRY & NEUROLOGY

1 BEHAVIOURAL NEUROLOGIST

§  NEUROPSYCHOLOGIST & PSYCHOMETRIST

§  NURSING STAFF, SOCIAL WORKER, OCCUPATIONAL THERAPIST,

PHYSIOTHERAPIST

§  PROGRAM COORDINATOR & ADMINISTRATIVE ASSISTANT

§  RESEARCH COORDINATOR

ORIGINS OF THE PROGRAM

COMPONENTS OF THE TERTIARY NEUROPSYCHIATRY PROGRAM

§  ACUTE DIAGNOSTIC ASSESSMENT & TREATMENT (INPATIENT UNIT)

§  AMBULATORY ASSESSMENT, TREATMENT & OUTREACH (OUTPATIENTS)

§  NEUROBEHAVIORAL STABILIZATION (HILLSIDE CENTRE)

ORIGINS OF THE PROGRAM

ACUTE DIAGNOSTIC ASSESSMENT & TREATMENT (INPATIENT UNIT)

§  UBC HOSPITAL

§  10-BED OPEN UNIT

§  MOSTLY VOLUNTARY

§  AVG 74 DISCHARGES PER YEAR

§  AVG LENGTH OF STAY 49 DAYS

ORIGINS OF THE PROGRAM

AMBULATORY ASSESSMENT, TREATMENT & OUTREACH (OUTPATIENTS)

Ø  UBC HOSPITAL, VANCOUVER GENERAL HOSPITAL & OUTREACH

Ø  SUBSPECIALTY FOCUS AREAS: §  EPILEPSY (CO-LOCATED)

§  MOVEMENT DISORDERS (CO-LOCATED)

§  MULTIPLE SCLEROSIS & DEMYELINATING DISORDERS (CO-LOCATED)

§  NEURODEGENERATIVE DISORDERS & HUNTINGTON’S DISEASE (CO-LOCATED)

§  LIMBIC SURGERY & DBS FOR NEUROPSYCHIATRIC DISORDERS

§  NEUROPSYCHIATRIC GENETICS & NEUROMETABOLIC DISORDERS

§  TRAUMATIC BRAIN INJURY

§  NEUROVASCULITIDES

§  TIC DISORDERS

§  SOMATOFORM DISORDERS

§  PAIN

ORIGINS OF THE PROGRAM

NEUROBEHAVIORAL STABILIZATION (HILLSIDE CENTRE)

§  KAMLOOPS, BRITISH COLUMBIA

§  10-BED SECURE UNIT

§  MOSTLY UNDER CERTIFICATE

§  DISINHIBITION AND AGGRESSION

§  LENGTH OF STAY UP TO 1 YEAR

ORIGINS OF THE PROGRAM

COMPONENTS OF THE TERTIARY NEUROPSYCHIATRY PROGRAM

§  ACUTE DIAGNOSTIC ASSESSMENT & TREATMENT (INPATIENT UNIT)

§  AMBULATORY ASSESSMENT, TREATMENT & OUTREACH (OUTPATIENTS)

§  NEUROBEHAVIORAL STABILIZATION (HILLSIDE CENTRE)

ORIGINS OF THE PROGRAM

COMPONENTS OF THE TERTIARY NEUROPSYCHIATRY PROGRAM

§  ACUTE DIAGNOSTIC ASSESSMENT & TREATMENT (INPATIENT UNIT)

§  AMBULATORY ASSESSMENT, TREATMENT & OUTREACH (OUTPATIENTS)

§  NEUROBEHAVIORAL STABILIZATION (HILLSIDE CENTRE)

§  CENTRALIZED TRIAGE WITH SINGLE POINT OF ENTRY

ORIGINS OF THE PROGRAM

ORIGINS OF THE PROGRAM

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

COMPONENTS OF THE TERTIARY NEUROPSYCHIATRY PROGRAM

§  SETTING: DEMOGRAPHICS AND HEALTHCARE SYSTEM §  ORIGINS OF THE PROGRAM §  PROGRAM FLOWCHART §  CLINICAL-ACADEMIC SPECIALIZATION WITHIN THE PROGRAM §  CLINICAL EDUCATION ROLE

OUTLINE

PROGRAM FLOWCHART

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

REFERRAL SOURCES (2015; N=423)

PROGRAM FLOWCHART

HOME

RESIDENTIAL FACILITY

58%

40%

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

1%

HOSPITAL

REFERRAL SOURCES (2015; N=423)

PROGRAM FLOWCHART

HOME 58%

HOSPITAL 40%

RESIDENTIAL FACILITY

1%

HILLSIDE 1%

REFERRAL SOURCES (BY SETTING, 2015)

PROGRAM FLOWCHART

PSYCHIATRIST 72%

NEUROLOGIST 11%

FAMILY PHYSICIAN

17%

REFERRAL SOURCES (BY SPECIALTY, 2015)

PROGRAM FLOWCHART

FRASER 43%

VANCOUVER COASTAL 35%

REFERRAL SOURCES (BY REGION, 2015)

PROGRAM FLOWCHART

FRASER 43%

VANCOUVER COASTAL 35%

REFERRAL SOURCES (BY REGION, 2015)

PROGRAM FLOWCHART

FRASER 43%

VANCOUVER COASTAL 35%

REFERRAL SOURCES (BY REGION, 2015)

PROGRAM FLOWCHART

HOME

RESIDENTIAL FACILITY

58%

40%

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

1%

HOSPITAL

TRIAGE OUTCOMES (2015; N=423)

CENTRALIZED TRIAGE WITH SINGLE POINT OF ENTRY

§  DEFINE APPROPRIATE PRESENTATIONS:

Ø  KNOWN NEUROLOGIC DISEASE WITH PSYCHIATRIC COMORBIDITY

Ø  COMPLEX PRESENTATIONS WITH BOTH NEUROLOGIC AND

PSYCHIATRIC SYMPTOMS, FOR DIAGNOSTIC CLARIFICATION

Ø  CHALLENGING SOMATOFORM, FOR DIAGNOSTIC CLARIFICATION

§  MUST MEET A THRESHOLD OF COMPLEXITY (TERTIARY PROGRAM)

§  LIMITED RESOURCES - WAITLIST

PROGRAM FLOWCHART

PROGRAM FLOWCHART

HOME

RESIDENTIAL FACILITY

58%

40%

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

1%

HOSPITAL

TRIAGE OUTCOMES (2015; N=423)

PROGRAM FLOWCHART

HOME

RESIDENTIAL FACILITY

58%

40%

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

1%

HOSPITAL

55%

11%

6%

28%

TRIAGE OUTCOMES (2015; N=423)

DID NOT MEET CRITERIA

PROGRAM FLOWCHART

SOMATOFORM DISORDERS

20%

NEUROLOGICALDIAGNOSESWITHPSYCHIATRICSYMPTOMS

80%

DIAGNOSES INPATIENT DATA (2006-2015; N=782)

PROGRAM FLOWCHART

0 5 10 15 20 25 30

DEMENTIAS/NEURODEGENERATIVE

MOVEMENTDISORDERS

EPILEPSY

MSANDOTHERDEMYELINATING

NEURODEVELOPMENTAL

OTHER(INCLUDINGTBI)

PERCENTAGE

DIAGNOSES

SUBCLASSIFICATION BY NEUROLOGIC DIAGNOSIS - INPATIENTS (2006-2015)

DIAGNOSES

SUBCLASSIFICATION BY PSYCHIATRIC DIAGNOSIS - INPATIENTS (2006-2015) (EXCLUDING SOMATOFORM)

PROGRAM FLOWCHART

0 5 10 15 20 25 30 35 40 45

DEPRESSIVEDISORDERS

PSYCHOTICDISORDERS

BIPOLARAFFECTIVEDISORDER

ANXIETYDISORDERS

SUBSTANCEUSEDISORDERS

OTHER

PERCENTAGE

DISCHARGE DISPOSITION (2015; N=423)

PROGRAM FLOWCHART

HOME

RESIDENTIAL FACILITY

58%

40%

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

1%

HOSPITAL

55%

11%

6%

28%

DID NOT MEET CRITERIA

DISCHARGE DISPOSITION (2015; N=423)

PROGRAM FLOWCHART

HOME

RESIDENTIAL FACILITY

58%

40%

OUTPATIENTS

INPATIENT UNIT

STABILIZATION UNIT

TRIAGE

1%

HOSPITAL

55%

11%

6%

28%

78%

16%

4%

HOME

HOSPITAL

RESIDENTIAL FACILITY

DID NOT MEET CRITERIA

§  SETTING: DEMOGRAPHICS AND HEALTHCARE SYSTEM §  ORIGINS OF THE PROGRAM §  PROGRAM FLOWCHART §  CLINICAL-ACADEMIC SPECIALIZATION WITHIN THE PROGRAM §  CLINICAL EDUCATION ROLE

OUTLINE

CLINICAL-ACADEMIC SPECIALIZATION

§  NUMBER OF CLINICIANS FACILITATES (SUB-)SUBSPECIALIZATION §  CLINICAL RESEARCH: EXTENSION OF WELL-CHARACTERIZED

PATIENT POPULATION §  COLLABORATION WITH UBC BASIC SCIENCE RESEARCHERS

CLINICAL-ACADEMIC SPECIALIZATION

ACTIVE RESEARCH AREAS §  BEDSIDE NEUROCOGNITIVE ASSESSMENT INSTRUMENTS

BNCA, RAM-T, PROSPEE, GAUTENG §  LIMBIC SURGERY PROGRAM

OUTCOMES & DTI POST-ANT. CAPSULOTOMY

§  NEUROGENETICS MAGERS

§  MILD TBI OUTCOMES AND ADVANCED IMAGING POST-MTBI

CLINICAL-ACADEMIC SPECIALIZATION

ACTIVE RESEARCH AREAS (CONT’D) §  MOVEMENT DISORDERS

PSYCHIATRIC ASPECTS OF PHARMACOTHERAPY & DBS

§  SOMATOFORM DISORDERS OUTCOMES OF THERAPY

§  MULTIPLE SCLEROSIS IMAGING CORRELATES OF NEUROCOGNITIVE DEFICITS

CLINICAL-ACADEMIC SPECIALIZATION

ACTIVE RESEARCH AREAS (CONT’D) §  EPILEPSY

PROSPECTIVE DB (EMU ASSESSMENTS; COLOCATED CLINIC); COMORBIDITES; SURGERY; PNES TREATMENT

§  CASEBOOK OF NEUROPSYCHIATRY

§  SETTING: DEMOGRAPHICS AND HEALTHCARE SYSTEM §  ORIGINS OF THE PROGRAM §  PROGRAM FLOWCHART §  CLINICAL-ACADEMIC SPECIALIZATION WITHIN THE PROGRAM §  CLINICAL EDUCATION ROLE

OUTLINE

CLINICAL EDUCATION ROLE

§  WEEKLY NEUROPSYCHIATRY GRAND ROUNDS

Ø  LOCAL, NATIONAL AND INTERNATIONAL INVITED SPEAKERS Ø  BROADCAST VIA TELECONFERENCING TO 20 SITES

IN BRITISH COLUMBIA AND ALBERTA §  WEEKLY NEURORADIOLOGY ROUNDS

ONE HOUR DEDICATED TO NEUROPSYCHIATRY CASES §  WEEKLY NEUROSCIENCES GRAND ROUNDS

§  NEUROPSYCHIATRY ROUNDS VIA TELECONFERENCING WITH SOUTH AFRICAN NEUROPSYCHIATRY GROUP

CLINICAL EDUCATION ROLE

UBC FACULTY OF MEDICINE TEACHING

§  3RD YEAR NEUROLOGY RESIDENTS (CORE ROTATION)

§  4TH AND 5TH YEAR PSYCHIATRY RESIDENTS (ELECTIVE)

§  MEDICAL STUDENTS (ELECTIVE)

HOSTING VISITING TRAINEES AND CLINICIANS INTERPROVINCIALLY AND INTERNATIONALLY

CLINICAL EDUCATION ROLE

TWO –YEAR NEUROPSYCHIATRY FELLOWSHIP §  ACCREDITED BY UCNS

ucns.org2016

CLINICAL EDUCATION ROLE

TWO –YEAR NEUROPSYCHIATRY FELLOWSHIP

Ø  CLINICAL FELLOWSHIP Ø  OPEN TO PSYCHIATRISTS AND NEUROLOGISTS

Ø  CLINICAL SUPERVISION & DIDACTIC PROGRAM OF

LECTURES EVERY OTHER WEEK COVERING UCNS CURRICULUM

CLINICAL EDUCATION ROLE

TWO –YEAR NEUROPSYCHIATRY FELLOWSHIP

Ø  FIRST YEAR (NEUROLOGY)

§  GENERAL NEUROLOGY WARD (+ CALL DUTIES) §  STROKE UNIT (+ CALL DUTIES) §  NEUROLOGY CONSULTATION SERVICE (+ CALL DUTIES) §  SEIZURE INVESTIGATION UNIT §  NEUROLOGY AMBULATORY CLINICS §  NEURORADIOLOGY §  NEUROLOGICAL REHABILITATION §  NEUROANATOMY TEACHING ASSISTANT

CLINICAL EDUCATION ROLE

TWO –YEAR NEUROPSYCHIATRY FELLOWSHIP

Ø  SECOND YEAR

§  INPATIENT NEUROPSYCHIATRY WARD

§  OUTPATIENT NEUROPSYCHIATRY CLINICS

CLINICAL EDUCATION ROLE

TWO –YEAR NEUROPSYCHIATRY FELLOWSHIP

Ø  ALUMNI INCLUDE

§  7 NEUROPSYCHIATRISTS RETAINED AS CONSULTANTS

§  2 NEUROPSYCHIATRISTS IN CALGARY, ALBERTA

§  1 NEUROPSYCHIATRIST IN SINGAPORE

THE BRITISH COLUMBIA NEUROPSYCHIATRY PROGRAM

www.bcnp.ca

Professor Trevor Hurwitz t.hurwitz@ubc.ca

Dr. Islam Hassan islam.hassan@vch.ca