MH Strategic Plan-Multi-Year Implementation

Transcription

Mental Health Multi-Year
Implementation Framework
May 2013 Report
Erie St. Clair Local Health Integration Network
Appendices
Agenda Item 9.1
Table of Appendices
Appendix 1 - Terms of Reference
1
Appendix 2 - Assumptions Underlying the Erie St. Clair Mental Health Strategic Plan
5
Appendix 3 - Future State Mapping Summary
7
Appendix 4 - Erie St. Clair Mental Health and Addictions Funding Commitments
(2012 - 2014)
10
Appendix 5 - Decision Making Template
12
Appendix 6 - Phase One: Opportunities
13
Appendix 7 - Phase Two and Three Opportunities
18
Appendix 8 - Assertive Community Treatment Transition Readiness (ATR) and Ontario
Common Assessment of Need (OCAN) Key Domains Aligned
21
Appendix 9 - Mental Health Driver Diagram
22
Appendix 10 - Next Day Bookings
23
Appendix 11 - Cost, Benefit, Risks, Options Template
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Erie St. Clair MH Multi-Year Implementation Framework
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ii
Appendix 1 - Terms of Reference
Background
In December 2011, the Erie St. Clair Local Health Integration Network (Erie St. Clair LHIN)
commissioned a consulting firm to undertake the development of an adult (age 16+) Mental
Health (MH) Strategic Plan for the Erie St. Clair region. The planning process was overseen by
an advisory committee comprised of consumer-family initiatives, community mental health,
acute and specialized (tertiary) mental health providers, and representation from primary care.
The strategic plan was informed by engagement activities with a total of 496 individuals
providing feedback. The cumulative outcome includes 67 opportunities for change clustered
into nine strategic directions. Additional outcomes include future state vision statements,
14 unique population groups, and performance-based advancement plans to decrease mental
health emergency department (ED) repeat visits and readmissions within 30 days. In
November 2012 the Mental Health Strategic Plan was accepted in principal by the
Erie St. Clair LHIN Board of Directors as a going forward working document. The Erie St. Clair
LHIN Board directed staff to form a Mental Health Implementation Task Force with the mandate
of developing a multi-year work plan that includes conducting options based, cost-benefit
feasibility analysis and final recommendations. This action item is tabled for presentation to the
Erie St. Clair LHIN Board for May 2013.
Role Of The Mental Health Implementation Task Force
Task force members reflect strategic leadership experience and a broad mental health
knowledge base. Members will provide expert advice reflecting the best interests of the people
and families in the Erie St. Clair region living with mental health issues. The Erie St. Clair
Mental Health Implementation task force members have the decision-making ability and
authority to:
1. Determine the priority ranking of the 67 proposed opportunities and timelines.
2. Review and endorse opportunities on a regional or county by county basis.
3. Provide pertinent information to the task force and the Erie St. Clair LHIN with respect to
risks, mitigation strategies, benefits, and options for change.
4. Present research evidence based information.
5. Prioritize proposed quick win opportunities that strengthen service coordination, access,
clinical and performance based outcomes.
6. Review and prioritize opportunities requiring service enhancements.
7. Provide expert advice for the restructuring of the Erie St. Clair Mental Health and Addictions
Network as it relates to incorporation of the following future leadership tables:
a. Psychiatry Leadership Table
b. Primary Care and Mental Health Leadership Table
c. Community Mental Health and Inter-Hospital Leadership Table
d. Consumer/Family Stakeholder Engagement Table
e. Performance and Data Quality Leadership Table
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Erie St. Clair Mental Health Multi-Year Implementation Framework – Appendix 1
8. To declare reservations and/or disagreement about a proposed opportunity.
9. To recommend changes/expansion of the strategic plan timelines.
10. To utilize the Erie St. Clair LHIN dispute resolution process.
11. Identify opportunities that need further planning.
12. Review the 14 unique population groups as it relates to priority ranking and opportunities.
A quorum for task force members will be a simple majority. In the absence of a simple
majority, a meeting may proceed, and decisions or advice may be formulated with reference
in the minutes to the absence of a quorum. When a vote is taken a simple majority of those
present is sufficient to determine a vote.
Task Force Membership
Name
Dr. Mary Broga
Alan Stevenson
Kristen Williams
Lynda Robinson
Dr. Sonja Grbevski
Jean Laforge
Kelly Gottschling
Paula ReaumeZimmer
Mary Wilson
Frank Chalmers
Dawn Maziak
Organization & Area of Expertise
Windsor Regional Hospital, Vice President (VP)
Family Mental Health, Tertiary Care, Assertive
Community Treatment (ACT) Teams, Child and
Adolescent MH care (and beds)
Canadian Mental Health Association Lambton Kent,
CEO, Community Mental Health
Chatham-Kent Community Health Centre, CEO,
Primary Care, Rebound, Youth
Bluewater Health, VP Mental Health, Acute Care and
Rural Health
Hôtel-Dieu Grace Hospital, Director of Mental Health
and Inpatient Surgery, Schedule One Facility,
Outpatient Programs including community crisis
(Community Outreach and Support Team (COAST
Model)
Mental Health Connection, Executive Director – Peer
Support and Family Network, Psycho Social Rehab
Models
Mental Health Network, Executive Director, Peer
Support and Family Network, Psycho Social Rehab
Models
Chatham-Kent Health Alliance, Director Schedule
One Facility and Outpatient Mental Health Programs
including crisis (HELP model) and Director of
Operations, Canadian Mental Health Association
Lambton Kent
Canadian Mental Health Association Windsor
Essex, Acting CEO, Community Mental Health
Erie St. Clair LHIN – Co-Chair
Erie St. Clair LHIN – Co-Chair
Sub LHIN Area
Windsor/Essex
Lambton-Kent
Chatham-Kent
Sarnia/Lambton
Windsor/Essex
Windsor/Essex
Chatham-Kent
Chatham-Kent
Windsor/Essex
-
2
Role of Co-Chairs
The Erie St. Clair Mental Health Implementation Task Force will be co-chaired by
Frank Chalmers, Health System Manager, and Dawn Maziak, Health System Design Manager,
of the Erie St. Clair LHIN. In the absence of the co-chairs a delegate will be selected from the
task force membership.
Agendas and Minutes
The co-chairs are responsible for preparing written agendas and ensuring that supportive
material and resources are disseminated in advance of the meetings. Meeting minutes will be
prepared by the Erie St. Clair LHIN administrative assistants. The minutes will reflect major
themes discussed decisions, and rationales, as well as action items for future meetings.
Minutes are considered draft until they are approved at the next task force meeting.
Guests and Delegates
The task force, the Erie St. Clair LHIN or individual members may request that a guest attend a
meeting as it relates to presenting evidence-based information or as a subject matter expert.
Attendance of a guest or delegate must be approved in advance by task force members and the
Erie St. Clair LHIN.
Task Force Life Span And Frequency Of Meetings
The task force will begin its work in January 2013 with a completion date of June, 2013. The
task force will meet every three weeks (face to face or by teleconference). Members will
determine if a future monitoring role is required e.g. quarterly meetings.
Confidentiality
The task force members agree that any information shared amongst the group is not
confidential unless a member or the Erie St. Clair LHIN advices otherwise. Each member
assumes the responsibility of advising the task force when any shared information is
confidential. In this circumstance the co-chairs shall ensure that the minutes do not contain
confidential information. Materials and or specific items deemed sensitive or confidential will be
determined at each meeting.
Principals For Decision Making
In carrying out its mandate and decision-making the task force will consider:
1. The Erie St. Clair Mental Health Strategic Plan and Vision Statements.
2. Evidence based practices and mental health research.
3. Existing provincial mental health planning documents.
4. The Erie St. Clair LHIN Integrated Health Service Plan overarching directions.
5. Client and family centred care.
6. Equity of scarce resources, directed to areas of greatest need including addressing
geographical/population hot spots that are high users of the system.
3
7. Decisions are designed to reduce barriers and service duplication, increase access,
responsiveness, coordination and integration.
8. The most effective, efficient and creative use of available resources.
9. System and client needs as opposed to individual organizations.
10. Sustainability and cost effectiveness.
11. Performance driven and consistent with the Erie St. Clair LHIN aims of reducing repeat
mental health ED visits, wait times for community services and re-admissions within 30
days.
12. Care is coordinated, integrated and seamless, “right care, right time, right place”.
13. Integration opportunities and tactical changes are designed to advance clinical outcomes
and system improvements.
Dispute Resolution
The task force members acknowledge that notwithstanding the intention of each to ensure open
and honest communication, they are separate organizations with different backgrounds and
cultures that may inevitably lead to honest differences of opinion. The members agree to
minimize, if not prevent, disputes by clearly articulating expectations, and establishing clear
lines of communications.
Where disputes remain in spite of honest and sincere efforts of the parties to resolve them, the
Erie St. Clair LHIN will determine the required process in an expeditious manner.
1. To declare reservations about a proposed opportunity: Task force members, who have
reservations about a given opportunity but are willing to allow the opportunity to be
approved, are expected to declare their concerns which are documented in the minutes of
the meeting. Although the expression of such disagreement does not stop a proposed
opportunity from being approved it is taken seriously by other task force members and the
Erie St. Clair LHIN. Every effort will be made to address the concerns of the dissenting
member(s) through clarification, discussion, and/or identifying opportunities for compromise.
2. To express disagreement with a proposed opportunity: Task force members who have
a serious disagreement with a proposed opportunity, and are not willing to let the
opportunity pass will be directed by the Erie St. Clair LHIN to complete a standardized
business case template. Both parties will have an opportunity to present their viewpoints to
the Erie St. Clair LHIN Chief Executive Officer, (CEO), Gary Switzer and Senior Directors.
The Erie St. Clair LHIN CEO has the authority to determine a final resolution with respect to
the disputed opportunity which may include a facilitated integration order.
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Appendix 2 - Assumptions Underlying the
Erie St. Clair Mental Health Strategic Plan
1. Planning for a complex system like mental health needs to be thorough and detailed enough
to reflect that complexity.
2. Complexity must be accompanied by simplicity. A mental health strategic plan must group
the complexities into a comprehensible and manageable set of strategic directions.
3. Some elements of the system may not be clear enough to allow highly specific system
improvements to be identified. In such instances it is appropriate for a strategic plan to
identify areas that need further planning.
4. Strategic planning for mental health will be followed by operational planning that will develop
detailed outcome indicators and more specific timelines.
5. Any proposed course of action put forward in a strategic plan will have unintended
consequences, sometimes positive consequences and sometimes negative ones. Followup operational planning must further define any of the consequences that are risks, and
must identify ways to reduce and manage the risks.
6. Strategic changes will take longer to implement than the three year timeframe for this plan,
and even longer to begin to show desirable results.
7. The chances of turning strategy into action will only be high if the strategic plan is seen as
the community’s plan, not the Erie St. Clair LHIN’s plan. Most of the time and energy it will
take to implement the plan must come from service providers (including agency board
members), service users, their families, and their time maybe in short supply.
8. Stakeholders generally believe that mental health strategic planning has failed more often
than it has succeeded. This perception is rooted in people’s belief that the problem was not
with the plans; it was failure of the will or resources needed to implement the plans, or a
tendency to allow other health priorities to override the priority that mental health should
have.
9. The ninth assumption (based on evidence from other jurisdictions) is that planned service
integration, be it loose or tight, seldom saves money directly, and often requires sizeable
initial investment. The payoff comes less from directly saved dollars than from improved
system efficiency and effectiveness (which can equate to savings in the long run).
Refreshed Assumptions
•
To support the provincial action plan’s goal of providing more community based care the
2012 budget will increase funding for home and community services by four percent
annually over the next three years (Ontario Budget 2012).
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Erie St. Clair Mental Health Multi-Year Implementation Framework - Appendix 2
•
In addition, the province will launch a Seniors Strategy building upon the successes of
the Aging at Home Program. This will put renewed focus on keeping people from being
unnecessarily admitted to hospital. The expansion of community based care, and the
call to empower LHINs to shift resources to where the need is greatest will be based on
local needs and plans developed throughout the Integrated Health Service Plan (IHSP).
This will require changes in the funding of the traditional health care providers in the
system and our hospitals will see some large changes in how the LHIN funds them to
make the system more patient-centred. LHINs will work with hospitals and community
partners to transition procedures out of high cost hospital settings into non-profit,
community-based clinics.
•
Further, hospitals’ base budgets will be transitioned into a patient-centred funding model
where the provider is rewarded for high quality care and better use of resources. LHINs
will work with hospitals to manage the plan for phased implementation of this change,
which began in April 2012. To help address the fiscal concerns of the province, hospital
base budgets have been frozen, and there will only be a two per cent increase in funding
for certain activity-based initiatives, such as targeted wait-times reductions, and priority
treatments (adopted from the IHSP 3).
•
Recently, a new initiative known as Health Links has been a primary focus of the 14
LHINs and the Ministry of Health and Long-Term Care (MOHLTC). Health Links is
based on multiple organizations using a concentrated approach towards addressing the
needs of the top users of the health care system. Health Links are defined by a
geographical population size of approximately 50,000 which essentially means that a
sample size of 200–300 individuals is potentially the highest users of the system. Health
Links is designed to enhance access, coordination/integration and transitions of care as
it relates to primary care, home care, community support services, mental
health/addictions and hospitals. Health Links as an operational entity has significant
implications for future planning and delivery of mental health services in the Erie St. Clair
region.
•
The Mental Health Strategic Plan identified a number of hospital sponsored programs for
future potential divestment to one integrated (Erie St. Clair LHIN-wide) Canadian Mental
Health Association (CMHA), referenced as the community mental health coordinating
agency. It is assumed that divestment of hospital sponsored programs to CMHA is
contingent upon integration occurring.
•
The task force engaged in a future state mapping exercise as a means of facilitating
decision making for prioritizing the strategic plans 67 opportunities. It is assumed that
the task force will adopt the future state mapping recommendations as phase one (12–
18 months) priorities.
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Appendix 3 - Future State Mapping Summary
Juncture One: Community to Emergency Department to
Schedule One Admission to Discharge to Community Key
Findings
Community
Regionally, there remains a need to educate the general public about how to access mental
health services in each community.
•
Mapping participants indicated that if the provincial philosophy of “Every Door is the
Right Door” was in place, there would be well publicized information about mental health
services in each community.
•
Concurrently, if a 24/7 single point of access was made available this mechanism could
provide an intake function with the ability to deploy a rapid response for service. It is
noteworthy that a mobile crisis response model already exists in Windsor-Essex. This
type of service is also available for mental health police mobile response teams in
Chatham-Kent (HELP TEAM) and Windsor-Essex Community Outreach and Support
Team (COAST). In Sarnia/Lambton mobile response can be accessed 24 hours/day.
The mobile response after regular business hours is initiated by the 24 hour telephone
crisis line (operated by CMHA staff in Chatham). When the staff of the crisis line
determines that a mobile response is required they page the on-call worker in Sarnia.
The on-call worker collaborates with Sarnia police to respond jointly to the caller in
mental health crisis.
•
Regionally, there is a gap in time from when a client is first seeking help to the time that
they actually receive the service. This gap in time is pervasive and mapping participants
identified that this is where clients require short-term support, and access to
determinants of health (income support, food and shelter/housing). As a root cause this
may explain some repeat ED mental health visits within a 30 day time span.
•
This need was further expanded upon with the identification of a system coordinator
function to align mental health clients with short term support while they waited for formal
placement with a mental health provider.
•
Additional elements required in the community include:
o
Enhanced primary care with access to next day mental health support.
o
Need for a range of housing options within each Erie St. Clair LHIN sub region.
o
Primary care practices that support mental health clients.
o
Vulnerable population groups noted as having significant access issues include the
Dually Diagnosed, elderly with dementia, youth transitioning from the Ministry of
Children and Youth Services (MCYS) service structure to the Erie St. Clair LHIN
adult (16+) mental health system.
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Emergency Department and Discharges to the Community
From the point of presenting at the ED mapping participants identified the following regional
needs:
•
Access to prior health and mental health information. Preferably via an Electronic Health
Record (EHR). In lieu of an EHR some form of identifier of past ED visits, the name of
the primary care provider and current (or former) mental health providers on a plastic
card.
•
Faster triage, moving mental health clients from the waiting room to another quieter area
for assessment. The ED is a fast paced, noisy environment.
•
For mental health clients in acute distress who may experience auditory or visual
symptoms; the ED is not a good environment for mental health clients to wait.
•
Psychiatric Assessment Nurses (PAN) based in the ED exists at each Schedule One
Facility specifically, Hôtel-Dieu Grace Hospital (HDGH), Chatham-Kent Health Alliance
(CKHA) and Bluewater Health (BWH). The mapping participants identified the need for
standardized evidence based assessment tools. The PAN model provides consultation
to the ED staff or act as a critical hand off for ED mental health clients after they have
been medically cleared as stable. The mapping participants further identified the need
for each PAN model to develop and communicate with external providers care paths and
where applicable mental health order sets.
•
The mapping participants also identified not being aware of the minimal admission
criteria for a Schedule One psychiatric admission.
•
From the family members perspective there is a desire to be informed that their loved
one is in the ED, and or being considered for admission.
•
Referrals and follow up appointments should be arranged while the patient is still in the
ED for such services as: mental health or psychiatry consults as next day appointments,
primary care referrals initiated (if the patient is orphaned) within 5 days. Standardized
referral/transfer forms that include recommendations from the PAN.
•
Given the wait times to access community based mental health services the mapping
participants recommended creation and funding for short-term support provided by a
case coordinator/case manager. This function would provide outreach addressing
determinants of health needs as well as monitoring until the client is formally accepted
by a community based mental health provider and/or psychiatrist.
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Juncture Two: Schedule One Admission & Discharge to
Tertiary or Transfer to Community Key Findings
Schedule One Admission
•
Emergency Department PAN or intake registered nurse needs to follow the patient when
admitted to a Schedule One bed. Ideally, the flow of patient information would occur via
an electronic record. Note: In some hospitals this activity is already in place via the
Emergency Psychiatric Screener (EPS). This recommendation illustrates the lack of
awareness of Schedule One processes, and assessment tool advances. The hospital
sector needs to better inform other sectors regarding processes for patient flow, criterion
for admission, and areas that they experience challenges. For instance, not every ED is
physically equipped with a quiet room/observation area separating acutely distressed,
mental health patients from the mainstream ED population.
Schedule One Discharge to Tertiary
•
Early identification of Schedule One patients requiring longer treatment or more
specialized tertiary services. The mapping participants suggested fast tracking to
ensure patients receive the right service in the right bed, as well as facilitating flow for
both acute and tertiary bedded services.
•
Communicate and educate providers about the eligibility criterion and various programs
provided by Windsor Regional Hospital, tertiary care.
•
Need for a LHIN-wide consistent methodology for discharging clients from Assertive
Community Treatment (ACT)/Program of Assertive Community Treatment (PACT) to
step down services provided by intensive case management.
Schedule One Discharge to Community
•
Schedule One staff should establish better linkages with existing community based
mental health providers by inviting them to participate in grand rounds when their client
is admitted and receiving treatment. This suggestion is inclusive of the consumer/family
initiatives that provide peer support and psycho-social rehabilitation.
•
Similarly, Schedule One needs to develop individualized discharge/transition plans in
collaboration with the patient, patient’s family members, and community based mental
health staff (if client has an existing provider).
•
Family members especially those with newly diagnosed loved ones need to be linked by
Schedule One facilities, psychiatrists, and staff to local family support initiatives. Family
members require greater education and coping skills as an equal care partner. The
National Alliance for the Mentally Ill (NAMI) Family to Family Education Program needs
to be leveraged, implemented, and publicly advertised as a key resource.
•
Transition plans would be developed collaboratively and could include primary care
providers who are often not aware that their patient has been admitted
.
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Appendix 4 - Erie St. Clair Mental Health and
Addictions Funding Commitments (2012 - 2014)
Table 1: Erie St. Clair LHIN Funding Commitments (12/13–13/14) Fiscal Year
Name of
Initiative
2012/13
(13–14)
MOHLTC
3 Year
Plan
Nurse
Practitioners for
Eating Disorders
ESC LHIN
IHSP 3
Priority
ESC LHIN
Board
Approved
Alignment
with
MH
Strategic
Plan
√
√
Provide help
early
Regional
Mental Health
Nurses in District
School Boards
√
√
Regional
Opiate Strategy
MOHLTC
prescribed
as per 4%
allocations
Provide help
early child
and
adolescents
Out of Scope
√
√
Regional/County
Specific
Health Service
Provider (HSP)
•
Regional
Addicted
Pregnant
Women
Erie St. Clair
and
Bluewater
Methadone
Clinic
Therapists
•
Erie St. Clair
Windsor, and
Bluewater
Methadone
Clinic ChathamKent and
Sarnia/Lambton
Withdrawal
Management
Services
(WMS)
City Centre CHC
RN Injection
Clinic
•
WMS
Sarnia/Lambton
•
Caring
Connections
•
priority
pop
addictions
•
√
Windsor and
primary care
long acting
injection
clinics
Windsor
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Table 1: Erie St. Clair LHIN Funding Commitments (12/13– 3/14) Fiscal Year (cont’d)
Name of
Initiative
2012/13
(13–14)
MOHLTC
3 Year
Plan
ESC LHIN
IHSP 3
Priority
ESC LHIN
Board
Approved
Alignment
with
MH Strategic
Plan
Regional/County
Specific
(HSP)
Inner City Model
Implementation
√
√
Reduce ED
Repeat Visits
Windsor
COAST and
HELP Teams
(Mental Health
and Police
Teams)
√
√
Mobilize help
for people
with complex
persistent
problems
(crisis)
Windsor
Chatham-Kent
Addiction
Residential Bed
Enhancements
Addiction
Program for
homeless men
Behavioural
Supports Ontario
(BSO)
Sustainability
√
√
Out of scope
√
√
Out of scope
Windsor-Essex
and ChathamKent
Windsor-Essex
√
√
Help for
complex
persistent
MH problems
Regional
Psycho Social
Rehab
√
√
Erie St. Clair
LHIN MH Next
Day Bookings
Wait List Strategy
√
√
Strengthen
CS/Family/
Peer Support
Provide Help
Early
Windsor-Essex
and ChathamKent
Regional
Help for
complex
persistent
problems
Windsor Super
Jail MOHLTC
driven
Integrate the
system and
enhance
community
MH services
Lambton Kent
Release from
Custody MH
Workers
CMHA
Integration
√
√
Note: Out of Scope refers to the Addiction Sector
11
Appendix 5 - Decision Making Template
Decision Criteria Summary #
INDICATOR
• Feasibility (high feasibility = 5)
• Degree that the opportunity can be implemented within reasonable time frames
Client and family focused (patient experience)
• Degree of support for the empowerment of the client (Recovery Model)
• Degree of support for services being available closer to home
• Impact on increasing client satisfaction
Evidence-based
• Extent of evidence available to support the model
• Ability to measure outcomes/results
• Standardized and reliable tools and measures
Sustainability Impact on the System:
• Short term impact (2)
• Medium term impact (3)
• Long term impact ( 4 -5)
Risk Impact
• Client- family risk - 0 no risk; 1 low; 2 medium and 3 high risk
• Operational - 0 no risk; 1 low; 2 medium and 3 high risk
• Financial - 0 no risk; 1 low; 2 medium and 3 high risk
• Political - 0 no risk; 1 low; 2 medium and 3 high risk
Navigation - Ease of Client Movement through the System
• Degree of enhancement of ease of movement, wrap around supports and continuity
through the system
Collaboration/Partnership
• Degree of support for establishing or strengthening partnerships models
Long-term impact on population health
• Impact on improving the health status of the population (health gain)
• Degree of support for effective health promotion and disease prevention (reducing
burden of disease)
Efficiency and Effectiveness:
• Degree of support for efficiency gain/improved utilization of existing resources
Quality and Client/Patient Safety Degree of impact on improving quality of services
 Humanization/Art of care (respect, support, communication)
 Quality (doing the right thing, appropriateness and doing it well, conformity of
process–standardization and ability to measure
 Accessibility
 Continuity
 Comprehensiveness
Opportunity #
Potenti Actual
al
Score
Score
5
5
5
5
12
5
5
5
5
5
Comments
•
•
•
Score of < 45 equates to Phase 2 (2015-2016)
Score of 46 – 50 equates to the Phase 3 of the Implementation Plan ( 2016+)
12
The Erie St. Clair LHIN should work with its communities as a strong voice for the
promotion of good mental health, understanding mental health, and helping build a
community response to support people with mental health problems.
The Erie St. Clair LHIN should encourage or require all health agencies it funds in Erie
St. Clair to prominently display access information about the Connex Ontario help lines
on their home pages and to post the information in their lobbies, and in other places
where people congregate. It should also encourage other helping sectors (municipal
offices and websites for instance, as well as drop-in centers and shelters) to display this
information.
The Erie St. Clair LHIN and its service delivery partners should continue, and if
necessary expand, their collaborative work with other sectors to improve child and youth
mental health, since the child and youth sectors are crucial in early identification and
help for mental health problems. The Erie St. Clair LHIN and its partners should:
•
Identify who does what in Erie St. Clair within the transition process between child
and youth mental health service systems.
•
Identify problems within the transition process / Identify best transition practices
•
Develop the capacity to act quickly on government policies supporting transition
•
Develop a collaborative transition support plan.
Leadership Table or
Responsible Party
Erie St. Clair LHIN and
all MH providers
Erie St. Clair LHIN,
mental health
providers and Connex
Ontario. This
opportunity has been
incorporated into
mental health
addiction
(Multi-Sectoral Service
Accountability
Agreement (MSAA)
Ministry of Children
and Youth Services
(MCYS) and mental
health providers
(existing work ongoing)
•
Create a multi-sectoral urgent need resolution process for youth and their families
facing immediate transition problems.
• Ensure that seamless transition takes place between anti-suicide strategies that
begin in childhood or teen years, and anti-suicide strategies that continue into young
adulthood.
Mental health services in Erie St. Clair should develop a collaborative wait list and wait
time management strategy, including ways to:
•
Remove unnecessary procedural barriers to receiving timely help using techniques
such as value stream mapping (a “lean manufacturing” technique), thereby reducing
wait times for service.
• Support people while they are on wait lists so they do not withdraw from the lineup,
so they can be quickly assessed in terms of their current condition (e.g. a worsening
of their condition that means they may need to move up the list or be diverted to a
crisis service), and so they know they have not been forgotten.
The use of mental health and addiction screening tools as part of primary care and of
emergency department procedures should be confirmed, expanded and supported in
Erie St. Clair.
Community Mental
Health and Inter
Hospital Leadership
Table
Community Mental
Health and Inter
Hospital Table in
collaboration with
Primary Care and
Mental Health Table
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Appendix 6 - Phase One: Opportunities (cont’d)
Assessment providers in Erie St. Clair should decide whether it is worth finding a way to
compare assessment information from Ontario Common Assessment of Need (OCAN)
and RAI-MH to provide more comprehensive information on a client’s needs if the client
has been served by both an inpatient unit and a community program. Optimize use of
Integrated Assessment Record (IAR).
Mental health providers in Erie St. Clair should examine whether and how aggregated
OCAN assessment results can be used as a system monitoring and tracking tool in
terms of unmet client need. Optimize use of Integrated Assessment Record (IAR)
Mental health service providers should examine ways to minimize wait time been initial
contact and assessment, and the time between assessment and the start of care or
support service.
In collaboration with primary care, the MH system should develop protocols and a
potential pool of resources to be provided via service agreements with primary care
organizations or practitioners to help them serve people with mental illness.
The Erie St. Clair LHIN should help create an Erie St. Clair Psychiatry Consortium to
foster discussion among psychiatrists and the rest of the mental health service system
about current and future needs for psychiatry in Erie St. Clair, and how best to meet
these needs.
The Erie St. Clair LHIN should negotiate and execute a joint hospital mental health
service accountability agreement with all hospitals in Erie St. Clair that provide mental
health services.
Hospitals in Erie St. Clair that provide mental health services should create an interhospital mental health service integration committee to:
•
Help hospitals to achieve the outcomes specified in the joint hospital mental health
services accountability agreement between the hospitals and the LHIN.
Leadership Table or
Responsible Party
Data, Quality and
Performance
Leadership Table
Data, Quality and
Performance
Leadership Table
Community Mental
Health and Inter
Hospital Leadership
Table
Primary Care and
Mental Health
Leadership Table
Psychiatrist
Leadership Table
Community Mental
Health and Inter
Hospital Leadership
Table
Community Mental
Health and Inter
Hospital Leadership
Table
•
Explore other opportunities for joint action related to hospital-based mental health
services in and for Erie St. Clair.
With support from the Erie St. Clair LHIN, mental health service agencies in Erie St. Clair
should conduct impartial canvasses of their clients to find out if agency hours of service
delivery match the expectations of clients.
The Connex Ontario next day booking model, as a way to connect crisis services with
the non-crisis mental health service system, should be introduced into Erie St. Clair.
Primary care groups and the CMHAs should harmonize the case management services
they provide across Erie St. Clair. (***may or may not be aligned with Health Links
initiative).
The Erie St. Clair LHIN should give high priority to expansion of mental health
rehabilitation services, and in particular (but not exclusively) to expansion of
consumer/provider/family rehabilitation services, starting with a refreshed and broadened
needs assessment-based analysis to create equitable distribution of rehabilitation
resources across Erie St. Clair, and to identify other rehabilitation needs.
mental health
providers. Consumer
and Family Leadership
Table
Tele Med and early
adopters mental health
and addiction health
service providers
Primary Care and
Mental Health
Leadership Table
Erie St. Clair
LHIN/Consumer and
Family Leadership
Table
14
Mental Health Connections should be designated as the agency to provide back office
functions for consumer/survivor/family-run rehabilitation agencies in Erie St. Clair, such
functions to include but not be limited to human resource support, training, data
management/information technologies and communications technologies.
Consumer/survivor/family-run rehabilitation agencies should remain or become
autonomous, but should enter as a group into a joint accountability agreement with the
Erie St. Clair LHIN.
Consumer/survivor/family-run rehabilitation agencies that serve both people with mental
illness and their families should ensure that their board membership comprises a
balance between people with a mental illness and family members of people with a
mental illness.
Mental health service providers and other service providers serving Windsor should
develop and implement an Inner City model for addressing the housing, mental health
and other needs of multi-service users (repeat ED MH clients) in Windsor.
The Erie St. Clair LHIN should explore, with stakeholders from a variety of fields:
•
The desirability and feasibility of creating a residential mental health facility for
younger people who exhibit responsive behaviours, very early onset of dementia,
some other neurological condition.
How mental health programming can be provided to this population either in-home, in a
long-term care home or in the specialized facility described above.
The Erie St. Clair LHIN should host a meeting of interested parties from within the
mental health services system to explore the possibility of creating a Mental Health in
Erie St. Clair website for both information compilation and retrieval purposes and
knowledge/opinion exchange purposes.
In the long-term, mental health services in Erie St. Clair should explore possibilities for
easily accessible co-location of mental health and related human services in Sarnia,
Chatham and Windsor. In the shorter term, the mental health service system in Erie St.
Clair should:
•
Ensure the co-location of mental health services and selected primary care
organizations via visiting mental health services provided on specific days at
community based sites and / or primary care organizations.
•
Create multi-service hubs in smaller communities, where few human service
agencies can afford to have a full-week presence, but where a number of agencies
can afford to have a presence for part of the week if hub space is available to them.
Mental health service providers in Erie St. Clair should continue to implement
innovative and effective ways to bring services to rural people, or to help rural people
to get to the services they need.
• Make further use of tele-links to create virtual co-location.
Mental health service providers should decide whether they want to develop a tiered
navigation model. If so, they should develop an estimate of the resources needed to
implement the tiered navigation model.
Leadership Table or
Responsible Party
Erie St. Clair LHIN/
Consumer and Family
Leadership Table
Consumer and Family
Leadership Table
Task Completed √
Windsor specific as an
ED diversion. HDGH
and partners
Initiative is part of Erie
St. Clair LHIN
Behavioral Supports
Sustainability Plan.
Specialized behavioral
units are being
explored.
Erie St. Clair LHIN
Community
Engagement/Web
Master
Co-location underway
via CMHA LK and
CKHA as per ED
diversion strategy
Tele Med links to Erie
St. Clair LHIN next day
bookings initiative
Erie St. Clair
LHIN/Consumer and
Family Leadership
Table
15
The Erie St. Clair LHIN should encourage and fund consumer/survivor/family-run
organizations to develop and operate programs to train and support people so they can
become better self-advocates (including greater use of the NAMI Family-to-Family
Program), with particular attention to providing this training in or for people living in
smaller communities in Erie St. Clair.
Mental health service agencies should identify/publicize opportunities for people with
mental illness and family members to serve on their boards and on committees within
their agencies.
The Erie St. Clair LHIN, the hospitals group, and the Community Mental Health should
establish a joint consumer/family member advisory group. The foundation for its advice
can be the visions for the service system and for supportive communities that were
developed during the strategic planning project.
Mental health service providers should develop or adopt and regularly review care
pathway templates for populations served by the mental health service system and
should ensure that these templates are used to develop care pathways and care plans
for people receiving mental health services.
Mental health and addiction services in Erie St. Clair, through the redesigned Mental
Health and Addictions Network should develop common and complementary
approaches to the engagement of stakeholders in planning, monitoring and evaluation of
mental health and addiction services and systems in Erie St. Clair in ways that make the
results of engagement activities comparable with each other.
Mental health services in Erie St. Clair, with the support and participation of the
Erie St. Clair LHIN, should create and commit to support a programs and Services Data
Group to help improve the quality, timeliness and specificity of data for use in program,
service and system monitoring, evaluation and planning in Erie St. Clair. Once the
program definitions and data are comparable as a result of the work of the Programs and
Services Data Group, a review of programs and services should be undertaken to move
toward a consistent and equitable set of services across Erie St. Clair.
Through the Erie St. Clair MH and Addiction Network, conduct an Environmental Scan of
Francophone (French speaking) Mental Health and Addiction Providers.
The mental health service system should develop a network of five leadership tables,
integrated under an umbrella table that is a redesigned version of the Mental Health and
Addictions Network, to help implement the Mental Health Strategic Plan and to conduct
further planning, monitoring and evaluation activities.
The Erie St. Clair LHIN and its service partners should continue to plan for eating
disorder services in Erie St. Clair, including coordination/integration between Bulimia
Anorexia Nervosa Association (BANA) and Community Health Centres.
The Erie St. Clair LHIN and stakeholders in Erie St. Clair should develop a plan for
seniors mental health services in Erie St. Clair that produces integration with other
mental health services (including primary care), integration with other services for
seniors, and integrated caregiver support.
To foster a collaborative approach to inclusion and income security for people with
mental illness, mental health service providers in Erie St. Clair, as well as champions in
the broader community, should work closely with consumer/survivor/family-run
organizations to document and publicize issues of income and employment
disadvantages faced by many people with mental illness. Erie St. Clair LHIN-wide
separate Mental Health client/patient advocate.
Leadership Table
or Responsible
Party
Consumer and Family
Leadership Table
Task Completed √
Community Mental
Health, Inter Hospital
and Consumer –
Family Leadership
Tables
Community Mental
Health and Inter
Hospital Leadership
Table
Mental Health and
Addiction Network in
partnership with
Consumer – Family
Leadership Table
Data, Quality and
Performance
Leadership Table
Erie St. Clair LHIN
Mental Health and
Addiction Network
Mental Health and
Addiction Network
(see driver diagram)
BANA, Teen Health
Centre (on-going work
in process)
Existing LHIN BSO
Governance Structure
Consumer/Family
Leadership Table
16
All hospitals and mental health programs in Erie St. Clair should adopt and use a suicide
risk screening tool. To help reduce suicides and suicide attempts, mental health
services in Erie St. Clair should continue to:
•
Be alert to the possibility of suicide among people who are already engaged with the
mental health system or the primary care system, particularly people who exhibit risk
factors or precipitating factors, and follow emerging suicide prevention practices with
them.
•
Work with community groups such as crisis lines and with coalitions to develop
community-wide suicide prevention strategies.
Leadership Table
or Responsible
Party
Community Mental
Health and Inter
Hospital Leadership
Table
(Future Potential
Project for one Lead)
•
Promote and disseminate anti-suicide materials.
Planning, operation and evaluation of mental health services and addiction services
should be carried out in an integrated manner between the mental health and addiction
service systems in Erie St. Clair. While respecting different philosophies of care within
and between these two systems, both systems should pursue integration based on
evidence-based approaches and not merely philosophical approaches to service
delivery.
Repurpose (vacant) group homes currently managed by CMHA Windsor-Essex
Erie St. Clair LHIN
Future Addiction
Strategic Plan (poised
for 2013)
Erie St. Clair
LHIN/Provincial
Programs Branch
MOHLTC
Task completed √
17
Appendix 7 - Phase Two (2015)and Three
(2016-17) Opportunities
Appendix 7 - Phase 2 Opportunities
The Erie St. Clair LHIN should fund the integrated CMHAs to conduct a
change readiness review, to ensure that the agency has in place, or
develops, the infrastructure it needs so it can successfully incorporate other
services under its scope of responsibility.
The Erie St. Clair LHIN should support the establishment of long acting
injection clinics in selected community health centres, Family Health Teams
(FHTs), nurse-practitioner-run clinics and CMHA branches. A best practice
sub-committee will examine long acting injection clinics in Erie St. Clair and
the literature bringing recommendation for change to the Mental Health and
Addictions Erie St. Clair LHIN Network Phase Two.
All mental health crisis service stakeholders, as well as other health and
non-health crisis service providers, should work together to create an
equitably funded and geographically distributed mental health crisis service
system for Erie St. Clair.
The future of mental health-related housing in Erie St. Clair should continue
to be guided by these principles:
• Specialized housing programs need to be maintained, and created to
take into account the complexity of need.
• Each housing program should be as flexible as it can be in terms of
who it serves and how it serves them. When it comes to a choice
between making the service user adapt to the program, or the program
adapt to the service user, generally the program should adapt to the
user.
• Some people will inevitably be inappropriately placed or their
circumstances and capabilities will change, making it necessary to for
them to change their housing environment or volume and mix of
support services.
Mental health service providers in Erie St. Clair, with support from the
LHIN, should develop a way to provide step-down housing capacity (and if
necessary, step-up capacity as well) in Erie St. Clair’s three major
communities. Options to be considered should include but not be limited
to:
• Converting a group home in each community into a step-down unit.
• Creating new purpose-designed step-down units in one or more of Erie
St. Clair’s three major communities.
• In Windsor, creating a step-down unit adjacent to or as an extension of
Windsor Regional Hospital’s Residential Rehabilitation/Treatment
Program. (Viability and fit for Sarnia/Lambton).
Leadership Table/
Responsible Party
Erie St. Clair LHIN / CMHA
Sub-Committee of the
Community MH – InterHospital Leadership Table
Community Mental Health
– Inter-Hospital Leadership
Table/ Erie St. Clair LHIN
Creation of a Mental
Health/Addictions Housing
Committee
(Reports up to the Erie St.
Clair LHIN Mental Health
and Addiction Network)
18
Appendix 7 - Phase 2 Opportunities (cont’d)
Leadership Table/
Responsible Party
Mental
health
stakeholders
in
Erie
St.
Clair,
including
consumer/survivor/family-run organizations, should explore the desirability
and feasibility of creating a mental health respite bed capacity in Erie St.
Clair.
Respite vs. crisis housing?
The housing system should be highly flexible in helping with transitions
from one setting to another. Mental health service providers in Erie St.
Clair, with support from the LHIN, should further examine the Housing First
model and should track the outcomes of the model as applied through At
Home/Chez Soi demonstration projects. If the model shows further
evidence of its success elsewhere, it should be introduced into Erie St.
Clair through a minimal barrier housing option for people who experience
long term or multiple-episode homelessness.
Subject to clarification of the role of IRIS House in an integrated mental
health housing system in Erie St. Clair, the Erie St. Clair LHIN should
consider providing funding to IRIS House through augmentation of its per
diem rates, via money flowed to the Community Mental Health Coordinating
Agency and in turn flowed to IRIS House on the basis of an accountability
agreement between Iris House and the Community Mental Health
Coordinating Agency. (Role Clarification Review in terms of “fit” as a Mental
Health Housing)
In the long-term, mental health services in Erie St. Clair should explore
possibilities for easily accessible co-location of mental health and related
human services in Sarnia, Chatham, and Windsor. Determine multi service
hub concept.
Upon completion of the Phase One Environmental Scan of the number and
location of Francophone (French speaking) Mental Health and Addiction
providers, the Erie St. Clair LHIN, L’entité de planification des services de
santé en français Erie St-Clair/SudOuest, mental health service providers
and Francophone communities and organizations in Erie St. Clair should
collaborate to:
• Encourage and assist mental health and related services that have
been identified under the French Language Services Act, but have not
yet been designated, to achieve designation as French Language
service providers.
• Develop strategies for encouraging designated French language
mental health service providers to actively offer services to
Francophones.
• Develop a virtual system or network of Erie St. Clair French language
service providers.
• Develop strategies for enhancing mental health services for
Francophones at the primary care level in Erie St. Clair.
– Inter-Hospital Leadership
Table
Erie St. Clair Mental Health
and Addiction Network
(Phase One )
Virtual Network vetted
through Mental Health and
Primary Care Leadership
Table (Phase Two)
19
Appendix 7 - Phase 3: Opportunities (cont’d)
The mental health system should create a strategic alliance with the
University of Windsor as a way to augment research, monitoring, and
evaluation capacities in the system. The Erie St. Clair LHIN and its service
partners should engage fully in the Excellent Care for Mental Health and
Addictions (ECMHA) initiative meant to improve quality in the mental health
and addition sectors and should monitor and learn from the introduction of
this initiative in the first wave of LHINs that will be asked to participate.
The mental health service system should pursue opportunities to explore,
understand and value the cultures that have developed within populations
with disabilities. Guided by an advisory group of people with disabilities
(including consumers and providers of mental health services who have
disabilities), mental health service agencies in Erie St. Clair should conduct
”best practice” accessibility audits of their physical plants, processes, and
structures to ensure there are no physical, procedural, communications or
cultural barriers to serving people with disabilities.
Leadership Table/
Responsible Party
Data, Quality and
Performance Leadership
Table
Creation of an
Accessibilities Committee
Reports up to the Erie St.
Clair LHIN Mental Health
and Addictions Network
The mental health services system and the developmental services system
should maintain and, when possible, augment their individual and joint
efforts to serve, advocate for and help remove stigma related to people with
dual diagnoses and their families The Erie St. Clair LHIN and the mental
health service system should:
• Develop an inventory of current good practices in delivering mental
health services in Erie St. Clair for immigrant, refugee, ethno-cultural,
and marginalized groups.
• Host a summit on improving mental health services for immigrant,
refugee, ethno-cultural, and marginalized groups.
• Create a working group to find ways to better serve these groups.
The Erie St. Clair LHIN should ensure that each of the three major
communities in Erie St. Clair has at least one program providing mental
health treatment and support specifically tailored to lesbian, gay, bisexual,
and transgendered people
After developing and sharing a compendium of best practices in providing
mental health services to lesbian, gay, bisexual and transgendered people,
the Erie St. Clair LHIN should require all mental health agencies and
programs to indicate how they will develop and maintain competency in
serving this population.
20
Appendix 8 - Assertive Community Treatment
Transition Readiness (ATR) and Ontario Common
Assessment of Need (OCAN) Key Domains Aligned
Assertive Community
Treatment Transition
Readiness (ATR)
Themes
Stability
(Symptoms, behaviors,
housing etc)
ATR Domains
-
OCAN Domains
Stability
Criminal Justice
contacts
Housing Stability
Hospitalization
-
Psychological distress, Psychotic symptoms,
harm-self/other
OCAN Common Data Set (CDS)
Accommodation
OCAN (CDS)
Daily Structure
-
Time
Structure and
Employment
-
Daytime activities
OCAN/Activity during the day
Complex Needs
(substance abuse Axis II etc)
-
Substance Use
Complexity
Intensity
Engaged with ACT
Medication
-
OCAN Addictions (three kinds)
OCAN Health and Life Domains
OCAN Level of Need Assessment
OCAN info on condition and treatment
OCAN – use of meds, info on symptoms &
treatment
-
Independence
Dependence
Benefits
-
Social Support
-
Social Support
Resources
-
OCAN – Food, Activities of Daily Living, self
care
OCAN –Psychological distress, company,
personal vision
OCAN - Benefits
Company, daytime activities
OCAN – Broader, needs and family
involvement
Insight
-
Insight
-
Engagement and
Compliance
Independence
-
OCAN – Information on condition
21
Appendix 9 - Mental Health Driver Diagram
Erie St. Clair Local Health Integration Network - Mental Health System Driver Diagram
ESC LHIN
Mental Health
System Goals
Strategic
Directions
Governance
Structure
Mobilize help for people
with complex or
persistent problems
Integrate the system &
enhance community
mental health service
Reduce Service
Disparities among areas,
populations & programs
Strengthen the
Consumer / Survivor &
Family system
Augment & Support
Psychiatry & Psychiatric
Extenders
Engage Primary Care in
the Mental Health Service
System
Build an evidence-based
& experience driven
service continuum
Get the right numbers &
knowledge to shape the
system
Leadership
Tables
Tactical Functions & Key Aims
•
•
•
•
•
•
•
Implement Next Day Bookings & Wait List Strategy
Implement (Urban) Inner City Model / (Rural) Emergency Department Diversion
Integrated care paths, standardized suicide risk screening & assessment tools
Implement step down / up transitional models of care (includes child & youth)
Provide supports for primary care via service agreements
Surge capacity, relevant protocols & refreshed bed board (includes child & youth)
Agreed upon targeted improvements – joint Multi-sectoral Accountability Agreements
•
•
•
•
Refreshed system assessment leveraging psycho social rehab model LHIN wide
Tiered Navigation, family support & psycho social rehab embedded with other Mental
Health providers
Consumer–Family Networks group (one Multi-sectoral Accountability Agreement)
Strengthen peer & family support LHIN wide
Erie St. Clair Psychiatry
Leadership Table
•
•
•
Spread existing best and promising new practices Erie St. Clair LHIN-wide.
Foster preceptor role with School of Medicine (Future Health Human Resources)
Psychiatry support for primary care physicians (shared care models)
Primary Care / Mental
Health – (Health Links)
Leadership Table
•
•
•
•
Targeted participation next day bookings / wait list strategy
Standardize MH protocols, care paths & suicide tools
Establish stronger linkages with Psychiatrists
Develop pool of resources via service agreements with existing community mental
health providers
Data, Quality &
Performance Leadership
Table
•
Optimize Integrated Assessment Record (IAR), Emergency Deparment Psych
Screener, Ontario Common Assessment of Need (OCAN) & data collection
methodology
Improve data quality & standardized measures & report back on service disparities,
variances & opportunities for improvement
Data monitoring & support for health service provider & Mental Health – Add Network
& Inter Hospital
Integration Leadership
Table
One Overarching Collaborative Governance Structure
Erie St. Clair LHIN Mental Health & Addictions Network
Oversees
five Leadership Tables
SYSTEM GOALS
Provide Help Early
Reduce ED visits for suicide attempts from a range of 5%-10%.
Reduce repeat ED MH visits from 10% to 16.9%
A full and integrated continuum of person-centred and accountable mental health
services for adults with mental illness and their families
VISION
ESC LHIN
Mental Health
Vision
Consumer & Family
Leadership Table
•
•
22
Appendix 10 - Next Day Bookings
Connex Ontario
OTN
MH and Addictions
Providers
• Respond to calls
from residents
across the
province interested
in receiving
information on
mental health and
addictions
services.
• Train and provide access to
OTN’s telemedicine Directory
to ensure Erie St. Clair LHIN
funded resource has up to
date information on site
profiles and mental health
and addictions provider
availability.
• Share available
time to provide
initial mental health
and addictions
intake
assessments (via
face to face or by
telemedicine).
• Establish Erie St. Clair LHIN
funded resource as a selfschedulers:
• Conduct initial
mental health and
addictions intake
assessments.
• Identify location of
LHIN resident and
determine if initial
mental health and
addictions intake is
appropriate.
• Ask (assuming
clinically
appropriate) if
clients interested in
having a next day
initial mental health
and addictions
intake assessment
over Telemedicine
or face to face.
• Locate mental
health and
addictions provider
availability through
Connex Ontario’s
GSS and book
appointment
o Conduct training
o Provide tools(compass)
o Launch support
• Support LHINs to ensure
mental health and addictions
providers:
o Block time for
appointments and share
with Erie St. Clair LHIN
funded resource
o Participate in scheduled
telemedicine
appointments
o Identify and share lessons
learned
• Initiate required
patient follow up, if
relevant, in person
or through
telemedicine.
• Work with Erie St.
Clair LHIN next day
bookings resource
to resolve issues
and identify
lessons learned.
Tele Medicine (TM)
Nurses/TM
Coordinators
• Continuously
updates Site
Profiles and
availability in
directory.
• Support mental
health and
addictions patients
for their
telemedicine
appointment.
• Work with mental
health and
addictions
providers and Erie
St. Clair LHIN
funded resource to
resolve issues and
identify lessons
learned.
LHIN
• Engage mental
health and
addictions
health service
provider to
inform them of
the next
business day
initial mental
health and
addictions
intake service
via face to face
and
telemedicine.
• Provide funding
resource
responsible for
coordination.
• Work with OTN
and Connex
Ontario to
determine what
system impacts
are anticipated
and how best to
measure if they
are achieved.
• Support telemedicine so that:
o telemedicine nurse site
and mental health and
addictions health service
provider profiles and their
availability is up to date in
the Directory
o Support is provided to
next business day initial
mental health and
addictions intake
assessment
* Mental health and addictions providers to deliver initial mental health and addictions intake assessment include
Telemedicine Nurses, Assessment and Referral Resources, and Intake Coordinators.
**Erie St. Clair LHIN funded resource is envisioned to be a person within the Erie St. Clair region (existing or new)
who will ensure next day initial MH and Addictions intakes (face to face or via Telemedicine) is coordinated and
tracked.
23
Erie St. Clair LHIN Next Day Initial Mental Health and Addictions Intake – Providers by
Phase
Erie St. Clair LHIN Providers involved in delivery of next day initial Mental Health and Addictions
intake (early adopters).
Phase 1
Provider Name
Service Delivery
OTN
Service Delivery
Face to Face
Telemedicine Mental Health Add RNs Leamington District
Memorial
Brentwood
CK CHC
Chatham Kent Health Alliance – Telemedicine RN, Crisis
Staff, Addiction Assessment and Referral staff and
Psychiatric Assessment Nurses in the ED.
Bluewater Methadone (Sarnia/Chatham/Wallaceburg)
HDGH Crisis Team and Psychiatric Assessment Nurses in
the ED
Telemedicine Mental Health and Addictions RN Regional
Children’s Centre – Maryvale (youth crisis)
√
√
√
√
√
√
√
√
√
√
√
Telemedicine Mental Health and Addiction Bluewater
(Chatham, Sarnia, Wallaceburg)
Erie St. Clair Methadone Clinic (Windsor)
Windsor CHC
Grand Bend CHC
VON Chronic Pain Program (links to addictions/methadone
√
√
√
TBD
√
√
√
√
√
√
Phase 2
Provider Name
CMHA WE
CMHA LK
Westover
House of Sophrosyne
Bulimia Anorexia Nervosa Association
Windsor Regional Withdrawal Management
North/West Lambton CHC
Bluewater Health Crisis Team ED
Service
Delivery
OTN
Service
Delivery
Face to Face
√
√
√
√
√
√
√
√
√
√
√
Requires TM
Equipment
√
√*
√
24
Phase 3
Provider Name
Service
Delivery
OTN
Service
Delivery
Face to Face
Requires
TM
equipment
Thamesville Family Health Team (FHT) (Chatham)
Tilbury FHT
Chatham FHT (Wallaceburg, Chatham, Ridgetown)
Windsor FHT
Harrow FHT
Leamington FHT
Amherstburg FHT
Petrolia FHT
The Rapids (Sarnia) FHT
Bluewater NPLC (TM to be confirmed)
Essex NPLC
Belle River (VON run) NPLC (to confirm TM)
Key Roles and Responsibilities–LHIN Coordinator Next Day MH and Addictions Initial
Intake
Role
Responsibilities
Telemedicine Coordination
•
•
•
•
Stakeholder Relationship
•
•
•
•
•
Responsible for administrative functions including
scheduling, documentation and ensuring that the Patient
Host site is appropriately resourced.
Arranging for the initial MH&A intake to occur when
required at an OTN access site as close to home as
possible for the client.
Liaising with clients to share location details of visit
including patient host site information.
Tracking of client’s journey until a permanent provider is
determined.
Receiving (being copied) on non-clinical updates from
service providers on client’s next destination in care path
and following up as required.
Promoting the service to healthcare professionals, clients
and the community.
Working with identified Erie St Clair LHIN providers to
ensure their availability is published on a timely basis and
clients are seen as scheduled.
Identifying any training and learning needs from providers
(technical/process)
In collaboration with MH HSP develop “success stories”
for posting on the Erie St. Clair LHIN website.
25
Role
Tracking and Measurement
Responsibilities
•
•
Tracking the volume of next day initial intakes through
the ConnexOntario channel. Metrics to track include:
o # of initial intake requests by agency site.
o # of completed initial intakes by site via face to
face or OTN.
o # of NO SHOWS (client)
o # of missed appointments (inaccuracy of
scheduling)
o Final destination/agency responsible for
providing on-going care.
o TM/ Face to face activity
o # of consults with Psychiatrists
Regularly measuring client and provider satisfaction with
the service.
The Next Day Bookings Coordinator is an employee of the site (HSP) with a LHIN-wide mandate and
performance metrics. Metrics will be submitted to the LHIN on a quarterly basis. Initially, data will be
submitted more frequently to ensure that changes are implemented quickly.
26
Client Journey Face to Face Intake and Post Intake Referral
27
Client Journey Initial Intake via Telemedicine (Videoconferencing) and Post Intake
28
Appendix 11 - Cost, Benefit, Risks, Options Template
1. Program Name: ____________________________________
2. Number of Years in Operation: ________________________
Utilization:
3. Total number of clients served last fiscal year (12 / 13): _______________________
4. Total Number of New clients in last fiscal year: _____________________________
•
5. Total Number of discharges in last fiscal year:_____________________________
•
a) Please indicate discharge destination (e.g. CMHA, Other) _________________
6. Current wait time: __________________________________________________
29
Resources and Costs
7. Total Number of FTEs (current): _______________________
8. Cost per Client (12/13): ____________________________
9. Total Number of Units of Service (12/13): ___________________________
10. Total Annual Expenditure / Program Cost: _______________________________
11. Psychiatric sessionals and other funds to support psychiatry e.g. stipend / base salaries
(total funds as per last fiscal year to support the program): _________________________
Risks
12. Are staffs associated with this program unionized? If yes, please identify the name of the
Union: _________________________________________________________
13. Projected cost of staff severance packages:
_____________________________________
14. Please identify all risks to clients, staff, community, program and hospital if program was
divested in the future to a community based provider:
a) Client Risks
____________________________________________________________________
b) Staff Risks:
_____________________________________________________________________
c) Program and Hospital Risks:
____________________________________________________________________
d) Political and other Risks: _______________________________________________
30
Benefits:
15. Please describe the current state of the program as it relates to partnership with community
based agencies e.g. shared care model, grand rounds/integrated discharge planning, step
down process etc.
16. Please identify all benefits (client, staff, community) associated with the current program:
•
Future State and Proposed Level of Integration:
17. As a result of the future state mapping what areas will be strengthened with community
based providers as it relates to this program and proposed future level of integration?
a) Vertical Integration – refers to integration of different inter-related or inter-dependent
health sector elements. For example: primary care provided by generalist in the
community and secondary care provided by a specialists in hospital. Services that
exhibit an agreed upon “mix” of primary and secondary care demonstrate vertical
integration.
b) Horizontal Integration – refers to integration of organizations that are similar or at the
same stage of service delivery e.g. hospitals that have shared consolidated services.
c) Partial Integration (also referred to as Network Integration). Network Integration is high
on communication and moderate to high in terms of structure for coordination. Networks
aim for care coordination e.g. protocols, pathways, shared vision for care and / or system
navigation. Shared clinical and management leadership and using administrative and
information mechanisms to increase efficiencies are examples of partial integration.
d) Full Integration: Implies that resources of different organizational units are pooled to
create a new organization (the merging of parts into a working whole). Full integration
involves governance, functions and resources.
18. Please include identification of the various components of Integration (clinical teams, support
activities, values / norms, processes, back office, IT etc).
Additional comments
31
Ontario’s Local Health System Integration Act, 2006
“Each local health integration network and each health service provider shall separately and in
conjunction with each other identify opportunities to integrate the services of the local health
system to provide appropriate, coordinated, effective and efficient services 2006, c.4 s 24”.
32
33

MH Strategic Plan-Multi-Year Implementation

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