Mental Healthcare Delivery in London-Middlesex Ontario – The Next Frontier
The next frontier for mental healthcare delivery will be focused on three facets of innovation, namely structure, process and outcome. The structure innovation will seek to develop new models of care delivery between the two hospitals and with the community. The process innovation will focus on embedding strategies to adopt a recovery and rehabilitation approach to care delivery. Lastly, the outcome innovation will use system wide quality improvement methods to drive breakthrough performance in mental healthcare.
The mental health services in the London-Middlesex area of Ontario have undergone a significant amount of transformation over the past two decades. This transformation has been focused on the development of innovative models of care within the hospital-based and community-based mental health programs. In 2014, St. Joseph’s Health Care (St. Joseph’s) completed a 17-year journey to transform its tertiary mental healthcare service delivery following directives made by Ontario’s Health Services Restructuring Commission (HSRC) in 1997. The HSRC provided direction for three tiers of change. Tier 1 called for the transfer of governance and management of the then London and St. Thomas Provincial Psychiatric Hospitals to St. Joseph’s Health Care London; Tier 2 called for the transfer of 138 beds and related ambulatory services to four partner hospitals in the region as well as the closure of 70 beds; and Tier 3 recommended investment in building community capacity to enable persons living with serious mental illnesses to achieve successful community living. Finally, the HSRC also directed the building of two purpose-built facilities to replace aging hospital infrastructure.
Mental health services at the London Health Sciences Centre (LHSC) have also undergone significant changes. Prior to 1995, there were four independent acute care departments of psychiatry. In 1995, University Hospital and Victoria Hospital amalgamated to become LHSC, with a single mental health program.
There has been significant growth and expansion in the capacity and capability of community mental health and addictions services in London and across the South West Local Health Integration Network (LHIN) over the last two years. The South West LHIN has made funding investments over the last two years to strengthen community-based mental health and addiction services ($7.8 million, representing 90 new community-based staffing positions).
We are well poised to build the next frontier of mental healthcare delivery, by leveraging the transformation that has taken place and addressing the structure, process and outcome of mental healthcare delivery within the hospital-based programs we lead, while continuing to build strong linkages and integration with the community.
The Next Frontier – Structure
Amalgamation of Hospital Programs
We have embarked on a feasibility study to explore amalgamation of mental health programs at LHSC and St. Joseph’s while we continue to strengthen integration efforts with the community. LHSC provides Schedule 1 psychiatric services, including acute inpatient and ambulatory care services, to the residents of London and Middlesex and a larger catchment area for selective programs. St. Joseph’s offers specialized inpatient and ambulatory mental healthcare services to all residents of the South West LHIN and receives referrals from all six Schedule 1 hospitals in the LHIN. A significant number of patients transfer from LHSC to Parkwood Institute Mental Health Care. In fiscal year 2014–15, 50% of all admissions to Parkwood Institute Mental Health Care came from LHSC.
Access and wait times issues continue to be a challenge for hospital-based mental health services. LHSC’s acute care mental healthcare unit has been operating at 110% occupancy for over one year, and mental health volumes presenting to the emergency room have increased by 30% over the last year. Also, more than 50% of the registered outpatients of St. Joseph’s who require inpatient admission still end up in the emergency room as the point of entry into the system. LHSC and St. Joseph’s have made great strides with successful discharge of long-stay patients; however, numbers of patients requiring alternate level of care continue to be an issue, at about 10% of the bedded volumes.
The voluntary integration of hospital-based mental health programs is seen as a foundational step to achieve the following objectives:
- Develop a single, comprehensive, cohesive and strategic approach to the delivery of all hospital-based mental health services and associated teaching/research programs
- Improve the patient experience, coordination and continuity of care and clinical outcomes
- Synchronize patient populations and models of care within the integrated program and enhance integration with the community
- Optimize allocation of resources and alignment with funding reform
There is a further opportunity to define patient populations served across the continuum of care and develop care pathways and integrated outcomes for these populations.
Integration With Community
The feasibility study will also examine opportunities to further strengthen partnerships and integration with the community. There are existing strong partnerships between the hospitals and the community mental health and addiction programs of the Canadian Mental Health Association (CMHA) Middlesex and Addictions Services of Thames Valley (ADSTV). Under formal agreements between these entities, addictions transitional case managers (ATCMs), transitional case managers (TCMs) and nurse practitioners (NPs) hired by the community sector work at LHSC to support the transition of patients with mental health and addictions issues to community services. LHSC, CMHA Middlesex and ADSTV have worked in partnership to create a new crisis centre, including residential supports, in the city of London. LHSC, St. Joseph’s, Hotel Dieu Grace Hospital in Windsor and Western University’s Division of Child and Adolescent Psychiatry have partnered to support the Ontario Child and Youth Telepsychiatry Program – Western Hub to increase access to psychiatric consultation for professionals and for children and youth living in rural, remote and underserved communities. Since 2010, St. Joseph’s geriatric psychiatry program has been responsible for the regional coordination of a Behavioural Supports Ontario (BSO) program. The aim of BSO is to improve the lives of caregivers and older adults with responsive behaviours due to dementia, mental health and addictions issues and other neurological disorders.
Building on these strong linkages, we are also increasing our collaborations with primary care providers.. Over the past two decades, some of the greatest advances in the field of mental healthcare have been new evidence-based practices that are shown to improve the outcomes of individuals with mental illness. For those with severe mental illness, these evidence-based practices have included Assertive Community Treatment and Illness Management and Recovery models of care (Mueser et al. 2003). Collaborative care interventions for depression for patients with primary care providers have demonstrated a twofold increase in treatment adherence, improvement in depressive outcomes lasting up to five years, increased patient satisfaction with care and improved primary care satisfaction with treating depression (Katon and Seelig 2008). The mental healthcare program at LHSC and St. Joseph’s Health Care have been leaders in practice innovations including our Mental Health Consultation and Evaluation in Primary Care (MHCEP) and Transition into Primary-Care Psychiatry (TIPP) services, which provide a spectrum of linkages between mental healthcare and family physicians to improve care and access. In addition, our programs are evaluating the use of SMART technologies to improve the care of patients with severe mental illness and patients with multiple comorbid medical and psychiatric disorders.
The future of our community collaboration involves 1) extending our collaborative practice innovations to new community partners; 2) developing team-based patient care, targeting multiple disease states in conjunction with other medical care providers and 3) implementing and evaluating these models of care using the latest technologies. Our plans include establishing a Practice Innovation Centre that will develop and deliver the latest service innovation models to our integrated mental health service, developing self-management approaches for patients with multiple comorbid conditions and using SMART technologies to provide decision support, patient-based feedback and program evaluation.
The Next Frontier – Process
Recovery and Rehabilitation
The tertiary mental health program of St. Joseph’s is located in a new building on the campus of the Parkwood Institute, which was established in November 2014. The patient and resident populations served at this one purposeful geographic location include rehabilitation, specialized geriatrics, complex care, palliative care, veterans care and specialized mental healthcare. Bringing these teams together presents us with the potential to leverage and create new synergies to achieve breakthroughs in care, recovery and rehabilitation. We are at an important crossroads, where we can fully embrace and renew the ageless knowledge that care of the body, mind and spirit go hand in hand (Anthony et al. 1990; Anthony and Liberman 1986; Mental Health Commission of Canada 2015).
St. Joseph’s strategic plan for 2015–2018 has identified three areas of clinical, academic and educational focus. One of these three areas is recovery and rehabilitation, which the Parkwood Institute will play a critical role in advancing. The Lawson Health Research Institute has also recently led the development of a research strategic plan aligned with Parkwood Institute and the focus on recovery and rehabilitation. The St. Joseph’s Health Care Foundation is also well aligned and supporting the priorities within this plan. Under the umbrella of recovery and rehabilitation has been the development of cognitive vitality and brain health, which has enabled us to bring together clinical and research leaders in the areas of rehabilitation, geriatrics, dementia care, acquired brain injury and mental healthcare – many already nationally and internationally recognized leaders in their individual fields – to explore new ground in advancing collaborative, interdisciplinary research, education and clinical care. Their work continues as they offer interdisciplinary-team–learning opportunities and identify a set of collaborative research and care projects to further together.
As our new future emerges, St. Joseph’s regional and provincial role as a leader in recovery and rehabilitation models will grow. This priority will now come alive through the development of a comprehensive blueprint, in addition to articulating the overall care, teaching and research priorities, to achieve the vision of Parkwood Institute. By 2018, Parkwood Institute will be regarded as the provincial leader in integrated recovery and rehabilitation models of care, built on leveraging knowledge and synergies across programs and through interdisciplinary teaching and research.
Within the context of our strategic plan, the development of a blueprint for recovery and rehabilitation is envisioned, inclusive of our tripartite mission of care, education and research. This blueprint will leverage the current strengths to scale up quick-win opportunities while developing the infrastructure for a long-term centre of excellence for recovery and rehabilitation – body, mind and spirit. In addition, the recalibration of a research chair to encompass a recovery and rehabilitation focus at Parkwood Institute is regarded as a key enabler for this work.
The Next Frontier – Outcome
Our program is dedicated to the relentless pursuit of safety for our patients, family and staff. In addition to our day-to-day work to support quality and safety for our patients, we will focus on bold and audacious goals for safety. For example, one of our future focuses on safety will be directed to the prevention of suicide in patients under our care. A broad, multi-level approach is required to prevent suicide. First, we understand that our services must address the risk of suicide behaviour over and above interventions that are directed to treat and manage the individual’s mental illness. Second, certain psychotherapies for patients at risk for recurrent suicide behaviour have led experts to extract a limited number of psychotherapy principles that may be effective in reducing the risk of future suicide behaviour. These basic principles of management include the following (Links 2011):
- Adopting a theoretical model of understanding suicide behaviour to promote the confidence and understanding to work with patients who are suicidal
- Providing a stable treatment framework by increased activity of the therapist
- Conveying empathic validation plus the need for the patient to control destructive behaviours
- Fostering a greater sense of self-agency through the therapeutic relationship
- Establishing a connection between destructive behaviours and current feelings
- Developing methods with the patient to differentiate nonlethal from true suicidal intention
- Setting a low threshold for seeking consultation or supervision
Third, managing transitions in care, for example after discharge from hospital, can be an effective way to prevent suicides. Knesper and colleagues (2010) summarized the evidence for rapid followup after discharge from emergency departments or inpatient settings and concluded that early contact after discharge led to significant reductions in suicide reattempts versus usual care. Attempts to improve community linkages after hospitalization appear to be simple but effective ways of preventing repeated suicide behaviour and, perhaps, suicides.
Finally, the prevention of suicide may be advanced by striving for perfection rather than incremental goals, and the zero-suicide approach promoted by the Suicide Prevention Resource Center provides a toolkit to health and mental health programs to follow and implement (https://zerosuicide.sprc.org/ about). Our approach will be to adopt and adapt these various novel strategies to our own integrated mental health program.
Our program is also engaged in quality assurance projects targeting certain diagnostic patient groups; for example, one project being launched aims to increase engagement in mental health treatment for patients with schizophrenia to improve outcomes (Kreyenbuhl et al. 2009). Three outcomes will be evaluated as part of the quality assurance project: readmission to our psychiatric services, compliance with follow-up appointments and compliance with mental health treatment (including medications). The quality assurance project will measure the outcomes pre- and post-initiating low-intensity interventions across the integrated mental health program. The low-intensity interventions include minimizing wait time to first appointment, reaching-out techniques prior to first appointment and enhancing our community reintegration curriculum during hospitalization (Boyer et al. 2000).
The goal of the project is to improve by 50% our readmission rates in 30 days or less after discharge, which is currently approximately13% overall across the integrated mental health program.
The next frontier of mental healthcare delivery will leverage the transformation that has taken place within our region by addressing the structure, process and outcome of mental healthcare delivery within the hospital-based programs, while we continue to build strong linkages and integration with the community.
About the Author
Karima Velji, RN, PhD, is integrated vice president for Mental Health at London Health Sciences Centre and St. Joseph’s Health Care in London Ontario. Prior to this appointemnt, Dr. Velji was the chief operating officer and chief nursing executive at Baycrest, a global leader in innovations in aging and brain health and vice president of Patient Care and chief nursing executive at Toronto Rehabilitation Institute, which is now a program of University Health Network.
Paul Links, MD, MSc, FRCPC is professor and chair of the Department of Psychiatry in the Schulich School of Medicine & Dentistry at the The University of Western Ontario. He is also Chief of Psychiatry at London Health Sciences Centre and St. Joseph’s Health Care, London, Ontario. Prior to coming to Western University, Dr. Links held the Arthur Sommer Rotenberg Chair in Suicide Studies at the University of Toronto for three terms.
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Anthony, W.A. and R.P. Liberman. 1986. “The Practice of Psychiatric Rehabilitation: Historical, Coneptual and Research Base.” Schizophrenia Bulletin 12: 542–59.
Boyer, C.A., D.D. McAlpine, K.J. Pottickand M. Olfson. 2000. “Identifying risk factors and key strategies in linkage to outpatient psychiatric care.” American Journal of Psychiatry 157:1592-1598
Katon, W.J. and M. Seelig. 2008. “Population-Based Care of Depression: Team Approaches to Improving Outcome.” Journal of Occupational and Environmental Medicine 50:459–67.
Knesper, D.J. 2010. Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths Subsequent to Discharge From an Emergency Department or an Inpatient Psychiatry Unit. American Association of Suicidology and Suicide Prevention Resource Center. Newton, MA: Education Development Center, Inc.
Kreyenbuhl, J., I.R. Nossel and L.B. Dixon. 2000. “Disengagement from Mental Health Treatment among Individuals with Schizophrenia and Strategies for Facilitating Connections to Care: Review of the Literature.” Schizophrenia Bulletin 35 (4):696-703.
Links, P.S. 2011. “The Role of Physicians in Advocating for a National Strategy for Suicide Prevention.” CMAJ 183(17): 1987–90. doi:10.1503/cmaj.111008 Mental Health Commission of Canada. 2015. Guidelines for Recovery- Oriented Practice. Mental Health Commission of Canada.
Mueser, K.T., W.C. Torrey, D. Lynde, P. Singer and R.E. Drake. 2003. “Implementing Evidence-Based Practices for People With Severe Mental Illness.” Behavior Modification 27(3):387–411.
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