Youth in Canada are experiencing mental health and substance use challenges at alarming rates. One response to address these concerns that has received considerable provincial/territorial, federal and philanthropic support is Integrated Youth Services (IYS). The British Columbia (BC) IYS initiative, called Foundry, is quickly approaching its 10-year anniversary, with the original proof-of-concept centre having opened in 2015. With 47,000 unique youth attending over 320,000 visits from April 2018 to March 2024 and with 17 operating physical centres (additional 18 in development) and a provincial virtual service, Foundry is filling a gap for youth mental health and substance use services in BC. In this article, we look back at the development of Foundry, share lessons for jurisdictions pursuing their own IYS initiatives, outline the vital role of policy makers in progressing IYS in Canada and look ahead to the next phase of IYS.

Introduction

Youth in Canada are experiencing mental health and substance use challenges at alarming rates, with approximately 25% of youth ages 12–24 years facing a mental health issue in a given year (Kessler et al. 2005; Solmi et al. 2021). Harmful drug use and misuse of prescription medication are additional concerns (Erskine et al. 2015). While no single factor accounts for this youth mental health and substance use crisis (McGorry et al. 2024; Wiens et al. 2020), evidence is emerging for the impact of social media (Office of the U.S. Surgeon General 2023; Zenone et al. 2021), climate change (Hickman et al. 2021), the rise of vaping (Government of Canada 2024) and the legalization of cannabis (Hawke and Henderson 2021), along with long-recognized adverse childhood experiences including abuse, neglect and violence (Madigan et al. 2023). The lingering effects of colonization and its consequences (Turpel-Lafond 2020), including residential schools (Truth and Reconciliation Commission of Canada 2015), are an additional consideration for Indigenous Peoples.

A lack of resources to address mental health (e.g., limited or no funding available through public health plans, long waitlists) and substance use concerns (e.g., limited beds in detoxification facilities, limited access to harm reduction measures such as opioid agonist therapy) has long been an issue in Canada (Malla et al. 2018; Mental Health Commission of Canada 2013; Wiens et al. 2020). Furthermore, youth may face additional challenges in accessing care when trying to address complex issues such as multiple diagnoses or when transitioning from child to adult services (Cleverley et al. 2018). Recently, both federal and provincial/territorial governments and philanthropic organizations have responded with funding injections to address these concerns (CIHR 2022a, 2022b; Department of Finance Canada 2024; Health Canada 2022; MMHA 2023). One area that has received support is Integrated Youth Services (IYS) (Hetrick et al. 2017; McGorry et al. 2022; McHugh et al. 2024). While IYS vary in their manifestation, they typically offer coordinated care by multiple service providers through a single point of access to address a variety of concerns for youth ages 12–24 years, including mental health and substance use (Hetrick et al. 2017; Rickwood et al. 2019). Other features are usually low or no cost to the client, low barrier to access (i.e., no referral required) and a focus on early intervention and prevention (Hetrick et al. 2017).

The British Columbia (BC) IYS initiative, called Foundry, is quickly approaching its 10-year anniversary, with the original proof-of-concept centre having opened in 2015 (Mathias et al. 2022). With 47,000 unique youth attending more than 320,000 visits from April 2018 to March 2024 (Foundry Toolbox Data 2024) and with 17 operating physical centres (additional 18 in development) and a provincial virtual service, Foundry is filling a gap for youth mental health and substance use services in BC by identifying service providers needed and offering co-location with partners (Barbic et al. 2024; Mathias et al. 2022). In this article, we look back at the development of Foundry, share lessons for jurisdictions pursuing their own IYS initiatives, outline the vital role of policy makers in progressing IYS in Canada and look ahead to the next phase of IYS.

A brief history of Foundry

Vancouver, BC, has long had a visible population of people who use drugs and/or are experiencing homelessness (Barbic et al. 2018). The Downtown Eastside (DTES) neighbourhood in Vancouver is consistently characterized among the most economically deprived neighbourhoods in Canada (El-Akkad et al. 2021; Linden et al. 2013). St. Paul's Hospital, operated by Providence Health Care, is the closest hospital to the DTES and often receives patients who have multi-morbidities related to the converging syndemics and deprivations in the DTES. In 2007, a group of psychiatrists (including co-author SM) at St. Paul's Hospital developed the Inner-City Youth Program, initially an outreach model run out of shelters and low-barrier housing offices. This program focused on early intervention for youth, with the model initially based on intensive case management and later informed by Headspace, an initiative in Australia often cited as the inspiration for IYS models (McGorry et al. 2007; Rickwood et al. 2019). Headspace, along with Jigsaw in Ireland (Illback et al. 2010), continues to be a valuable source for insight into developing, operating and scaling an IYS initiative, including in BC (BC-IYSI Working Group 2015b; McGorry et al. 2022).

In September 2014, author SM submitted a proposal to the Select Standing Committee on Children and Youth within the legislative assembly of BC outlining a BC IYS initiative (Mathias 2014). In March 2015, the Granville Youth Health Centre opened as the first IYS centre in Canada. The Inner-City Youth Program also moved into this centre, providing a connection to previous efforts. Months later, and with the backing of philanthropic organizations, a working group of leaders and consultants in youth mental health and substance use in BC (including co-authors KT, SM and SB) submitted a workplan approved and supported by the Government of BC's Ministry of Health for an IYS proof-of-concept phase (BC-IYSI Working Group 2015a). First, a nationwide branding process was undertaken to ensure that a co-designed brand was youth- and family-friendly (Mathias et al. 2022). Through this process, the name Foundry was chosen along with the colour scheme and design themes, which focused on the natural world. Soon thereafter, the Granville Youth Health Centre evolved into the first official Foundry centre, Foundry Vancouver-Granville, expanding services to include single-session counselling. An additional five centres located across the province of BC (Mathias et al. 2022) were announced and opened in 2017 and 2018. Four additional expansion stages (2017, 2020, 2023 and 2024) followed, with a total of 35 Foundry centres open or in various stages of development.

In 2020, Foundry began work on a provincial virtual service; with the onset of the COVID-19 pandemic in March 2020 and restrictions affecting access to physical centres, development was fast-tracked and Foundry Virtual BC launched in April 2020 (Barbic et al. 2024). Foundry Virtual BC offers services to youth across BC, regardless of their vicinity to a Foundry centre (Zenone et al. 2022). By 2021, a Foundry-designed app was implemented to improve virtual services update; it was soon adopted by many centres to continue offering virtual services and provide youth the option of visiting their local centre or connecting with the same service providers virtually.

The Foundry model

A “backbone” organization, called Foundry Central Office (FCO), serves as a coordination team and standards organization for the initiative. FCO is a program of Providence Health Care, a non-profit healthcare organization with more than 8,000 employees. Providence Health Care supports operations and administrative needs, such as financial and human resources services. Providence Health Care philanthropic partner, St Paul's Foundation, supports fundraising efforts. Foundry also receives annualized operational funding from multiple Government of BC ministries (Health; Mental Health and Addictions; Social Development and Poverty Reduction) and, since 2019, has been part of provincial government policy to address mental health and addictions care in BC (Government of British Columbia 2019). The model includes partnerships with ministry offices, health authorities, divisions of family practice, school districts and community non-profit agencies in order to provide comprehensive health and social services with a focus on social determinants of health in spaces that young people access.

The FCO team is charged by the provincial government with establishing new centres and ensuring all Foundry locations provide high-quality, evidence-informed, culturally agile services and supports across the social determinants of health and meaningful engagement of youth and families/caregivers. In addition, the Foundry Virtual team provides virtual services to youth across the province. FCO has more than 100 staff and its teams include business support, service development and implementation, capital development, youth and family/caregiver engagement, planning and project management, communications, knowledge mobilization, Indigenous wellness, community development, equity, strategic policy, education and capacity building, philanthropy, technology, evaluation, data and research.

Each physical centre is operated by a Lead Agency already present in the community. These Lead Agencies are non-profit organizations and include regional health authorities, local services organizations or Indigenous-led organizations. FCO supports Foundry communities by working with Lead Agencies, health authorities, Indigenous organizations and service providers to support co-location and integration of existing resources and services. During each Foundry expansion stage, communities are invited to submit expressions of interest for a Foundry centre in their community and identify a Lead Agency. The expansion review committee at FCO includes diverse voices and takes numerous factors into consideration, including a history of integration and connection in the community. When an application is successful, the Lead Agency and Providence Health Care enter into contractual agreements to establish the centre. Critically, the Foundry model involves the Lead Agency establishing the centre in partnership with FCO and the local community. This engagement includes youth, families/caregivers, service providers, local First Nations and Métis and other community members. While this approach takes time, typically 18–36 months of engagement to bring community partners together and open a centre, the approach is vital to ensure that centres meet community needs and the processes to support integration of health and wellness services are established. Some funding is available for start-up costs, but the Lead Agency raises additional money to support capital costs. Foundry centres can be retrofitted or new builds initiated. Design elements include natural light, and floorplans include a waiting area, rooms for youth and family/caregiver appointments (including medical exam rooms) and spaces for gatherings, such as peer support groups or wellness activities. FCO staff support the Lead Agency with a start-up guide to serve as a blueprint for the process. Training is available at all stages of development and operations, with a learning management system serving as a central repository for training, resource sharing and ongoing professional development. Importantly, Foundry focuses on providing what communities need. Following environmental scans of existing services and subsequent service gap identification, operations funds are allocated to the Lead Agency to hire staff to fill these gaps. While communities may have unique funding needs, the funding model ensures that each centre has similar core services on offer.

There are five core service streams at Foundry: mental health, substance use health, physical and sexual health, peer support and social services (Barbic et al. 2024). While every Foundry centre must offer these streams for fidelity to the Foundry model, the service offerings vary depending on the resources available in that community, with a variety of service providers associated with each Foundry centre that may include family physicians, nurses and nurse practitioners, counsellors and social workers, occupational therapists, psychiatrists and administrative staff such as medical office assistants. This also includes youth peer support workers, who have lived/living experience and can help youth with navigation and client advocacy. Importantly, all of these providers coordinate care for youth, ensuring that youth do not have to repeat their stories and can receive support for multiple concerns at the same time. Foundry services are available to youth ages 12–24 years without a referral and at zero cost to the client. Family-inclusive services are also available to families/caregivers of youth, such as family peer support or counselling, even when a youth does not access Foundry services themselves. Youth may make appointments in a variety of ways. Foundry Virtual appointments are made directly through the app or browser, while at centres the appointments may be made through the app, via a form submitted online or by making appointments via phone, email or walk-in. Foundry offers accessible walk-in services, including single-session walk-in counselling, as well as walk-in physical and sexual health and peer support services. Foundry utilizes an integrated stepped care model with four steps: active engagement, low intensity, moderate intensity and high intensity, with high intensity located on-site or transitioned to another service in the community (Foundry 2023a). Overall, the Foundry model emphasizes youth-centredness, accessibility, equity and integration. An overview of the service framework can be seen in Figure 1.

Evaluation of Foundry

Foundry has been widely recognized for its integrated approach to youth services in BC. Evaluations of Foundry indicate that it effectively meets the needs of young people by providing a youth-friendly environment, fostering a sense of belonging and encouraging youth participation in their own care (Barbic et al. 2024; Mathias et al. 2022; Pullman 2020). Feedback from users often highlights the importance of having multiple services available under one roof, which streamlines the support process (Foundry 2023b). In addition, there is evidence suggesting positive outcomes in mental health, improved access to services and greater engagement among youth who utilize Foundry's resources (Foundry 2023b; Marchand et al. 2022; Ow et al. 2022, 2023). Overall, its integrated service model is viewed as a successful framework for addressing the diverse needs of youth in the province.

IYS and pan-Canadian policy

To date, IYS have received considerable support from decision makers and policy makers. The Canadian Institutes of Health Research (CIHR) along with the Graham Boeckh Foundation funded the ACCESS Open Minds initiative, which was launched in 2014 and established 16 sites in eight provinces/territories to provide youth mental health and other services (ACCESS Open Minds Espirits Ouverts 2021; Malla et al. 2019). While this time-limited funding has ended, many of the centres have come together as the IYS Indigenous Network in the IYS “Network of Networks” (IYS-Net) multi-phase CIHR initiative (CIHR 2022b), intended to bring together IYS thought leaders from across the country by supporting standards and infrastructure within a learning health system (Menear et al. 2019). These funding opportunities are intended to meet each province/territory where they are at in building an IYS initiative. To date, there have been open funding calls for territories/provinces that do not yet have an IYS initiative to bring together key informants to build a network, as well as targeted calls for the provinces at various stages of IYS development and for an IYS Data Platform (CIHR 2024). In Canada, Foundry, Youth Wellness Hubs Ontario, Aire Ouverte (Quebec) and the IYS Indigenous Network are the four most established IYS initiatives. Kickstand (Alberta), Huddle (Manitoba) and HOMEBASE (Saskatchewan) have all finalized their names, while initiatives in Newfoundland and Labrador and the Maritimes (Nova Scotia, New Brunswick and Prince Edward Island) are on paths to launching IYS.

Besides IYS-Net, IYS leaders have also come together through the Federation of IYS Networks, with a focus on building relationships among decision makers and advancing definitions and knowledge of IYS initiatives. Through the Canadian Youth Mental Health Insight Platform, this collaboration is designed to build infrastructure and processes for utilizing data across the country for improving youth mental health outcomes (Brain Canada Foundation 2022).

While these networks and platforms are still charting their paths forward, two common themes have emerged. The first is the universal desire to address youth mental health and substance use issues across Canada through bold, complex, transformative initiatives (Henderson et al. 2020). Efforts are coordinated to deliver better outcomes for youth across Canada, challenging traditional piecemeal, non-systems approaches that have proven to be expensive and unresponsive to the needs of youth. Expectations for funding recipients include capturing and utilizing data and sharing knowledge in a pan-Canadian learning health system (IYS-Net) to improve cost and resource efficiency (Menear et al. 2019).

The second theme has been the importance of including diverse voices in designing and implementing IYS initiatives: youth; their families/caregivers; service providers; and First Nations, Inuit and/or Métis Peoples, such as Elders from local First Nations bands. Representation from diverse geographic locations (urban, rural, remote) and Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual/Aromantic + (with the + signifying the ongoing evolution of the understanding of sexuality and gender) and/or racialized populations is also critical. Building related requirements into the design of funding opportunities, such as IYS-Net, helps ensure that IYS initiatives are meeting the needs of youth and their communities by ensuring that services are accessible, affordable, available and acceptable, for instance.

As this work gathers steam, continued support and coordination among decision makers and policy makers at all levels are key to the success of IYS.

Future directions

As Foundry heads into its second decade, there is much to consider for opportunities and areas of growth. At the forefront is understanding the short- and long-term impacts of Foundry on youth mental health and substance use outcomes. Work is underway to link Foundry data to administrative data in the province, such as hospitalizations, incidence of overdose and deaths, to better understand the outcomes of youth who use Foundry services as opposed to youth who do not.

Another area of work is fidelity to the Foundry model. The Foundry Model Integrity Framework is being used to guide processes and outputs within the organization to ensure high standards of integrity, transparency and accountability. While the framework ensures quality and consistency of services, it can also be tailored to address particular needs or challenges in a service or community (e.g., data sovereignty, regulatory compliance).

Foundry has elements of a learning health system (Menear et al. 2019), and these pieces are being organized through ongoing operational and project work, with a pilot study in progress under the IYS-Net umbrella (CIHR 2022b). As part of this work, measurement-based care is an area of priority both at Foundry and at IYS initiatives across the globe (Hickie et al. 2019). Determining the best tools, training and a minimum data set to fully utilize measurement-based care is in progress at Foundry and is described elsewhere (Barbic et al. 2020; Rodriguez Duque et al. 2024).

Finally, while Foundry leadership and staff have connected with their counterparts at various IYS initiatives across the globe, including headspace in Australia, Jigsaw in Ireland and allcove in the US, there is an opportunity for building additional infrastructure internationally to connect IYS initiatives around the globe and support their development in low- and middle-income countries.

While IYS initiatives are complex, their potential for addressing youth mental health and substance use concerns, particularly through prevention and early intervention, make them an exciting development in Canada's progress towards healthcare innovation and reform. As Foundry continues to evolve, we look forward to further optimizing the model to improve youth health and well-being and support youth in living a good life.

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