matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a...

52
the matryoshka project examining early intervention program development December 2009

Transcript of matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a...

Page 1: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

the

matryoshkaproject

examining

early intervention

program

development

December 2009

Page 2: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training
Page 3: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

authors

Chiachen Cheng, MD, FRPC(C), MPH

Carolyn S. Dewa, MPH, PhD

Paula Goering, RN, PhD

Desmond Loong

Page 4: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training
Page 5: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

Table of Contentsexecutive summary 2

background 6Introduction�� 6Brief��Description��of��the��Matryoshka��Project�� 7Project��Description�� 8

key findings 10

early intervention in psychosis 12Early��Psychosis��Prevention��and��Intervention��Centre��(EPPIC)�� 13Ontario��Early��Intervention��Program��Development�� 14

overall findings 16Key��Influences�� 16

Regional��Adaptations�� 18Challenges�� 19Successes�� 20Urban��and��Rural��Considerations�� 21

program flow charts 24Muskoka��/��Parry��Sound��Early��Intervention��Program�� 24Toronto��Early��Intervention��Program��(STEPS)�� 26Peterborough��Early��Intervention��Program��(LYNX)�� 28York��Early��Intervention��Program�� 30Windsor��Early��Intervention��Program�� 32Thunder��Bay��Early��Intervention��Program��(First��Place)�� 34

discussion 36

appendices 38APPENDIX��A:��References�� 38APPENDIX��B:��Pre-interview��Questionnaire�� 41APPENDIX��C:��Interview��Guide�� 41APPENDIX��D:��Analysis��Codes�� 43APPENDIX��E:��Acronyms�� 44

acknowledgments 46

Page 6: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

heading

[ The Matryoshka Project ] Examining Early Intervention Program Development2

executive summary

In�� 2004/05,�� the�� government�� of�� Ontario�� began�� investing�� significant�� new�� funds�� in�� the��community�� mental�� health�� system.�� Through�� the�� Health�� Accord�� for�� Home�� Care�� federal��initiative,��the��Ministry��of��Health��and��Long��Term��Care��allocated��$117��million��over��a��four-year��period.�� ��Recognizing��the��relationship��between��community��mental��health��services��and��inpatient��care,��the��Ministry��invested��the��funds��in��community��mental��health��services��to��support��intensive��case��management,��Assertive��Community��Treatment��(ACT),��crisis��intervention��and��Early��Intervention��Programs��(EIP).����

Page 7: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 3

The��Mental��Health��Systems��Enhancement��Evaluation��Initiative��(SEEI)��is��a��project��funded��by��the��Ontario��Mental��Health��Foundation��and��supported��by��the��Ontario��Ministry��of��Health��and��Long-Term��Care.����The��initiative��is��led��by��members��of��the��Health��Systems��Research��and��Consulting��Unit��at��the��Centre��for��Addiction��and��Mental��Health,��and��draws��upon��the��support��of��an��executive��advisory��committee��composed��of��members��of��stakeholder��groups.����As��part��of��the��System��Enhancement��Evaluation��Initiative��(SEEI),��the��Matryoshka��Project��is��a��3-year��project��looking��at��specific��programs��throughout��the��province.����Its��purpose��is��to��examine��the��effects��of��the��Government’s��new��investments��on��the��continuity��of��care��experienced��by��new��and��ongoing��clients��of��the��system.����The��Matryoshka��Project��focuses��on��two��types��of��specialized��programs:��a)��Early��Intervention��Programs��for��young��people��experiencing��their��first��psychotic��episode,��and��b)��Court��Support��Programs��for��individuals��with��mental��illness��who��are��involved��with��the��justice��system.����This��report��focuses��on��the��factors��that��influenced��how��the��development��and��implementation��of��the��study’s��Early��Intervention��Programs��emerged.

Many��of��the��programs��established��with��the��new��Ontario��funding��were��based��in��community��settings�� with�� an�� emphasis�� on�� outreach�� or�� rural�� service�� provisions.�� �� Prior�� to�� 2004/05,�� the��original��Early��Intervention��Programs��offered��in-house��training��methods��for��new��staff,��such��as��direct��supervision��and��clinical��shadowing.����Since��the��new��funding��roll-out��in��2004/05,��the��number��of��Early��Intervention��Programs��in��Ontario��grew��from��the��original��five��to��over��thirty.����

This��report��focuses��on��the��factors��that��influenced��how��the��study’s��new��Early��Intervention��Programs�� were�� developed�� and�� implemented.�� �� Data�� were�� collected�� using�� semi-structured��qualitative�� interviews�� and�� pre-interview�� questionnaires�� with�� program�� decision-makers�� for��each��of��the��research��sites��for��the��Matryoshka��Project.����During��the��interviews,��the��participants��spoke�� about�� local�� and�� provincial�� EIP�� networks�� as�� being�� very�� important�� with�� respect�� to��program�� development�� and�� implementation�� in�� the�� absence�� of�� Ontario-specific�� guidelines.����Clinical��mentors,��particularly�� from��the��original��five��Early�� Intervention��Programs,��were�� the��most�� influential�� in�� guiding�� new�� Early�� Intervention�� Program�� development.�� �� Most�� program��managers��developed��Early��Intervention��Programs��based��on��their��knowledge�� from��previous��experiences�� with�� other�� types�� of�� community�� mental�� health�� programs,�� in�� addition�� to�� advice��from��established��Early��Intervention��Programs��in��the��Ontario��Network.����The��end��result��was��schematically��unique��programs,��each��with��different��partnerships��that��suited��local��or��regional��needs.

Many��of��the��sites��for��the��Matryoshka��Project��had��rural��components��to��their��service��delivery.����Each��had��mandates��to��service��an��urban��core,��and��most��had��the��mandate��to��provide��outreach��to��rural��areas��as��well.����Initially��the��Matryoshka��Project��sites��adopted��the��hub and spoke��model,��but,��this��quickly��changed��for��practical��reasons.����One��site,��which��had��a��large��rural��component��to��the��program,��adopted��a��network��model��instead,��because��the hub and spoke��notion��was��perceived��

Page 8: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development4

to��be��too��hierarchical��and��centrally��driven.����They��also��thought��that��the��hub and spoke��model��promoted��top-down��decisions,��rather��than��building��consensus��across��all��sites.����Programs��that��initially��developed��hub��and��spoke��sites��often��changed��to��network��arrangements,��or��eliminated��the�� satellite�� offices�� for�� other�� forms�� of�� rural�� service�� delivery.�� �� Some�� considered�� embedding��EIP�� staff�� within�� other�� general�� mental�� health�� agencies.�� �� However,�� this�� created�� challenges��including��supervisory��difficulties,��scope��of��practice,��and��isolation��issues.����Within��a��single��Early��Intervention��Program,��the��challenges��of��trying��to��balance��the��needs��of��the��hub��and��spoke��were��often��seen��as��a��competition��between��urban��and��rural��needs.����To��this��day,��many��participants��continue��to��struggle��to��deliver��best��practice��EIP��services��to��rural��areas.����

Although�� many�� of�� the�� sites�� in�� the�� study�� faced�� challenges�� around�� not�� having�� Ontario��specific��service��guidelines,��or��EIP��standards,��this��also��may��have��been��beneficial.����Each��program��was��able��to��incorporate��components��of��best��practice��–such��as��early��identification��and��access,��assessment,�� case�� management,�� family�� education/support,�� and�� vocational�� or�� educational��supports–��and��adapt��them��to��their��local��circumstances.����In��fact,��participants��felt��that��some��of��their��successes��included��the��creativity��and��partnerships��that��were��developed��to��provide��EIP��services��in��their��respective��areas.����

Page 9: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development

Page 10: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

heading

[ The Matryoshka Project ] Examining Early Intervention Program Development6

Introduction

In��2002/03,��the��Ministry��of��Health��and��Long-term��Care��reviewed��the��results��of��the��nine��regional��mental��health��reform��taskforces.����The��recommendations��that��arose��from��these��reports��began��to��quantify��the��mental��health��service��needs��throughout��the��province��and��underscored��the��need��for��additional��funding��for��the��mental��health��system.

background

Page 11: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 7

In�� 2004/05,�� the�� government�� of�� Ontario�� began�� investing�� significant�� new�� funds�� in�� the��community�� mental�� health�� system.�� Through�� the�� Health�� Accord�� for�� Home�� Care�� federal��initiative,��the��Ministry��of��Health��and��Long��Term��Care��allocated��$117��million��over��a��four-year��period.����Interestingly,��Ontario��was��the��only��province��that��dedicated��Accord��funding��to��mental��health;�� but,�� the�� funding�� had�� important�� restrictions.�� One�� of�� the�� requirements�� for�� funding��was��that��it��had��to��be��earmarked��to��target��the��needs��of��a��population��who��meet��the��criteria��for��homecare,��specifically��those��who��were��discharged��from��hospital��and��could��be��supported��in��the��community.�� ��Recognizing�� the�� relationship��between��community��mental��health�� services��and�� inpatient�� care,�� the�� Ministry�� invested�� the�� funds�� in�� community�� mental�� health�� services��to�� support�� intensive�� case�� management,�� Assertive�� Community�� Treatment�� (ACT),�� crisis��intervention,��and��Early��Intervention��programs.����The��first��allocation��of��$20��million��was��made��in�� the�� summer�� of�� 2004,�� and�� a�� second�� of�� $50�� million�� in�� the�� summer�� of�� 2005.�� �� Additional��allocations��followed��in��2006��and��2007.��

The��Mental��Health��Systems��Enhancement��Evaluation��Initiative��(SEEI)��is��a��project��funded��by��the��Ontario��Mental��Health��Foundation��and��supported��by��the��Ontario��Ministry��of��Health��and�� Long-Term�� Care.�� �� The�� Initiative�� is�� led�� by�� members�� of�� the�� Health�� Systems�� Research��and��Consulting��Unit��at��the��Centre��for��Addiction��and��Mental��Health,��and��draws��upon��the��support��of��an��executive��advisory��committee��composed��of��stakeholder��groups.����The��purpose��of��the��SEEI��is��to��evaluate��and��communicate��the��effects��of��the��Government’s��new��investments.������

Brief Description of the Matryoshka Project

The��Matryoshka��Project��is��part��of��the��System��Enhancement��Evaluation��Initiative��(SEEI).����It��is��a��3-year��project��looking��at��specialized��programs��throughout��the��province.�� ��Its��purpose��is�� to�� examine�� the�� effects�� of�� the�� Government’s�� new�� investments�� on�� the�� continuity�� of�� care��experienced��by��new��and��ongoing��clients��of��the��system.����The��Matryoshka��Project��focuses��on��two��types��of��specialized��programs:��a)��Early��Intervention��Programs��for��young��people��experiencing��their�� first�� psychotic�� episode,�� and�� b)�� Court�� Support�� Programs�� for�� individuals�� with�� mental��illness�� who�� are�� involved�� with�� the�� justice�� system.�� �� This�� report�� focuses�� on�� the�� factors�� that��influenced��how��the��study’s��Early��Intervention��for��Psychosis��(EIP)��Programs��were��developed��and��implemented.

Page 12: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development8

Project Description

The��purpose��of��this��component��of��the��Matryoshka��Project��was��to��understand��the��processes��in��which��Early��Intervention��Programs��were��planned,��developed,��and��implemented��for��each��region.����The��goals��were��to:

A)��Understand��the��key��influences��of��how��the��Early��Intervention��Program��was��developed��for��their��region��or��program,B)��Identify��the��challenges��and��successes��of��program��development,��andC)��Describe��the��Early��Intervention��Programs��that��emerged.��

Data�� were�� collected�� using�� semi-structured�� qualitative�� interviews�� and�� pre-interview��questionnaires��with��program��decision-makers��for��each��of��the��research��sites��for��the��Matryoshka��Project.�� �� There�� were�� six�� sites�� with�� EIP�� programs�� in�� the�� study.�� �� Representatives�� from�� five��programs��were��successfully��interviewed.����

Prior�� to�� the�� qualitative�� interviews,�� each�� program�� was�� sent�� a�� pre-survey�� to�� collect��program�� information�� about�� staffing�� composition�� and�� their�� target�� populations.�� �� A�� copy�� of��the��questionnaire��can��be��found��in��Appendix��B.�� �� ��An��interview��guide��was��also��developed a priori,��which��can��be��found��in��Appendix��C.����Sampling��for��the��interviews��was��purposeful��and��key��informants��were��identified��using��a��snowball��technique.�� ��All��interviews��were��conducted��by��phone��with��the��written��consent��of��the��interviewees.�� ��The��interviews��were��conducted��in��late�� winter�� of�� 2007�� and�� seven�� interviews�� were�� completed�� with�� eight�� informants�� from�� five��programs.����The��interviews��lasted��between��1-2��hours��and��were��tape-recorded��and��transcribed��verbatim.����Emerging��themes��were��derived��in��an��iterative��process��through��a��series��of��discussions��involving�� two�� coders�� and�� a�� third�� member�� of�� the�� Matryoshka�� Project�� who�� was�� present�� to��provide��an��additional��perspective.����The��codes��that��were��developed��from��this��process��can��be��found��in��Appendix��D.

The��remainder��of��this��report��is��divided��into��three��sections.����The��first��section��summarizes��the��key��themes��that��emerged��when��interviewees��described��their��processes��of��Early��Intervention��Program�� planning,�� implementation,�� and�� development.�� �� The�� second�� section�� illustrates��diagrammatically��each��program,��their��client��flow��through��the��program,��as��well��as��key��successes��and�� challenges�� in�� regards�� to�� program�� development.�� �� The�� last�� section�� is�� a�� discussion�� about��future��implications.

Page 13: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development

Page 14: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

heading

[ The Matryoshka Project ] Examining Early Intervention Program Development10

The��purpose��of��this��report��is��to��describe��some��of��the��Early��Intervention��Programs��in��Ontario��and��to��examine��the��factors��that��shaped��the��new��program��service��models.����The��following��key��messages��were��observed.

key findings

Page 15: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 11

Key��Finding#1:

Program��developments��for��the��new��Early��Intervention��Programs��in��Ontario��were��significantly��influenced��by��the��provincial��EIP��Network,��local��champions,��and��clinical��mentors.����Program��decision-makers��often��relied��on��each��other��within��their��provincial��Network��for��guidance��about��program��implementation��and��development.����Programs��had��to��adapt��their��EIP��models��according��to��funding��and��local��service��characteristics,��in��the��absence��of��Ontario��specific��guidelines.

Key��Finding#2:

Although��the��research��evidence��assisted��program��decision-makers��to��develop��an��ideal��EIP��model��for��their��region,��implementation��of��the��ideal��was��often��shaped��by��funding��constraints.����

Key��Finding#3:

The��lack��of��specific��guidelines��may��have��allowed��innovation;��this��creativity��and��diversity��is��consistent��with��EIP��research��evidence.����

Key��Finding#4:

Despite��the��challenges��related��to��geography��and��staffing,��programs��experienced��important��successes��such��as��partnerships��across��sectors,��quality��clinical��service,��and��the��ability��to��engage��hard-to-serve��clientele��and��families.����

Key��Finding��#5:

Programs��were��passionate��about��serving��people��with��EIP��and��firmly��believed��that��their��services��provided��better��long-term��outcomes��to��individuals��with��severe��mental��illness.��

Page 16: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development12

heading

Over��the��past��fifteen��years,��early��intervention��for��psychosis��received��international��attention.����Emerging��research��indicates����EIP��may��improve��outcomes��for��young��people��experiencing��severe��mental�� illness��early�� in��their�� lives.1,2�� �� In��Ontario,�� the��first��Early��Intervention��Programs��were��established��in��1992��in��Hamilton��and��Toronto.����London��soon��followed��in��1997,��then��Ottawa��and�� Kingston�� in�� 2001.3�� �� All�� five�� programs�� were�� based�� in�� tertiary,�� urban�� academic�� centres.����The�� EIP�� models�� adopted�� by�� these�� clinical�� programs�� were�� based�� on�� pioneers�� in�� the�� field,��including��the��Early��Psychosis��Prevention��and��Intervention��Centre��(EPPIC)��from��Melbourne,��Australia.����

early intervention in psychosis

Page 17: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 13

Early Psychosis Prevention and Intervention Centre (EPPIC)

EPPIC�� is�� a�� specialized�� clinical�� program�� that�� aims�� “to�� facilitate�� early�� identification�� and��treatment��of��psychosis��and��therefore��reduce��the��disruption��to��the��young��person’s��functioning��and��psychosocial��development”.4,5����It��was��established��in��1992��as��a��“second��generation��model”��with��two��purposes:��a)��“to��identify��patients��at��the��earliest��stage��from��onset��of��psychosis”,��and��b)��“to��provide��intensive��phase��specific��treatment��for��up��to��2��years��thereafter”.6����Key��program��areas��identified��by��EPPIC��include:��assessment��and��community��treatment��team;��assertive��case��management;��inpatient��unit;��family��work;��cognitive��based��psychotherapy;��early��assessment��team;�� systematic�� treatment��of��persistent��positive�� symptoms;��group��and��day��programming;��brief��cognitive��therapy��for��acute��high-risk��suicide;��evaluation;��and��follow��up��of��prodromal��cases.7,8��An��illustration��of��the��EPPIC��service��model��is��shown��in��Figure��1.�� ��EPPIC��is��now��a��program��within��ORYGEN��Youth��Health��in��Melbourne,��Australia.����

��

��

Figure��1:��EPPIC��Service��Model9

Page 18: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development14

Through�� the�� work�� of�� EPPIC�� and�� other�� international�� EIP�� leaders,�� international�� best��practices�� for�� EIP�� were�� developed�� and�� components�� of�� best�� practice�� have�� been�� defined�� as:��public��education�� in��settings��that��are��youth-focused;��early�� identification��and��access�� to��care;����comprehensive�� assessment�� and�� case�� management;�� low�� dose�� neuroleptic�� treatment�� and��close�� ongoing�� monitoring;�� family�� education�� and�� support;�� group�� programming�� for�� various��psychosocial��treatment��modalities��such��as��cognitive��therapies;��occupational��and��educational��supports;��intensive��psychosocial��rehabilitation;��underlying��program��values��of��client-centred��services;��hope;��and��recovery.10

Ontario Early Intervention Program Development

Despite��the��accumulating��evidence��for��the��effectiveness��of��EIP,��there��is��still��relatively��little��research��on��which��to��base��operational��planning��and��implementation��of��EIP��in��either��rural��regions��or��community��settings.11,12����Many��of��the��programs��established��with��the��new��Ontario��funding�� were�� based�� in�� community�� settings�� with�� an�� emphasis�� on�� outreach�� or�� rural�� service��provisions.����Given��that��the��EIP��field��is��relatively��new��and��highly��specialized,��the��new��programs��were��charged��with��the��task��of��hiring��new��staff��who��needed��to��develop��specialized��EIP��skills��on��the��job.����Prior��to��2004/05,��the��original��Early��Intervention��Programs��offered��in-house��training��methods��for��new��staff,��such��as��direct��supervision��and��clinical��shadowing.�� ��Programs��found��this��to��be��manageable��because��staff��were��often��hired��in��small��numbers.����Since��the��new��funding��roll-out��in��2004/05,��the��number��of��Early��Intervention��Programs��in��Ontario��grew��from��the��original��five��to��over��thirty.����The��opportunities��and��challenges��associated��with��the��rapid��Early��Intervention��Program��expansion��in��Ontario��provided��a��unique��opportunity��to��examine��the��factors��that��shaped��service��models��for��the��new��programs.

Page 19: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development

Page 20: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development16

headingoverall findings

Key Influences

In��Ontario,��front��line��staff��observations��about��gaps��in��the��mental��health��system,��coupled��with��grass��roots��advocacy��groups’��actions,��helped��to��keep��EIP��on��the��agenda��with��decision��makers��and��funders.����For��example,��transitional��age��youth��between��the��ages��of��16��and��20��were��observed�� to�� be�� falling�� through�� the�� cracks�� between�� the�� adult�� and�� children’s�� mental�� health��systems.����In��response,��one��local��champion��started��to��service��this��age��group,��and��also��became��active��in��applying��for��funding��to��support��this��previously��unpaid��work.������For��a��subset��of��EIP��

Page 21: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 17

sites,��they��organized��themselves��prior��to��funding��decisions��and��submitted��proposals.����Local��leaders��and��champions��were��often��staff��from��existing��mental��health��service��organizations��who��galvanized��support��to��create��local��EIP��working��groups��or��community��advisory��committees��to��steer��the��funding��proposals.����Part��of��the��momentum��was��founded��on��the��belief��that��people��with��severe��mental��illness��could��achieve��better��long-term��outcomes��than��traditionally��believed.����

We were very persistent and kind of patient and we did a lot of different things along that way and lobbying while we were waiting

and building a ground of interest and support locally.

Many��people�� involved�� in��the��grass��roots��movement�� joined��the��provincial��EIP��Network.����This��provincial��Network��was��created��by��the��original��five��Ontario��Early��Intervention��Programs��that��were��based��in��tertiary��academic��centres.����The��Network’s��activities��also��kept��EIP��on��the��policy��agenda.�� ��For��example,�� the��group��conducted��outcomes��research��that��pointed��toward��the��positive��results��associated��with��Early��Intervention��Programs.13,14����Local��research��evidence,��coupled�� with�� discussions�� with�� various�� decision-makers�� and�� politicians�� from�� all�� political��parties��helped��to��shape��the��Health��Accord��funding��decisions��in��Ontario.����These��decisions��led��to��community��mental��health��agencies��across��Ontario,��including��those��that��did��not��participate��in��submitting��initial��funding��proposals,��to��receive��funding��for��EIP��services.����

Many��of��these��community��agencies��had��little��or��no��previous��experience��in��providing��clinical��EIP�� services.�� �� For�� guidance,�� they�� turned�� to�� practice�� guidelines�� and�� standards.�� �� With�� the��absence��of��Ontario-specific��guidelines,��the��participants��spoke��about��local��and��provincial��EIP��networks��as��being��very��important��with��respect��to��program��development��and��implementation.����Clinical��mentors,��particularly��from��the��original��five��Early��Intervention��Programs,��were��the��most��influential��in��guiding��new��Early��Intervention��Program��development.����Overall,��clinical��mentors��and��other��perceived��experts��were��found��to��be��more��influential��than��research��evidence��during��the��development��of��the��new��programs.��������

What I found myself doing of course and like other EIP managers is calling one another. Luckily we had the [provincial Network] … and so

through there I had mentors…

The�� program�� decision-makers�� who�� were�� charged�� with�� implementing�� the�� new�� Early��Intervention��Programs��often��relied��on��each��other��for��guidance��and��direction.����This��Network��was�� also�� more�� influential�� than�� published�� research�� evidence�� and�� direction�� from�� local��policy-makers.����

”“

”“

Page 22: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development18

The��values��associated��with��EIP��internationally��(from��EPPIC��and��others)��were��adopted��by��some��EIP��staff��wholeheartedly.����Staff��were��committed��not��only��to��the��EIP��service��philosophy,��but��also��to��the��EIP��work��ethic.

Well read, well informed, good regular supervision, flexible, smart, heaps of energy, good problem solver, passionate, likes young people.

NOT a control freak and NOT lazy.��15

It��is��important��to��note��as��well��that��some��staff��worked��in��conditions��that��others��may��not��have��tolerated.����For��example,��part��time��positions��doing��EIP��case��management��in��addition��to�� a�� regular�� case�� load,�� solo�� EIP�� clinicians�� with�� a�� wide�� scope�� of�� practice�� extending�� beyond��clinical��competencies,��and��unpaid��administrative��or��management��duties.

[Worker] joined the program as a public education and family support worker … she continued to be employed by SSO…In fact she continued to

act as the regional coordinator like the local director, she kept her old job … [she] just added on the EIP part.

Regional Adaptations

Early��Intervention��Programs��around��the��world��were��growing��at��a��rapid��rate.����As��program��managers��attempted��to��implement��new��EIP��service��models,��they��faced��the��tension��of��creating��new��services��based��on��research��evidence,��and��adapting��these��models��to��meet��local��service��needs.����Interviewees��have��expressed��frustration��with��the��lack��of��Ontario-specific��guidelines.�� ��Some��found��it��was��very��difficult��to��develop��new��programs��without��specific��guidelines��or��standards��to��follow.������And��the��guidance��that��interviewees��received��from��local��policy-makers��were��found��to��be��unhelpful.����Interviewees��believed��that��the��recommendations��that��were��given��were��either��too��restrictive��or��irrelevant��for��local��conditions.����In��hindsight,��some��participants��recognized��that��EIP��was��too��new��and��unfamiliar,��with��many��of��the��local��policy-makers��lacking��experience��and/or��knowledge��with��EIP��service��development.��

Overall,��most��program��managers��developed��Early��Intervention��Programs��based��on��their��knowledge�� from�� previous�� work�� experiences�� as�� well�� as�� on�� advice�� from�� established�� Early��Intervention��Programs��in��their��provincial��Network.����The��end��result��was��schematically��unique��

”“

”“

Page 23: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 19

programs,��each��with��different��partnerships��that��suited��local��or��regional��needs.����(Please��refer��to��the��Program��Flow��Charts��section��for��further��discussion��on��program��models).

One��of��the��many��challenges��that��program��decision��makers��faced��was��having��to��first��adapt��original�� visions�� to�� emulate�� best�� practice�� models,�� such�� as�� EPPIC,�� and�� then�� adapting�� their��service��model�� to��address�� local�� influences��and��needs.�� ��Program��decision��makers�� spoke��with��pride��about��these��creative��adaptations��and��collaborations��across��sectors��to��deliver��EIP��services.����

I think one of the things that has really shifted is around the staff complement…and that had to do with funding…It was very limited and

there were all sorts of different things that money had to pay for…so while the proposal might have called for 2 nurses, more social workers, OT’s…

The agency has gone with more generic kind of case managers…in making the money spread a little wider.

We don’t have any vocational assessment or resources on site…we go with established [services that] we have great connection with… employment

agencies in the community who are not necessarily geared towards people with major mental illnesses but who are so receptive…they’ve been really,

really excellent with our clients. What’s been great about them [,] they’ve actually found placements for our clients, but even before the placements

they have structured 2 week employment opportunity like they are getting ready for employment…[and] they get to know our clients really well…

The��participants��believed��that��they��positively��changed��the��existing��mental��health��system��by�� providing�� services�� where�� there�� were�� perceived�� gaps,�� specifically�� services�� for�� transitional��age��youth,��homeless��youth,��and��youth��in��trouble��with��the��law.����Early��identification��and��early��intervention��for��severe��mental��illness��were��also��provided.

Challenges

Although�� some�� of�� the�� themes�� identified�� under�� Regional�� Adaptations�� were�� cited�� as��challenges,�� the�� basic�� challenge�� voiced�� by�� all�� of�� the�� program�� decision-makers�� was�� the�� lack��of�� Ontario�� specific�� service�� guidelines.�� �� Some�� found�� that�� the�� restrictive�� nature�� of�� the�� early��

”“

”“

Page 24: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development20

funding,��coupled��with��lack��of��guidelines,��prevented��them��from��implementing��their��ideal��EIP��service��based��on��international��best��practice��guidelines.

the first thing that happened to the dollars was they were cut in half… So naturally everybody had to kind of squeeze into their implementation[.] So instead of a worker it was .5 of a worker… the money squeaked out

of the envelope year by year… It’s difficult because then you are trying to implement half of everything. It really compromised us.

Those�� who�� were�� new�� to�� delivering�� services�� that�� were�� traditionally�� hospital-based��faced��challenges��in��providing��these��services��in��the��community��setting.�� ��For��instance,��access��to��psychiatrists��and��family��physicians��decreased��as��services��branched��out��from��urban��hospital��centres�� to��community-based��or�� rural��programs.�� �� Interviewees�� spoke��about��difficulties��with��providing��aspects��of��the��clinical��service��such��as��prescribing��highly��regulated��medications��and��monitoring��potentially��harmful��side-effects.����This��was��also��compounded��by��the��lack��of��skilled��EIP��service��providers,��including��psychiatrists��trained��in��EIP.

P: We have one psychiatrist now who comes up from Toronto usually one day a week sometimes 2 days a week…But, but he works for the whole agency so

he is not specific to EIP at all…And he won’t prescribe[.] then we also have… videoconferencing….

I: So what do you do when you need to admit someone [to the hospital to manage their symptoms]?

P: [long pause] We are quiet here because that is a huge problem.

Successes

The��program��decision��makers��were��very��proud��of��the��successes��that��they��believed��they��had��achieved.����Partnerships��across��sectors��and��between��local��and��provincial��providers��were��things��they��believed��were��their��greatest��accomplishments.����

”“

Page 25: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 21

They��developed��service��partnerships��with��schools,��employment��agencies,��child��and��youth��mental��health��agencies,��youth��shelters,��youth��programs,��housing��and��hospitals.����

We have also been able to maintain some of our clients in the school system... we’ve been impressed with the level of co-cooperativeness they have

shown us with working with us and our clients, [For example] they’ve decreased [clients’] work load, they have provided rooms where they can

[have] stimulation to do their work…You know, a more protective setting during lunch....we’ve found them very, very cooperative.

The�� participants�� attributed�� their�� collaborations�� with�� other�� agencies�� to�� providing��better��clinical��services,��particularly��with��hard-to-serve��clientele;��and��in��turn,��achieving��greater��successes��in��client��outcomes,��staff��commitment,��and��client/family��satisfaction.����

I think the success is the family work we have been able to do and the families themselves have really helped us to be successful in intervening

in the lives of the youth.

They��also��believed��they��were��able��to��shift��the��mental��health��system��by��decreasing��resistance��to��the��EIP��model��and��change��through��education.����

I think that the public education, while we may not have had one person dedicated to it, we all of us have done a really great job of that.

And I think that we’re known in the community.”

The��program��decision��makers��attributed��their��ability��to��overcome��challenges��in��program��and�� service�� development�� to�� very�� collegial,�� coherent,�� and�� enthusiastic�� clinical�� teams.�� �� They��celebrated��their��successes��by��mutual��support��through��local��and��provincial��EIP��networks.��

Urban and Rural Considerations

Many��of��the��sites��for��the��Matryoshka��Project��had��rural��components��to��their��service��delivery.����Each��had��mandates��to��service��an��urban��core,��and��most��had��the��mandate��to��provide��outreach��to��

”“

”“

”“

Page 26: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development22

rural��areas��as��well.����The��EPPIC†��hub and spoke‡��model��to��deliver��services��to��rural��areas��has��been��adopted��by��many��programs��internationally.����Initially��the��Matryoshka��Project��sites��adopted��the��hub and spoke��model,��however,��this��quickly��changed��for��a��variety��of��practical��reasons.����One��site,��which��had��a��large��rural��component��to��the��program,��adopted��a��network��model��instead,��because��the��hub and spoke��notion��was��perceived��to��be��a��too��hierarchical��and��centrally��driven.����They��also��thought��that��the��hub and spoke��model��promoted��top-down��decisions,��rather��than��building��consensus��across��all��sites.����They��believed��that��the��hub and spoke��service��model��skewed��services��to��urban��areas,��rather��than��balancing��services��across��the��whole��region.����Programs��that��initially��developed��hub and spoke��sites��often��changed��to��network��arrangements,��or��eliminated��the�� satellite�� offices�� for�� other�� forms�� of�� rural�� service�� delivery.�� �� Some�� considered�� embedding��EIP��staff��within��other��general��mental��health��agencies.����Unfortunately,��this��created��challenges��including��supervisory��difficulties,��scope��of��practice,��and��isolation��issues.����Although��some��of��the��challenges��mentioned��earlier��were��accentuated��in��rural��areas,��there��was��a��severe��shortage��and�� lack��of��medical�� support.�� ��Videoconferencing��proved��to��be��a��very��useful�� tool,�� and��this��was��especially��true��in��hub��centres,��but��less��so��in��rural��areas��because��of��the��lack��of��IT��support��and��equipment.�� �� ��Within��a�� single��Early�� Intervention��Program,�� the��challenges��of��balancing��the��needs��of��the��hub��and��spoke��were��often��seen��as��a��competition��between��urban��and��rural��needs.����Many��participants��continue��to��struggle��with��delivering��best��practice��EIP��services��to��rural��areas.����

Many��of��the��programs��that��covered��large��geographies��faced��challenges��providing��services��to�� low�� population�� density�� areas.�� �� In�� some�� cases,�� a�� program�� would�� cover�� a�� vast�� geography��with��widely��differing��needs,��all��within��the��same��region��and��program.����Staff��travel��costs��and��regional��planning��complexities��were��some��of��the��unexpected��problems��that��surface��from��low��population��density��service��delivery.

†��EPPIC��was��one��of��the��first��Early��Intervention��Programs��internationally��to��publish��research��evidence��about��servicing��rural��areas.����

‡��Hub��and��spoke��refers��to��service��provision��that��resembles��the��hub��and��spoke��of��a��wheel.����The��hub��is��usually��located��in��a��central,��urban��area,��with��a��full��complement��of��EIP��service��provision,��including��family��education,��psychiatric��assessment��and��medical��care,��nursing��care��and��follow��up,��recovery��and��psychosocial��rehabilitation.����The��spokes��are��satellite��sites��of��EIP��service��with��access��and��clinical��support��from��the��hub,��but��specialist��EIP��service��is��delivered��within��a��generalist��agency��or��model.

Page 27: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development

Page 28: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development24

heading

Muskoka / Parry Sound Early Intervention Program

The��Muskoka/Parry��Sound��site��is��the��only��Matryoshka��study��site��that��could��be��considered��a�� spoke�� in�� the�� hub and spoke�� model.�� �� The�� central�� coordinating�� hub�� is�� based�� in�� North�� Bay,��which��does��not��provide��any��direct��clinical��EIP��service.����There��are��multiple��spokes,��each��with��1��to��2��EIP��case��managers��who��provide��all��the��direct��service��components��of��EIP.����Within��the��Muskoka/Parry��Sound��Early��Intervention��Program,��there��are��three��sites,��each��staffed��with��one��part-time��EIP��case��manager.����The��EIP��program��is��embedded��within��a��general��mental��health��

program flow charts

Page 29: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 25

agency��which��supports��the��lone��EIP��worker��clinically��and��administratively.������The��case��managers��are�� responsible�� for�� all�� EIP,�� including�� assessment,�� engagement,�� psychosocial�� intervention,��vocational��support,��and��family��support.����Case��managers��rely��on��the��hub��to��provide��education��and��training��opportunities,��clinical��assessment,��and��screening��scales.����Clients��typically��stay��for��up��to��3��years.����

EIP

wo

rk

Er

Par

t o

f g

rEa

tEr a

gEn

cy

tEa

m;

dr

aws

on E

xPEr

tIsE

In a

gEn

cy

lac

k o

f a

ny

MD

se

rv

ice o

r

ac

ce

ss

ru

ra

l g

eo

gr

ap

hy;

trav

el

tiM

e;

par

t ti

Me s

ch

eD

ule

s

iMp

leM

en

tin

g

re

gio

na

l to

ols

&

sta

nD

ar

Ds in

lo

ca

l/r

ur

al

po

pu

lati

on

Ref

erra

ls

self-

refe

rral

s;sc

hool

s;G

Ps;

fam

ilies

;co

mm

unity

age

ncie

s

Cen

tral A

genc

y In

take

scre

enin

g

0.8

FTE

: Clin

icia

n

initi

al a

sses

smen

t;in

tens

ive

care

man

agem

ent;

treat

men

t pla

nnin

g;ps

ycho

soci

al re

hab/

reco

ver;

fam

ily e

duca

tion

& s

uppo

rt;pu

blic

edu

catio

n

Impo

rtan

t Pa

rtne

rshi

ps:

Hos

pita

ls in

LH

INs;

Nor

thea

st E

IP H

ub

scre

enin

g to

ols;

satis

fact

ion

surv

eys

Hos

pita

lizat

ions

Musk

oka

Par

ry S

ound

EIP

PRO

GRAM

(SPO

KE)

Ref

erra

ls w

ithi

n EI

P te

am

LEGEND

(Gre

y ar

ea)

= E

IP T

eam

suc

cEs

sEs

ch

all

en

ge

s

vaca

ncie

s in

pr

ogra

m

Ref

erra

ls t

o/fr

om E

IP t

eam

Sea

mle

ss T

rans

itio

n/Tr

ansi

tion

out

of EI

P

The�� Muskoka/Parry��Sound�� site�� participants��felt��that��they��experienced��successes�� through��their�� innovation�� in��developing�� a�� program,��while�� working�� within��limited�� resources�� and��a�� large�� rural�� geography��to��service.�� ��Their��largest��challenge�� continues��to�� be�� finding�� medical��or�� psychiatric�� backup��for�� their�� EIP�� service��provision.������

Page 30: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development26

Toronto Early Intervention Program (STEPS)

The�� STEPS�� program�� is�� somewhat�� unique�� in�� a�� number�� of�� ways�� compared�� to�� other��Matryoshka�� Project�� sites.�� �� This�� program�� mainly�� services�� homeless,�� inner-city�� youth�� of��transitional��age,��16-24��years��old.����Given��that��the��clients��are��homeless,��there��is��very��little��family��involvement.�� �� Individuals�� from�� this�� population�� typically�� have�� significant�� legal�� problems��and��concurrent��substance��use��disorders.�� ��Clients��of�� this��program��are��referred��by��a��number��of�� sources,�� including�� inpatient�� units,�� youth�� shelters,�� youth�� justice�� programs,�� and�� general��practitioners.����Although��public��education��events��have��been��held��in��schools,��not��many��referrals��are��through��the��educational��system.����Intakes,��however,��are��completed��centrally��through��one��team�� member,�� who�� also�� completes�� the�� initial�� assessments�� and�� engagement�� of�� the�� client.����Psychiatric�� assessment�� referrals�� are�� made�� by�� the�� same�� nurse�� case�� manager�� when�� necessary.����Afterwards,��clients��are��assigned��to��a��case��manager��(from��occupational��therapy��or��social��work��disciplines)��who��coordinates��the��treatment��of��psychosis,��as��well��as��other��basic��aspects��such��as��housing,��disability��insurance,��and��reaching��vocational��goals.����Clients��typically��stay��with��the��program��until��they��reach��24��years��of��age,��at��which��point��they��will��transition��to��other��adult��mental��health��services.����The��STEPS��program��also��has��important��collaborations��with��family��medicine��residency��programs��and��youth��shelters��to��address��medical��and��housing��issues.

The�� STEPS�� program�� is�� uniquely�� part�� of�� a�� downtown�� hospital’s�� community�� outreach��program��and��it��is��one��of��five��programs��along��a��continuum��of��community��programs��providing��services��to��clients��with��severe��mental��illness.����The��main��challenge��faced��by��STEPS��was��program��development��without��established��guidelines��or��standards��for��EIP��in��Ontario.�� ��The��funding��restrictions��and��incremental��increases��also��made��it��a��challenge��to��plan��for��physical��space,��hiring��the��appropriate��number��of��staff,��compensating��for��the��lack��of��funding��for��psychiatry,��and��the��training��for��new��staff.����But��despite��the��challenges,��STEPS��was��successful��in��shifting��an��existing��mental��health��system��to��accommodate��and��provide��services��for��hard-to-serve��transitional��age��youth.����The��STEPS��team��is��very��collegial��and��cohesive,��and��has��attracted��learners��to��train��in��EIP.

Page 31: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 27

co

lleg

ial

tea

m;

eng

ag

ing h

ar

d t

o s

erve

yo

uth

;fi

llin

g g

aps

in s

ervi

ce

co

nti

nu

ity o

f c

ar

e (e

sp

ec

iall

y

fro

m in

pt)

lac

k o

f fu

nd

ing f

or m

ds

fun

din

g

re

str

icti

on

s;

lac

k o

f s

pac

e;

hir

ing t

ra

ine

d s

taff

Ref

erra

ls

Inpt

Uni

ts;

She

lters

;Yo

uth

Just

iice

Pro

gram

s;G

Ps

Cen

tral

Inta

ke

1 FT

E:

Nur

se C

ase

Man

ager

Initi

al A

sses

smen

ts;

Sho

rt Te

rm W

ork;

Out

reac

h

1 P

sych

iatri

st1

Res

iden

t

Import

ant

Part

ner

ship

s:Yo

uth

She

lters

;H

ousi

ng;

Fam

ily M

edic

ine

Link

with

To

ront

o E

IP

Net

wor

k

v

Vaca

ncie

s:2

FTE

1 FT

E:

OT

case

man

agem

ent;

hous

ing;

reco

very

/reha

b;ou

treac

h;C

BT,

soc

ial /

rec

grou

ps

1 FT

E: S

W

case

man

agem

ent;

hous

ing;

reco

very

/reha

b;ou

treac

h;gr

oups

1 FT

E: S

W

case

man

agem

ent;

hous

ing;

subs

tanc

e &

add

ictio

ns

wor

k;ou

treac

h;gr

oups

Sou

th

Eas

t Tor

onto

C

atch

men

t Are

a

Public

Educa

tion

Cas

e M

anag

emen

t

AC

T

Men

tal H

ealth

Clin

ic

Inpa

tient

& C

risis

Ser

vice

Oth

er

STEPS

CLI

EN

T F

LOW

CH

ART

shif

ted

exis

tin

g m

enta

l h

ealt

h s

yste

m t

o

ac

co

mo

dat

e tr

an

siti

on

al

you

th

Ref

erra

ls w

ithin

EIP

tea

m

LEGEND

(Gre

y ar

ea)

= E

IP T

eam

suc

ces

ses

ch

all

en

ge

s

vaca

ncie

s in

pr

ogra

m

Ref

erra

ls t

o/f

rom

EIP

tea

m

Sea

mle

ss T

ransi

tion/

Tran

sition o

ut

of

EIP

Page 32: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development28

Peterborough Early Intervention Program (LYNX)

Like�� the��other�� sites,�� the��LYNX��program�� is�� located�� in��a�� rural��part��of�� the��Province,��with��the�� mandate�� to�� provide�� services�� in�� a�� smaller�� urban�� centre�� and�� outreach�� to�� multiple�� rural��communities.����LYNX��is��unique��because��it��is��an��eight��agency��collaboration��across��four��counties.����There��is��a��central��Joint��Management��Committee��that��provides��coordination��and��management��decisions.�� ��The��Committee��also��works��closely��with��the��community��advisory��group��and��the��program��paymaster-lead��agency,��from��which��funding��is��flowed��through��to��each��site.����Referrals��to�� the�� program�� can�� be�� made�� from�� families,�� schools,�� other�� community�� agencies,�� hospitals,��general�� practitioners,�� and�� from�� clients�� themselves.�� �� Once�� a�� referral�� has�� been�� made,�� the��nearest/local��case��manager��completes��the��comprehensive��assessment,��assertive��outreach,��and��engagement.����The��case��manager��then��coordinates��other��referrals��for��psychiatric��consultation,��family��support,��and��education.����The��local��case��manager��also��manages��all��of��the��EIP��treatment,��such��as��medical��investigations,��school��or��vocational��support,��psychosocial��rehabilitation,��and��any��ongoing��medical��follow-up��required.��On��average,��clients��usually��stay��in��the��program��for��2��to��5��years��and��graduate��into��an��Alumni��Program��that��involves��three��scheduled��appointments��with�� a�� case�� manager�� and�� psychiatrist,�� as�� well�� as�� alumni�� peer�� supports.�� �� Clients�� may�� also��progress��into��other��community��mental��health��programs��or��even��achieve��independent��living��under��the��care��of��a��general��practitioner.

The��challenges��faced��by��LYNX’s��program��development��were��in��delivering��services��across��four��counties��with��only��half��the��funding��and��resources��that��they��applied��for.����The��incremental��increases��in��funding��over��four��years��created��difficulties��in��delivering��services.����It��was��only��when��LYNX��reached��the��full�� funding��complement��were��they��able��to��overcome��their��obstacles��–��three��years��after��the��start��of��the��program.����The��main��successes��of��the��LYNX��program��were��the��collaborations�� and�� partnerships�� established�� among�� the�� eight�� agencies�� across�� four�� counties.����These��partnerships��were��instrumental��in��delivering��quality��clinical��services��with��a��high��degree��of��early��identification��and��prevention��of��hospital��admissions.

Page 33: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 29

Ref

erra

ls w

ithin

EIP

tea

m

Ref

erra

ls t

o/f

rom

EIP

tea

m

Sea

mle

ss T

ransi

tion/

Tran

sition o

ut

of

EIP

LEGEND

(Gre

y ar

ea)

= E

IP T

eam

suc

ces

ses

ch

all

en

ge

s

vaca

ncie

s in

pr

ogra

m

LYNX

CLI

EN

T F

LOW

CH

ARTd

ecr

easi

ng

res

ista

nc

e to

eip

mo

del

a

nd c

ha

ng

e

eip

wo

rk

ers

emb

edd

ed in

oth

er

men

tal

hea

lth a

gen

cie

s,

oft

en a

t 0.

5 ft

e

de

liv

er

ing

se

rv

ice

s w

ith

re

so

ur

ce

s f

or 0

.5

wo

rk f

or

ce;

fun

din

g s

low

to in

cr

ea

se,

for

cin

g 0

.5 f

tes;

ne

ed c

rit

ica

l m

as

s o

f fu

nd

ing t

o d

eli

ve

r

se

rv

ice

geo

gr

aph

y ( r

ur

al)

Ref

erra

ls

self-

refe

rral

s;fa

mili

es;

scho

ols;

hosp

itals

;co

mm

unity

age

ncie

s

LYN

X N

etw

ork

Coo

rdin

atio

n;Jo

int M

anag

emen

t Com

-m

ittee

;C

omm

unity

Adv

isor

y G

roup

;P

sych

iatry

AC

T

Oth

er C

omm

unity

Men

tal

Hea

lth A

genc

ies

Fam

ily S

uppo

rt an

d P

ublic

Edu

catio

n

Toll

Free

Num

ber;

Pub

lic E

duca

tion;

Pro

fess

iona

l Tra

inin

g

Ass

essm

ent

psyc

hiat

rist;

case

man

ager

Out

reac

h C

ase

Man

ager

initi

al s

cree

ning C

MH

A - L

inds

ay0.

5 FT

E F

amily

Sup

port

& P

ublic

Edu

catio

n

Cob

ourg

: Lak

esho

re

Com

mun

ity M

enta

l Hea

lth S

ervi

ce1.

0 FT

E C

ase

Man

agem

ent

Lind

say:

Com

mun

ity C

ouns

ellin

g S

ervi

ces

1.0

FTE

Cas

e M

anag

emen

t

Cam

pbel

lford

& D

istri

ct

Com

mun

ity M

enta

l Hea

lth C

entre

1.0

FTE

Cas

e M

anag

emen

t

Min

den

Hal

ibur

ton

Hig

hlan

ds

Men

tal H

ealth

Ser

vice

s1.

0 FT

E C

ase

Man

agem

ent

Pet

erbo

roug

h R

egio

nal H

ealth

Cen

tre1.

0 FT

E C

ase

Man

agem

ent

0.2

FTE

Psy

chia

try

Pet

erbo

roug

h: S

SO

0.75

FTE

Fam

ily S

uppo

rt &

Pub

lic E

duca

tion

CM

HA

- Pet

erbo

roug

hLe

ad A

genc

y: P

aym

aste

r/Pro

gram

Coo

rdin

atio

n

0.5

FTE

Fam

ily S

uppo

rt &

Pub

lic E

duca

tion

1.0

FTE

Cas

e M

anag

emen

t

Psy

chia

tryC

ase

Man

agem

ent

Cas

e m

anag

emen

t; ps

ychi

atric

car

e;m

edic

al in

vest

igat

ions

;sch

ool/v

ocat

ion;

reha

b/re

cove

ry w

ork

impo

rta

nt

par

tner

ship

s:p e

ter

bo

ro

ug

h

ho

spit

al;

sso

;h

igh d

egr

ee o

f c

oll

ab

or

atio

n

am

on

gst

8

ag

enc

ies

an

d 4

c

ou

nti

es

qu

ali

ty

cli

nic

al

ser

vic

e;h

igh d

egr

ee o

f ea

rly

iden

tifi

cat

ion;

prev

enti

on o

f h

osp

ita

liza

tio

n

Page 34: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development30

York Early Intervention Program

Like�� many�� of�� the�� other�� Matryoshka�� sites,�� the�� York�� Region�� Early�� Intervention�� Program��accepts�� referrals�� from�� many�� sources�� including�� families,�� hospital�� units,�� client�� self-referrals,��community��agencies,��and��general��practitioners.����Consistent��with��published��literature,��public��education�� efforts�� increased�� the�� number�� of�� referrals�� following�� an�� education�� event.16,17,18,19����Preliminary��screening��is��completed��to��determine��appropriate��fit��into��the��Early��Intervention��Program.����If��a��client��fulfills��the��intake��criteria,��a��full��assessment��is��completed��by��the��program��manager��and��one��front-line��staff.����Following��this��assessment,��a��case��manager��(from��any��one��of��the��disciplines:��social��work,��nursing,��peer��support,��occupational��therapy)��will��service��the��client.����The��York��Region��program��has��established��partnerships��with��schools,��employment��support��agencies,��housing��programs,��and��other��youth��services��to��provide��psychosocial��rehabilitation��and��recovery��support.����The��York��program��started��implementing��the��hub and spoke��model��by��initially��establishing��a��satellite��site��in��the��rural��portion��of��their��region.����However,��over��the��first��few��years��following��the��opening��of��services,��the��York��program��decided��to��close��their��satellite��site��and��operate��all��of��their��services��from��a��central��site��in��Aurora.

The��main��challenges��faced��by��the��York��Early��Intervention��Program��were��providing��adequate��training��for��new��staff,��compensating��for��the��lack��of��funding��for��psychiatry,��recruiting��additional��psychiatry��time,��and��balancing��the��needs��of��both��urban��and��rural��regions��in��one��program.����The��main��successes��were��the��partnerships��and��positive��community��presence��that��they��established.����This�� was�� in�� part�� due�� to�� public�� education�� efforts,�� family�� education,�� and�� support�� groups�� –��including��those��provided��for��clients.

Page 35: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 31

kn

ow

n

in c

om

mu

nit

y:pu

bli

c e

du

cat

ion e

ffo

rts

; fa

mil

y w

or

k

hig

h

cli

ent

sati

sfa

cti

on

ge

og

ra

ph

y;

trav

el

tim

e;

sta

ff t

ra

inin

g n

ee

ds;

lim

ite

d f

un

din

g

lac

k o

f fu

nd

ing f

or m

ds;

dif

fic

ult

y r

ec

ru

itin

g

ad

dit

ion

al

md

s

sta

rti

ng

clo

zap

ine in

c

om

mu

nit

yR

efer

rals

fam

ilies

;ho

spita

ls;

self-

refe

rral

s;G

Ps;

com

mun

ity a

genc

ies

Pre

limin

ary

scre

enin

g w

ith

Ref

erra

l sou

rce.

Inta

ke A

sses

smen

t 1

Pro

gram

Man

ager

1 C

linic

ian

Import

ant

Part

ner

ship

s:G

Ps;

3 lo

cal h

ospi

tals

;H

eads

Up

Pro

gram

;K

ick

Sta

rt P

rogr

am;

YM

CA

;S

choo

ls;

Cro

sslin

ks H

ousi

ng;

310

Cop

e P

rogr

am

vVa

canc

ies:

1 FT

E: O

T0.

5 FT

E: N

urse

1 FT

E:

Pee

r Sup

port

Wor

ker

0.2

FTE

: P

sych

iatry

med

ical

car

e;fa

mily

wor

k

2 FT

E: S

W

case

man

agem

ent;

publ

ic e

duca

ctio

n;fa

mily

wor

k

1 FT

E: N

urse

case

man

agem

ent;

publ

ic e

duca

tion;

fam

ily w

ork

4 FT

E: C

M

case

man

agem

ent;

publ

ic e

duca

ctio

n;fa

mily

wor

k

Gro

ups

fam

ily e

duca

tion;

fam

ily s

uppo

rt;pe

er e

duca

tion;

peer

sup

port

Oth

er C

MH

A P

rogr

ams

AC

T;ca

se m

anag

emen

t

Public

Educa

tion

Em

ploy

men

t Ser

vice

s

Sch

ool

Hos

pita

lizat

ions

York

Reg

ion

CLI

EN

T F

LOW

CH

ART

effe

cti

ve

par

tner

ship

s

Ref

erra

ls w

ithin

EIP

tea

m

LEGEND

(Gre

y ar

ea)

= E

IP T

eam

suc

ces

ses

ch

all

en

ge

s

vaca

ncie

s in

pr

ogra

m

Ref

erra

ls t

o/f

rom

EIP

tea

m

Sea

mle

ss T

ransi

tion/

Tran

sition o

ut

of

EIP

Page 36: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development32

Windsor Early Intervention Program

The��Windsor��Region��Early��Intervention��Program��is��one��of��a��handful��of��EIP��services�� in��Ontario��accepting��individuals��less��than��16��years��of��age.����The��actual��intake��criteria��for��Windsor’s��EIP��program��are��clients��between��the��ages��of��14��and��35��years.����Referrals��to��this��program��can��be�� made�� from�� inpatient�� units,�� families,�� school�� officials,�� community�� agencies,�� and�� clients��themselves.�� �� Like�� many�� other�� mental�� health�� services,�� preliminary�� screening�� is�� conducted��to�� assess�� appropriate�� fit�� to�� the�� EIP�� services�� available.�� �� If�� appropriate,�� a�� full�� consultation�� is��completed�� with�� a�� program�� psychiatrist�� and�� family�� educator.�� �� Ongoing�� case�� management��involving��mental��health��education,�� symptom��management,��coping��skills��development,��and��advocacy,��are��performed��by��registered��nurses.����Other��services��such��as��psychiatric/medical��care,��family��education��and��support,��housing��and��vocational��support��are��also��available��to��complement��case�� management�� services.�� �� However,�� the�� enrolment�� time�� is�� limited�� to�� a�� maximum�� of�� 2��years,��after��which,��individuals��are��discharged��from��the��program��when��they��have��either��been��transitioned��to��another��level��of��service,��or��when��their��service��goals��have��been��completed.��The��Early��Intervention��Program��has��also��developed��a��community��partnership��with��City��Centre��Health�� Care�� located�� at�� the�� Canadian�� Mental�� Health�� Association�� Windsor-Essex�� County��Branch��office.����Services��that��are��provided��include��a��dietician,��a��nurse��practitioner,��therapists,��a��chiropodist,��a��health��promoter,��psychiatrists,��and��general��practitioners.��

The��main��successes��from��Windsor’s��Early��Intervention��Program��were��the��establishment��of��community��partnerships��and��a��positive��community��presence.��As��part��of��the��family��support��offered��in��the��Early��Intervention��Program,��Multi-Family��Groups��are��utilized.����These��groups��are�� intended�� for�� both�� the�� clients�� of�� the�� Early�� Intervention�� Programs�� and�� the�� people�� who��are�� identified�� as�� ‘family’�� by�� the�� client.�� �� Group�� meetings�� are�� held�� bi-weekly�� and�� about�� 90��minutes��per�� session.�� ��The��focus��of�� the��group�� is�� for��participants�� to��gain��support�� from��their��peers,�� as�� well�� as�� to�� increase�� communication,�� problem-solving,�� and�� coping�� skills�� in�� dealing��with�� symptoms�� that�� are�� reported.�� �� Group�� meetings�� typically�� begin�� with�� a�� few�� minutes�� of��informal��socialization,��followed��by��a��check-in��where��all��participants��indicate��“something��that��has��gone��well��since��the��last��group��and��something��that��they��wish��had��gone��better”.����From��the��“things��that��could��have��gone��better”,��the��facilitators��choose��one��of��the��situations��to��problem��solve.����With��the��permission��of��the��client��and��family,��the��facilitators��then��lead��the��group��in��a��problem��solving��exercise.����This��results��in��the��client��and��family��leaving��the��group��with��a��plan��to��begin��solving��their��problem.����A��copy��of��the��plan��is��provided��to��the��client’s��case��manager,��and��at��the��following��session,��the��facilitators��check��back��with��the��family��and��client��to��inquire��if��the��plan��was��successful.����One��of��the��challenges��experienced��by��this��program��was��the��continued��need��for��services��and��the��straining��of��limited��resources.

Page 37: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 33

Windsor

CLI

EN

T F

LOW

CH

ART

Ref

erra

ls w

ithin

EIP

tea

m

LEGEND

(Gre

y ar

ea)

= E

IP T

eam

suc

ces

ses

ch

all

en

ge

s

vaca

ncie

s in

pr

ogra

m

Ref

erra

ls t

o/f

rom

EIP

tea

m

Sea

mle

ss T

ransi

tion/

Tran

sition o

ut

of

EIP

co

nti

nu

al

ne

ed

for s

er

vic

es t

hat

s

tre

tch

es t

he r

es

ou

rc

es

ava

iila

ble

fun

din

g

re

so

ur

ce

s

Ref

erra

ls

inpa

tient

;fa

mily

;sc

hool

s;se

lf;co

mm

unity

age

ncie

s

Pre

limin

ary

scre

enin

g

Full

Consu

ltat

ion

Fam

ily E

duca

tor

Psy

chia

trist

Psy

chia

try

med

ical

car

e; in

divi

dual

and

fam

ily s

uppo

rt

3.5

FTE

: C

ase

Man

agem

ent

(RN

s)

case

man

agem

ent;

educ

atio

n;ho

usin

g;em

ploy

men

t;sc

hool

1.0

FTE

: Fa

mily

Edu

cato

r

fam

ily g

roup

wor

k; fa

mily

edu

catio

n;fa

mily

sup

port;

pee

r gro

up w

ork;

peer

edu

catio

n; p

eer s

uppo

rt

Neg

ativ

e S

cree

ning

Ref

erra

l bac

k to

so

urce

, or r

efer

rals

to

com

mun

ity s

ervi

ces

Em

ploy

men

t

Sch

ool

AC

T

Com

mun

ity A

genc

ies

dev

elo

pin

g

par

tner

ship

s in

th

e c

om

mu

nit

y

posi

tive

c

om

mu

nit

y pr

esen

ce

esta

bli

shed

by

the

pro

gr

am

Page 38: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development34

Thunder Bay Early Intervention Program (First Place)

The��First��Place��Clinic��&��Resource��Centre��in��Thunder��Bay��accepts��adolescents��and��adults��between��the��ages��of��14��and��35��years.����Younger��clients��are��also��routinely��accepted.����Individuals��are�� typically�� referred�� by�� a�� variety�� of�� sources�� including�� hospital�� inpatient�� units,�� addiction��services,��family��practitioners,��psychiatrists,��housing,��schools/education��sector,��child��welfare,��aboriginal��mental��health,��and��other��community/social��services.����Referrals��are��screened��initially��by��a��senior��clinician.����If��early��psychosis��is��suspected,��an��assessment��consultation��is��provided��by��a��psychiatrist,��nurse��case��manager,��family��educator,��and��recovery��care��coordinator.����After��the��initial��appointment,��a��decision��is��made��to��provide��short-term��extended��consultation,��or��long-term��treatment��and��recovery.����The��time��limit��registered��in��the��program��is��dependent��on��individual��needs.����At��times��care��is��transitioned��to��ACT��or��other��intensive��case��management��services,�� such�� as�� housing,�� employment/vocational�� support,�� and�� other�� community�� mental��health��services.����Individuals��who��achieve��their��recovery��goals��are��then��enrolled��in��an��Alumni��Program��where��they��have��annual��follow��up��with��the��Early��Intervention��Program,��but,��First��Place��maintains��a��shared��care��model��with��the��individual’s��family��physician��or��general��practitioner.����A��key��accomplishment��in��the��program��was��the��development��of��important��partnerships��with��regional��aboriginal��mental��health��services,��hospitals,��other��adult��and��children’s��mental��health��services,��and��recreational/leisure��facilities.

The��challenges��in��program��development��at��First��Place��included��servicing��a��vast��geography��with��varying��stakeholder��needs.����The��challenges��of��balancing��needs��in��Thunder��Bay��with��the��service��needs��in��the��region��were��illustrated��by��the��demand��for��services��before��the��clinical��team��was��appropriately��trained.����Staff��were��asked��to��develop��a��wide��range��of��clinical��skills,��servicing��clients�� ranging�� from��children��to��adults.�� �� Important�� successes��of�� this��program��included��the��partnerships��established��with��local��and��regional��mental��health��providers.����First��Place��also��has��a��skilled��and��collegial��team��that��has��engaged��youth��and��families��to��achieve��clinical��goals.

Page 39: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 35n

ee

d f

or

se

rv

ice b

efo

re

se

rv

ice r

ea

dy;

var

yin

g s

tak

eh

old

er

ne

ed

s

vas

t g

eo

gr

ap

hy;

ba

lan

cin

g h

ub a

nd

re

gio

na

l n

ee

ds

cli

nic

al

tea

m

ne

ed a

wid

e r

an

ge

of

sk

ills

(c

hil

d ->

ad

ult

)

Impo

rtan

t Pa

rtne

rshi

ps:

Dili

co; C

hild

ren’

s C

entre

;R

egio

nal H

ospi

tals

;G

Ps

Hou

sing

Ser

vice

s

Em

ploy

men

t S

ervi

ces

Add

ictio

ns

Con

sults

Abo

rigin

al

Ser

vice

s

AC

T

Oth

er In

tens

ive

Cas

e M

anag

emen

t

ALU

MN

I P

RO

GR

AM

Year

ly re

view

;G

P ca

re

Firs

t Pla

ce C

linic

&

Res

ourc

e Cen

tre

CLI

ENT

FLO

W C

HART

effe

cti

ve

par

tner

ship

s

skil

led

co

lleg

ial

tea

m;

suc

ces

sfu

l en

ga

gem

ent

wit

h y

ou

th &

fam

ilie

s;a

ch

ievi

ng c

lin

ica

l g

oa

ls

( ho

pe, a

void

ad

mis

sio

ns,

etc

)

Ref

erra

ls

Ado

lesc

ent I

npt;

Adu

lt In

pt;

Chi

ld/A

dole

scen

t Men

tal H

ealth

A

genc

y;A

borig

inal

Men

tal H

ealth

A

genc

y;C

hild

Wel

fare

;R

egio

nal A

genc

ies

1.0

FTE

: Pro

gram

D

irect

or

Initi

al S

cree

ning

INTA

KE

C

ON

SU

LTAT

ION

Psy

chia

trist

& 1

Clin

icia

n

Edu

catio

n &

Tra

inin

g

Ref

erra

l to

Oth

er

Ser

vice

s

first

epi

sode

psy

chos

is

rule

d ou

t

2.0

FTE

: N

urse

Car

e C

oord

inat

or(s

)

1.0

FTE

: E

duca

tion

& T

rain

ing

Coo

rdin

ator

1.0

FTE

:Fa

mily

Car

e C

oord

inat

or

0.6

FTE

: P

sych

iatry

Car

e

0.4

FTE

: N

euro

spsy

chom

etris

t

1.0

FTE

: R

ecov

ery

Car

e C

oord

inat

or

vVa

canc

ies:

4.0

FTE

: Reg

iona

l Cas

e M

anag

er(s

)

Ref

erra

ls w

ithi

n EI

P te

am

LEGEND

(Gre

y ar

ea)

= E

IP T

eam

suc

ces

ses

ch

all

en

ge

s

vaca

ncie

s in

pr

ogra

m

Ref

erra

ls t

o/fr

om E

IP t

eam

Sea

mle

ss T

rans

itio

n/Tr

ansi

tion

out

of

EIP

Page 40: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development36

heading

In��some��ways,��funding��for��EIP��services��was��a��risk��to��funders��because��EIP��was��an��innovative,��specialized,��and��revolutionary��approach��to��treating��psychotic��disorders��such��as��schizophrenia.5����

In�� Ontario,�� the�� EIP�� services�� began�� in�� the�� early�� 1990’s�� when�� EIP�� was�� being�� established��internationally.�� �� Over�� twelve�� years,�� a�� collaborative�� provincial�� Network�� was�� created�� which��connected�� with�� the�� grassroots�� movement�� in�� the�� early�� 2000’s�� and�� also�� coincided�� with�� new��funding��for��EIP.��������

Interviewees��for��this��study��were��obviously��passionate��about��EIP,��and��firmly��endorsed��EIP��as��

discussion

Page 41: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 37

making��a��difference��for��clients��of��the��mental��health��system��who��were��previously��not��identified��or��treated��early,��causing��much��suffering��and��expense.����They��emphasized��the��message��that��EIP��was��worth��the��risk��to��funders.

Although�� many�� of�� the�� sites�� in�� the�� study�� faced�� challenges�� related�� to�� not�� having�� Ontario��specific��service��guidelines,��or��EIP��standards,��this��also��may��have��been��a��benefit.����As��illustrated��in�� the�� program�� client�� flow�� charts,�� each�� program�� appears�� unique,�� but�� each�� has�� adapted��the�� components�� of�� best�� practice,�� such�� as�� early�� identification�� and�� access,�� assessment,�� case��management,��family��education/support,��and��vocational��or��educational��supports.����Variations��were��seen��in��the��number��of��staff��and��program��sites,��the��disciplines��of��case��managers��(i.e.��social��work,��nursing,��occupational��therapist),��and��the��type��of��partnerships��developed.����

Interviewees��were��anxious��to��receive��feedback��about��whether��they��were��“doing��a��good��job”.����Part��of��this��may��have��been��to��show��funders��that��EIP��and��community��mental��health��was��worth��the�� investment.�� ��Perhaps�� the��ability�� to��gauge�� success��would��have��been��easier��by��measuring��themselves�� against�� provincial�� standards;�� however,�� in�� the�� absence�� of�� standards�� in�� Ontario,��the��programs��were��each��able��to��adapt��and��mould��their��EIP��service��to��local��conditions,��while��meeting��best��practices.����Experts��in��the��field��have��always��advocated��for��ingenuity��and��creativity��in��Early��Intervention��Programs��development.

An early psychosis service can be developed in many different ways. Diversity and creativity are to be encouraged, and services should be developed in ways

that are congruent and synergistic with the local setting.��20����

Certainly,�� the��participants�� felt�� that��some��of��their��successes��were��the��creativity��and��partnerships��developed��to��provide��EIP��service��in��their��area.�� ��Each��service��model��proved��to��be��quite��dynamic,��with��services��changing��depending��on��local��client��needs��and��learning��from��experience.����The��program��flow��charts��are��a��snapshot��in��time��and��have��shifted��–��even��as��this��report��is��being��written.����

Given��the��contextual��nature��of��much��of��this��report,��it��is��important��to��view��the��results��in��the��broader��context��of��all��the��results��in��the��Matryoshka��Project,��and��even��the��SEEI.����Qualitative��data��in��this��report��is��able��to��provide��the��program��and��systems’��context��of��other��outcomes��data��and,��ultimately,��the��effects��of��the��new��investments��made��by��the��Ontario��Ministry��of��Health��and��Long-Term��Care.

”“

Page 42: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development38

[APPENDICES]

APPENDIX A: References

(1)���� Malla��AK,��Norman��RM,��Joober��R.����(2005).����First-episode��psychosis,��early��intervention,��and��outcome:��what��have��we��learned?����Canadian��Journal��of��Psychiatry��-��Revue��Canadienne��de��Psychiatrie,��50(14),��881-891.

(2)���� Marshall��M,��Rathbone��J.����(2006).����Early��Intervention��for��Psychosis.��Cochrane��Database��of��Systematic��Reviews,��(4).

(3)���� Lhines,��Elizabeth.����(2001).����A��guide��to��Canadian��early��psychosis��initiatives.����Canadian��Mental��Health��Association.��

appendices

Page 43: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development

[APPENDICES]

(4)���� Early��Pyschosis��Prevention��and��Intervention��Centre.����(2004).����About��EPPIC.����Retrieved��June��1,��2009,��from��www.eppic.org.au/contentpage.asp?pageCode=ABOUT

(5)���� Edwards��J,��McGorry��PD.����(2002).����Implementing��Early��Intervention��in��Psychosis:����A��guide��to��establishing��early��psychosis��services.��London:��Martin��Dunitz��Ltd.

(6)���� McGorry��P,��Edwards��J,��Mihalapoulos��C,��Harrigan��SM,��Jackson��HJ.����(1996).����EPPIC:��an��evolving��system��of��early��detection��and��optimal��management.����Schizophrenia��Bulletin,��22(2),��309.

(7)���� McGorry��P,��Edwards��J,��Mihalapoulos��C,��Harrigan��SM,��Jackson��HJ.����(1996).����EPPIC:��an��evolving��system��of��early��detection��and��optimal��management.����Schizophrenia��Bulletin,��22(2),��305-326.

(8)���� McGorry��P,��Edwards��J.����(1998).����The��feasibility��and��effectiveness��of��early��intervention��in��psychotic��disorders:��The��Australian��experience.����International��Clinical��Psychopharmacology,��13��(Supplement��1),��S47-S52.

(9)���� Edwards��J,��McGorry��PD.����(2002).����“The��EPPIC��Service��Model”.��Implementing��Early��Intervention��in��Psychosis:����A��guide��to��establishing��early��psychosis��services.����London,��Martin��Dunitz��Ltd,��67.

(10)����International��Early��Psychosis��Association��Writing��Group.����(2005).����International��clinical��practice��guidelines��for��early��psychosis.����British��Journal��of��Psychiatry,��187(48),��120-124.

(11)����Welch��M,��Welch��T.����(2007).����Early��Psychosis��in��Rural��Areas.����Australian��and��New��Zealand��Journal��of��Psychiatry,��41(6),��485-494.

(12)����Welch��M,��Garland��G.����(2000).����The��safe��way��to��early��intervention:��An��account��of��the��SAFE��(Southern��Area��First��Episode)��Project.����Australasian��Psychiatry,��8(3),��243-248.

(13)����Archie��S,��Rush��BR,��khtar-Danesh��N,��Norman��R,��Malla��A,��Roy��P��et��al.������(2007).����Substance��use��and��abuse��in��first-episode��psychosis:��prevalence��before��and��after��early��intervention.����Schizophrenia��Bulletin,��33(6),��1354-1363.

(14)����Malla��A,��Schmitz��N,��Norman��R,��Archie��S,��Windell��D,��Roy��P��et��al.����(2007).����A��multisite��Canadian��study��of��outcome��of��first-episode��psychosis��treated��in��publicly��funded��early��intervention��services.����Canadian��Journal��of��Psychiatry��-��Revue��Canadienne��de��Psychiatrie,��52(9),��563-571.

(15)����Sainsbury��Centre��for��Mental��Health.����(2003).����A��window��of��opportunity:��A��practical��guide��for��developing��early��intervention��for��psychosis��services.����London:��Sainsbury��

Page 44: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development40

[APPENDICES]

Centre��for��Mental��Health.

(16)����Krstev��H,��Carbone��S,��Harrigan��SM,��Curry��C,��Elkins��K,��McGorry��PD.����(2004).����Early��intervention��in��first-episode��psychosis--the��impact��of��a��community��development��campaign.����Social��Psychiatry��&��Psychiatric��Epidemiology,��39(9),��711-719.

(17)����Joa��I,��Johannessen��JO,��Auestad��B,��Friis��S,��McGlashan��T,��Melle��I��et��al.����(2008).����The��key��to��reducing��duration��of��untreated��first��psychosis:��information��campaigns.����Schizophrenia��Bulletin,��34(3),��466-472.

(18)����Johannessen��JO,��Larsen��TK,��Joa��I,��Melle��I,��Friis��S,��Opjordsmoen��S��et��al.����(2005).����Pathways��to��care��for��first-episode��psychosis��in��an��early��detection��healthcare��sector.����British��Journal��of��Psychiatry,��187(48),��24-28.

(19)����Cassidy��CM,��Schmitz��N,��Norman��R,��Manchanda��R,��Malla��A.����(2008).����Long-term��effects��of��a��community��intervention��for��early��identification��of��first-episode��psychosis.����Acta��Psychiatrica��Scandinavica,��117(6),��440-448.

(20)����Edwards��J,��McGorry��P.����(2002).����Developing��an��early��psychosis��service��-��‘nuts��and��bolts’.����Implementing��Early��Intervention��in��Psychosis:��A��guide��to��establishing��early��psychosis��services.����London:��Martin��Dunitz��Ltd,��85-106.

Page 45: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 41

[APPENDICES][APPENDICES]

APPENDIX B: Pre-interview questionnaire

•�� Program��Characteristics :����Year��program��began,��Staff��members

•�� Client��demographics:����Average��age��(yrs),��%��Male

•�� Clients’��special��characteristics

•�� Intake��criteria

•�� Enrolment��time��limit��(yrs)

•�� Average��length��of��enrolment��in��program��for��clients��(yrs)

•�� Psychiatry:����Source��of��Funding��for��Psychiatrist,��Type��of��Funding��for��Psychiatry,��Amount��of��FTE��time��for��psychiatry,��Is��Psychiatry��position��filled?

•�� Formal��links��with��other��programs��that��help��provide��services

APPENDIX C: Interview guide

Program��Planning/Development

1.���� Compared��to��your��implementation��plans��and��proposals,��how��have��you��actually��spent������ the��money��over��the��three��phases��of��EIP��funding?�� a.��What��accounts��for��the��differences?

2.���� Some��of��the��core��features��of��EIP��include:��facilitating��access��and��early��identification,������ comprehensive��assessment,��case��management,��psychosocial��support,��family���� ���� education��and��support��…�� a.�� Did��your��program��incorporate��any��or��all��of��these��features?�� b.�� What��was��the��rationale��and��why��did��you��change��or��adapt��these��core��features?�� c.�� Can��you��describe,��or��walk��through,��how��you��might��service��an��18��year��old������ �� client��from��referral��to��discharge��from��the��program?������ d.�� What��does��your��program��look��like��in��accordance��to��this��prototype�� e.�� Is��there��a��clinical��model��for��your��program?�� f.�� If��so,��what��is��it,��or��what��does��it��look��like?�� g.�� How��did��you��pick��or��decide��on��your��model?

Page 46: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development42

[APPENDICES]

3.���� Did��you��have��to��make��accommodations��to��fit��the��needs��of��your��service��area?�� a.�� If��so,��how?�� b.���� Did��the��geography��or��population��of��your��service��area��influence��changes/���� �� accommodations��made?���� �� i.���� Provide��examples.

4.�� To��what��extent��has��your��intake��criteria��changed?

5.�� What��have��been��the��particular��challenges��in��implementing��your��program?

6.���� What��do��you��think��are��the��important��successes��of��your��program?

Key��Influences

7.���� Who��or��what��were��the��important��influences��that��directed��how��you��went��about������ developing��your��Early��Intervention��Program?

8.�� What��kind��of��direction��and��support��did��the��decision-makers��provide��with��regards��to��the���� �� implementation��and��design��of��the��program?�� a.�� Did��the��ministry��provided��any��standards��or��guidelines?

9.�� Are��you,��or��members��of��your��program,��part��of��the��provincial��EIP��network?�� a.�� Have��you��seen��the��standards��for��EIP��set��by��the��Ontario��provincial������ �� government?�� b.�� Have��you��seen��any��international��clinical��guidelines��for��EIP?�� c.�� Did��the��standards��(by��Ontario,��or��internationally)��have��any��influence��in��how������ �� you��designed��or��implemented��your��program?�� d.�� Did��they��have��to��be��modified��to��fit��your��geography��and��region?

10.�� Did��participation��in��the��provincial��EIP��network,��the��conference��help��you��in���� planning,��implementing��or��managing��your��program?

Other

12.�� What��advice��would��you��pass��onto��someone��else��starting��a��similar��program?��

13.�� Is��there��anyone��else��in��your��program��that��I��should,��or��need��to��talk��with?

Page 47: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 43

[APPENDICES]

APPENDIX D: Analysis codes���� 1�� (1)��/Key��Influences�� 2�� (1��1)��/Key��Influences/OWG�� 3�� (1��1��1)��/Key��Influences/OWG/Other��EIP��network�� 4�� (1��1��2)��/Key��Influences/OWG/Conferences�� 5�� (1��2)��/Key��Influences/Ministry�� 6�� (1��2��1)��/Key��Influences/Ministry/lack��of��direction�� 7�� (1��2��2)��/Key��Influences/Ministry/clear��direction�� 8�� (1��3)��/Key��Influences/Expert~Senior�� 9�� (1��3��1)��/Key��Influences/Expert~Senior/Clinician�� 10�� (1��3��2)��/Key��Influences/Expert~Senior/Program�� 11�� (1��3��3)��/Key��Influences/Expert~Senior/Leader�� 12�� (1��3��4)��/Key��Influences/Expert~Senior/Agency�� 13�� (1��4)��/Key��Influences/Front-Line��Observations�� 14�� (1��4��1)��/Key��Influences/Front-Line��Observations/lack��of��existing��service�� 15�� (1��5)��/Key��Influences/Research�� 16�� (1��6)��/Key��Influences/Funding�� 17�� (1��7)��/Key��Influences/Inter-Agency��Partnerships�� 18�� (1��8)��/Key��Influences/Stakeholders�� 19�� (1��8��1)��/Key��Influences/Stakeholders/grassroots��initiative�� 20�� (2)��/Regional��Adaptations�� 21�� (2��1)��/Regional��Adaptations/Population��Characteristics�� 22�� (2��2)��/Regional��Adaptations/Local��Agency�� 23�� (2��3)��/Regional��Adaptations/Stakeholders�� 24�� (2��4)��/Regional��Adaptations/Staffing��Needs�� 25�� (2��5)��/Regional��Adaptations/Geography�� 26�� (3)��/EIP��Model�� 27�� (3��1)��/EIP��Model/Characteristics�� 28�� (3��1��1)��/EIP��Model/Characteristics/Referral~Intake�� 29�� (3��1��2)��/EIP��Model/Characteristics/Case��Management��Model�� 30�� (3��1��3)��/EIP��Model/Characteristics/Discharge�� 31�� (3��2)��/EIP��Model/Challenges�� 32�� (3��3)��/EIP��Model/Successes�� 33�� (3��4)��/EIP��Model/Recommendations�� 34�� (3��5)��/EIP��Model/Psychiatry�� 35�� (4)��/Mental��Health��System�� 36�� (4��1)��/Mental��Health��System/Reform�� 37�� (4��2)��/Mental��Health��System/Effecting��Change

Page 48: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development44

[APPENDICES]

APPENDIX E: Acronyms/Abbreviations

ACT Assertive��Community��TreatmentCM Case��ManagerEIP Early��Intervention��PsychosisEPPIC Early��Psychosis��Prevention��and��Intervention��CentreFTE Full��Time��EquivalentGP General��PractitionersInpt InpatientLYNX Peterborough��EIP��programOT Occupational��TherapistRN Registered��NurseSEEI Systems��Enhancement��Evaluation��InitiativeSSO Schizophrenia��Society��of��OntarioSTEPS Toronto��EIP��ProgramSW Social��WorkerYR York��Region

��

Page 49: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training
Page 50: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development46

[APPENDICES]

During��the��time��of��this��project,��Dr.��Cheng��was��a��fellow��in��the��Research��in��Addictions��and��Mental��Health��Policy��&��Services��Program��(a��Canadian��Institutes��of��Health��Research��funded��Strategic��Training��Program).�� ��Dr.��Cheng��would�� like�� to��acknowledge�� the��Canadian��Mental��Health��Association-Thunder��Bay��Branch��and��St.��Joseph’s��Care��Group��-��Thunder��Bay��for��their��support.����The��Matryoshka��Project��is��funded��by��the��the��Ontario��Mental��Health��Foundation.����

acknowledgments

Page 51: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training

[ The Matryoshka Project ] Examining Early Intervention Program Development 47

[APPENDICES]

Principal InvestigatorCarolyn��S.��Dewa,��MPH,��PhD

Co-InvestigatorsJames��Dunn,��PhDJanet��Durbin,��PhDPaula��Goering,��RN,��PhDNora��Jacobson,��PhDElizabeth��Lin,��PhDJoan��Nandlal,��PhDRoss��Norman,��PhDGeorge��Tolomiczenko,��PhD,��MBA,��MPHRobert��Zipursky,��MD

The Matryoshka Coordinating CentreKathlyn��Babaran-HenfryNancy��Chau,��MStatWayne��deRuiter,��MScAlexander��KnibbDesmond��Loong��Kenneth��LeeAngela��YipNatalia��Zaslavska,��MA,��MPH

Research FellowsDiego��Bassani,��MPH,��PhDChiachen��Cheng,��MD,��MPH

CAMH RegionalAlan��Cudmore��(Hamilton)Mark��Erdelyan��(Windsor)Kim��Karioja��(Thunder��Bay)Brian��Mitchell��(Peterborough)Suzanne��Witt-Foley��(Parry��Sound)

Funded by:The��Ontario��Mental��Health��Foundation

Program PartnersCMHA��HamiltonMuskoka��Parry��Sound��Community��Mental��Health��ServicesThe��Lynx��Early��Intervention��Psychosis��Program,��PeterboroughCMHA��PeterboroughCMHA��Thunder��BayCMHA��TorontoCMHA��YorkCMHA��WindsorSt.��Michael’s��Hospital,��Toronto

SEEI PartnersMinistry��of��Health��and��Long-Term��CareCentre��for��Addiction��and��Mental��Health��Canadian��Mental��Health��Association��–��OntarioOntario��Federation��of��Community��Mental��Health��and��Addiction��Programs

SITE INTERVIEWERS and Program SupportsMichele��Caveen,��MScChiachen��Cheng,��MD,��MPH

Page 52: matryoshka - EENet · Systemnhancement E Evaluation Initiative (SEEI), the Matryoshka Project is a 3-year project ... originalarly E Intervention Programs offered in-house training