Objectives - Portico Network
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24/09/2011 1 The Gordian Knot for i i Early Psychosis Intervention: rural and remote service provision Chiachen Cheng, MD, FRCP(C), MPH Child & Adolescent Psychiatrist 1,2 Research Scientist (Associate) 3 Affiliated Investigator 4 1 Canadian Mental Health Association‐Thunder Bay Branch 2 St. Joseph’s Care Group 3 Centre for Research on Employment and Workplace Health, Centre for Addiction and Mental Health 4 Centre for Rural and Northern Health Research, Lakehead University Objectives Objectives Participants will learn about 1. the challenges and successes of program implementation and development from the perspective of program decision‐makers 2. rural early intervention outcomes data 3 increasing capacity among mental health 3. increasing capacity among mental health workers in the region through training and education programs
Transcript of Objectives - Portico Network
24/09/2011
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The Gordian Knot for i iEarly Psychosis Intervention:
rural and remote service provision
ChiachenCheng, MD, FRCP(C), MPHChild & Adolescent Psychiatrist1,2
Research Scientist (Associate)3( )Affiliated Investigator4
1 Canadian Mental Health Association‐Thunder Bay Branch2 St. Joseph’s Care Group3 Centre for Research on Employment and Workplace Health, Centre for Addiction and Mental Health
4 Centre for Rural and Northern Health Research, LakeheadUniversity
ObjectivesObjectives
Participants will learn about1. the challenges and successes of program implementation and development from the perspective of program decision‐makers
2. rural early intervention outcomes data3 increasing capacity among mental health 3. increasing capacity among mental health workers in the region through training and education programs
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OutlineOutline
Clinical contextE l P h i I t tiEarly Psychosis InterventionNorthwesternOntarioImplementing and developing EPI programTwo rural service modelsTraining and education to increase capacityg p yWhat’s next?
CLINICAL CONTEXT
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PsychosisPsychosis
Severe and persistent mental illnessC b t hi h i d bi l Common sub‐types are schizophrenia and bipolar affective disorderEffects psychosocial and cognitive developmentWHO ranks the burden of mental illness as one of the most disabling in the world (2008)Leading cause of years lost to disability among youth ages 10 to 24 years (Gore, et.al. 2011)
Youth Mental Health ServicesYouth Mental Health Services
“orphan of the orphan” (Senator Kirby, 2006)Ad l i ft ti f t f t l Adolescence is often time for onset of mental disordersTransition‐age youth (16‐24 years) esp at risk of falling through gapsYouth with psychosis at double disadvantage
Need identification, access to services and early intervention
How do you do this in rural and remote areas?
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WHAT IS EARLY PSYCHOSIS INTERVENTION (EPI)?
EPI in ContextEPI in Context
• EPI (early psychosis intervention) developed in early 1990’s in Australia, UKy 99 ,EPI is specialized assessment, medical treatment, education, family support and psychosocial rehabilitationMay involve intervention for a period that ranges from 1‐3 years Research suggests that EPI may improve
t i ll if d ti f t t d outcomes, especially if duration of untreated illness is minimized (Malla etal 2005, McGorry, etal)
EPI is founded on the principles of hope and recovery
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EPPIC Service ModelEPPIC Service Model
Edwards J, McGorry PD. (2002)
EPI In OntarioEPI In Ontario
Over $100 million annual accord money spent on mental health over 4 yearsmental health over 4 yearsSignificant proportion invested in Early Psychosis Intervention (EPI)5 original EPI programs based in large urban academic centres in OntarioO i f i i l iOver 35 new programs, expansion of original sitesMost have an outreach or rural component
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Literature on Rural EPI ServicesLiterature on Rural EPI Services
Welch et al 2007 SERA stralia So thern Area First Episode (SAFE)Australia: Southern Area First Episode (SAFE)Canada: South Fraser Area Health (BC)
Updated searchKelly et al 2007: commentaryStain et al 2008: New South Wales, AustraliaWilson 2007 New South Wales AustraliaWilson 2007: New South Wales, Australia
Literature Key MessagesLiterature Key Messages
Distinct differences from urban challengesIncreased role of primary healthcareIncreased role of primary healthcareSpecialist within generalist modelLonger DUP and decreased accessIncreased monies needed for similar servicesRole of social networkVit l l f d t d ti t i i i Vital role of adequate education, training, ongoing supervision
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NORTHWESTERN ONTARIO
Northwestern OntarioNorthwestern Ontario
size of France (525,193 km2)45 % of Ontario’s landmass 45 % of Ontario s landmass 2% of Ontario’s population~250,000 people
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Region is primarily rural, urban‐remote 51% of population live in Thunder Bay~ 51% of population live in Thunder Bay
~ 34% live in small communities~ 15% live in remote First Nation communities
Primary employmentforestry, paper mill, grain elevatorsBombardier manufacturing Bombardier, manufacturing healthcare or government jobs
GeographyGeography
Population by Location In Northwestern Ontario
51%34%
15%
City of Thunder Bay
Rural & Remote Communities
Ontario:1 City6 towns28+ Townships /Communities
34%First Nation Reserves
64 First Nations reserves
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DemographicDemographic
Total population: 235 000
Population by Ethnic, Ab i i l Mi i S~235 000
European Ethnicity:121 050 (51.5%)Visible minority:4270 (1.8 %)
19%
52%
2%
27%
Aboriginal, or Minority StatusAboriginal
European
Visible Minority
hAboriginal: 46 020 (19.6%)
Other
Data from the Matryoshka Project
EXPERIENCES OF EPI CLIENTS LIVING IN NON‐RURAL AND RURAL REGIONS
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Quality of Life MeasuresQuality of Life MeasuresMultnomah Community Ability Scale (MCAS)
80
100
e
25.7 30.2
74.3 69.8
0
20
40
60
Non-Rural (n=74) Rural (n=96)
Perc
enta
g
Low Score High Score
SF-12 Physical Health Component
51.780
100
e
SF-12 Mental Health Component
48.0 51 780
100
e
28.048.3
72.051.7
0
20
40
60
Non-Rural (n=25) Rural (n=29)
Perc
enta
ge
Low Score High Score
52.0 48.3
51.7
0
20
40
60
Non-Rural (n=25) Rural (n=29)Pe
rcen
tage
Low Score High Score
Admissions to HospitalAdmissions to HospitalAdmitted to Hospital in Last 12 Months
(p<0.05)
100
Number of Hospital Admissions in Last 12 Months
100
59.436.3
40.663.8
020
4060
80
Non-Rural (n=64) Rural (n=80)
Perc
enta
ge
Yes No
Number of Nights in Hospital in Last 12 Months
100
47.4 41.4
52.6 58.6
020406080
Non-Rural (n=38) Rural (n=29)
Perc
enta
ge
> 1 Hospital Admission 1 Hospital Admission
36.8 41.4
63.2 58.6
020406080
Non-Rural (n=38) Rural (n=29)
Perc
enta
ge
> 30 nights 30 nights or less
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Emergency Room VisitsEmergency Room Visits
ER Visit in Last 12 Months (p<0.05) Number of ER Visits in Last 12 Months(p )
56.938.0
43.162.0
0
20
40
60
80
100
Non-Rural (n=72) Rural (n=79)
Perc
enta
ge
46.3 43.3
53.7 56.7
0
20
40
60
80
100
Non-Rural (n=41) Rural (n=30)
Perc
enta
ge
Yes No >1 ER Visit 1 ER Visit
IMPLEMENTING AND DEVELOPING EPI PROGRAM
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Original Best Practice ModelOriginal Best Practice Model
EPPIC ©2001
MatryoshkaMatryoshka ProjectProject
System Enhancement Evaluation Initiative lti it j t3 year, multi‐site projectPurpose:
to examine the effects of new investments in community mental health programs on continuity of care
Research lead by Dr. Carolyn Dewa
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Wave 2 InterviewsWave 2 Interviews
Wave 2 qualitative interviews with EPI program decision makersdecision makersPurpose:
To understand how EPI programs were developedTo understand key influences on program developmentTo discuss how service model was adapted
MethodsMethods
Design based on grounded theoryPurposive sampling of program decision makers 7 Purposive sampling of program decision makers ‐ 7 interviews across 6 programsQuestions based on interview guideInterviews were recorded and transcribedDouble independent codingAnalysis through discussion and consensusAnalysis through discussion and consensus
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FindingsFindings
Key InfluencesChallengesChallengesSuccesses Regional Adaptations
Findings Findings –– Key InfluencesKey Influences
Clinical mentors and perceived expertsL l d i i l EPI t kLocal and provincial EPI networksFront‐line observations and grassroots movement Champion/leaderCommitment and passion for EPI
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Key InfluencesKey Influences
“what I found myself doing of course and like other EPI managers is calling one another Luckily we had the managers is calling one another. Luckily we had the [provincial network] right …and so through there I had mentors…”
ChallengesChallenges
Lack of program/clinical guidelinesE l f di t i ti Early funding restrictive Lack of skilled EPI service providersAdapting traditional hospital services to the community (ie: clozapine)Overcoming geographical challenges
Population densityBalancing differing needs in same region
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ChallengesChallenges
“I think one of the things that has uh really shifted is around the staff complement…and that had to do 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”money spread a little wider
“our initial proposal the first thing that happened to the dollars was they were cut in half So instead of a dollars was they were cut in half… So instead of a [full‐time] 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.”
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SuccessesSuccesses
Incredible partnerships and collaborationQ lit li i l i bl t h d t Quality clinical service; able to engage hard to serve clientele, familiesCollegial, coherent, enthusiastic teamDecreasing resistance to EPI model and changeShift existing mental health system
Transitional age youth, early rehabilitation, homeless youth, youth in trouble with law
SuccessesSuccesses
“I think the successes the family work we have been able to do and the families themselves have really helped to do and the families themselves have really helped us to be successful in intervening in the lives of the youth.”
“So our successes would be…a high degree of earlier identification and compliance with best identification and compliance with best practices…simply put.”
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Findings Findings –– Regional AdaptationsRegional Adaptations
Each program uniqueB ildi f h t i t d i t d f l t Building from what existed, instead of emulate “Cadillac” modelThinking “outside of box”Adapting ideologic model
Original Best Practice ModelOriginal Best Practice Model
EPPIC ©2001
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Key MessagesKey Messages
Program development was influenced by network, champions, mentorschampions, mentorsAdapting ideologic model to practice shaped by funding stipulationsFunding and human resources were major challengesSuccesses in outcomes, client/family satisfactionyLack of standards allowed innovation
TWO RURAL SERVICE MODELS
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Northern OntarioNorthern Ontario
Northwestern OntarioNorthwestern Ontario
Population:234 599
Land Mass:406, 819.56 km2
Population Density:0.6/km2
% Urban Population:% Urban Population:61.6%
% Rural Population:38.4%
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Northeastern OntarioNortheastern Ontario
Population:p551 691
Land Mass:395, 576.72 km2
Population Density:1.4/km2
% U b P l i% Urban Population:71.5%
% Rural Population:28.5%
EPPIC HubEPPIC Hub‐‐SpokeSpoke Service ModelService Model
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NORTHWESTERN ONTARIONORTHWESTERN ONTARIOSpecialized outreach SERVICE Specialized outreach SERVICE
MODELMODEL
NORTHEASTERN ONTARIONORTHEASTERN ONTARIOHUBHUB‐‐SPOKE SERVICE MODELSPOKE SERVICE MODEL
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Specialized outreach VS Specialized outreach VS HUBHUB‐‐SPOKE: Quality of LifeSPOKE: Quality of Life
Multnomah Community Ability Scale (MCAS)
80
100
e
26.7 29.9
73.3 70.1
0
20
40
60
Thunder Bay (n=15) Peterborough (n=77)
Perc
enta
ge
Low Score High Score
SF-12 Physical Health Component
25.0
63 680
100
e
SF-12 Mental Health Component
50.0 54.580
100
e
Sp. Outreach (n=15) Hub-Spoke (n = 77)
75.0
36.4
63.6
0
20
40
60
Thunder Bay (n=4) Peterborough (n=22)
Perc
enta
ge
Low Score High Score
50.0 45.5
54.5
0
20
40
60
Thunder Bay (n=4) Peterborough (n=22)
Perc
enta
gLow Score High Score
Sp. Outreach (n=4) Hub-Spoke (n = 22) Sp. Outreach (n=4) Hub-Spoke (n = 22)
Specialized Outreach VS Specialized Outreach VS HUBHUB‐‐SPOKE: Hospital AdmissionsSPOKE: Hospital Admissions
Admitted to Hospital in Last 12 Months (p<0.05)
30 0100
70.031.8
30.068.2
020406080
Thunder Bay (n=10) Peterborough (n=66)
Perc
enta
ge
Yes No
Number of Hospital Admissions in Last 12 Months
100
Number of Nights in Hospital in Last 12 Months
100
Sp. Outreach (n=10) Hub-Spoke (n = 66)
57.133.3
42.966.7
020406080
Thunder Bay (n=7) Peterborough (n=21)
Perc
enta
ge
> 1 Hospital Admission 1 Hospital Admission
28.6 42.9
71.4 57.1
020406080
Thunder Bay (n=7) Peterborough (n=21)
Perc
enta
ge
> 30 nights 30 nights or less
Sp. Outreach (n=7) Hub-Spoke (n =21) Sp. Outreach (n=7) Hub-Spoke (n =21)
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Specialized outreach VS Specialized outreach VS HUBHUB‐‐SPOKE: Emergency room visitsSPOKE: Emergency room visits
Number of ER Visits in Last 12 MonthsER Visit in Last 12 Months Number of ER Visits in Last 12 Months
42.9 40.9
57.1 59.1
0
20
40
60
80
100
Thunder Bay (n=7) Peterborough (n=22)
Perc
enta
ge
ER Visit in Last 12 Months
58.334.9
41.765.1
0
20
40
60
80
100
Thunder Bay (n=12) Peterborough (n=63)
Perc
enta
ge
Sp. Outreach (n=12) Hub-Spoke (n =63) Sp. Outreach (n=7) Hub-Spoke (n =22)
>1 ER Visit 1 ER VisitYes No
Northern Ontario Service ModelsNorthern Ontario Service Models
Northwest: Specialized Outreach NorthEast: Hub and Spoke
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SuccessesSuccesses
NorthWest NorthEastEd i i i i iEducation initiativesUse of videoconferencingShared care across regionFidelity to EPI modelQuality, flexibility
Regular trainingUse of videoconferencingCoordination across 10 agencies in 6 districtsLocal clinicians
Service <16 yrs youth Consistent, regular psychiatry services
New EPI services in remote areasFormalized partnerships
ChallengesChallenges
NorthWest NorthEast
dProviding EPI services equally across regionErosion of fundingWide scope of practicePsychiatric services
Variable access to GP/NPVariable access to psychiatric servicesNo funding for psychiatry
dependent on “good will” of hospital
psychiatryPart‐time equivalent staffingWide scope of practice
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Total number of people served in Total number of people served in the North East EIP: 2007the North East EIP: 2007‐‐20102010
350
100
150
200
250
300
Timiskaming
Nipissing
Muskoka Parry Sound
Sudbury/Manitoulin
Cochrane
0
50
2007/2008 2008/2009 2009/2010
Algoma
Total number of people served in Total number of people served in the North West EIP: 2007the North West EIP: 2007‐‐20102010
120
40
60
80
100
Northern/Remote Communities
Kenora/Rainy River District
Thunder Bay District
f
0
20
2007/2008 2008/2009 2009/2010
City of Thunder Bay
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Rural vs NonRural vs Non‐‐Rural &Rural &Sp. Outreach VS HUBSp. Outreach VS HUB‐‐SPOKESPOKE
30 Day Gap in Service
7.7 20.3
92.3 79.7
0
20
40
60
80
100
Th d B ( 13) P t b h ( 74)
Perc
enta
ge
30 Day Gap in Service (p<0.05)
5.6 17.6
94.4 82.4
020406080
100
Perc
enta
ge
Thunder Bay (n=13) Peterborough (n=74)
Yes No
Non-Rural (n=71) Rural (n=91)
Yes No
Sp. Outreach (n=13) Hub-Spoke (n =74)
Policy implicationsPolicy implications
Two different models of delivering specialized mental health services
NE developed hub‐spoke, modeled after AustraliaNW developed specialized outreach
Total numbers serviced in NE is double that of NWEach trying to provide specialized services across vast region in equitable mannerTrends in cross sectional data show distinct outcomes Trends in cross‐sectional data show distinct outcomes differences between rural vs. non‐rural and two modelsNeed follow up research to determine why differences
is it due to inequitable access to services?Is it because of the models of care?
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TRAINING AND EDUCATION TO INCREASE CAPACITY
RationaleRationale for Trainingfor Training
Train other service providers to detect, identify early psychosispsychosisDecrease the duration of untreated psychosisIncrease access to servicesPrior evaluation of EPI training focused on GPs
Shortage of GPsIn‐person lunch‐time seminars not possible
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Evaluation of Training ProgramEvaluation of Training Program
Purpose: to evaluate the EPI training curricula i th t O t i in northwestern Ontario. goal of training: to increase the capacity of mental health workers who service youth to identify psychosis symptoms early and to implement early intervention for psychosisp y p y
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PreliminaryPreliminary ResultsResultstest scores (%)test scores (%)
90
65
70
75
80
85
84
76
8784
82
89
83
73
86Overall
Onsite
Offsite
50
55
60
Pre Test Im Post Test 3m Post Test
Preliminary ThoughtsPreliminary Thoughts
Groups too small for statistical differencesV i il t t Very similar pre‐test scoresOnsite group does better overall
Was better even before the training
Two knowledge questionnaires are differentWill need to compare at 9 months followup
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SatisfactionSatisfaction
“ I now know the signs and symptoms of psychosis that are different than other disorders such as anxiety are different than other disorders such as anxiety, depression, etc.”
“ Videoconference allowed me to attend the workshop whereas I likely would not otherwise have been able to attend”to attend
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Areas to improveAreas to improve
All about the technology glitches
“the connection by video to the other sites cut out a number of times. Some of the sights were only able to connect part of the time”
“poorly organized (ex, materials not there on time, short notice on dates, mix‐up on location)”
What we have learnedWhat we have learned
Technology problems affect both off‐site and on‐siteAl t f d t b itAlmost everyone preferred to be onsiteYet this is not reflected in knowledge scoresNot enough to include remote and rural sitesNeed flexibility, comfort level with technologyImperative that technology worksp gyNext few months:
Focus groups with participants9 month follow up
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WHAT’S NEXT?
First Nations YouthFirst Nations Youth
Region has 20% self‐identify as AboriginalP t l h lth d h i l h lthPoorer mental health and physical healthAboriginal suicide rate is much higher
Females 8X higher, Males 5 x higherNishnawbeAski Nation territory one of highest in country
30% of youth in clinicSicker when present, first to disengage
Why?Culture? Social disparities? Remote access?
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OtherOther ProjectsProjects
Psychoeducational interventionsFamiliesFamiliesYouth with psychosisService providers
Pathways to careAboriginal youthYouth living in rural areasYouth living in rural areas
AcknowledgementsAcknowledgements
Centre for Addiction and Mental Health
Funders:CIHR Strategic Training Program (Research in Addictions and Mental Health Policy and Services
Dr. Carolyn DewaDr. Paula GoeringMr. Wayne de RuiterMr. Desmond Loong
Ms. Mirella FataNorth Bay Regional Health Centre
Health Policy and Services, RAMHPS)Ontario Mental Health FoundationOntario Ministry of Health & Long‐Term CareThe Provincial Centre of Excellence for Child and Youth Mental HealthFoundation of the Canadian Psychiatric Association
Dr. Barbara CrawfordMs. Nicolle Plante‐Dupuis
Canadian Mental Health Association‐Thunder Bay
Ms. Carole Lem
Canadian Mental Health Association‐Thunder Bay BranchSt. Joseph’s Care GroupCentre for Addiction and Mental Health
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Questions?Questions?
DiscussionDiscussion
