Optimizing Transitions: Addictions and Mental Health 2015

Presentation Objectives

1. To review emerging practices for developmentally appropriate care for TAY

2. To describe the components of a successful program for TAY

3. To describe key elements in optimizing transitions for TAY from hospital to community services

4. To describe an evaluation framework used by the LOFT, Sickkids, and CAMH partnership

5. To share preliminary results

Some facts about TAY with MH and Substance Use Problems

Youth experience more disconnection and are therefore less likely to receive appropriate support services in the transition to adulthood (Brown and Wilderson, 2010)

For more than 70% of adults living with mental health problems, symptoms developed when they were young. “Identifying youth at risk and intervening as early as possible improves their life trajectories, their productivity as Canadians and reduces the prevalence of mental health problems in adulthood.” (Mental Health Commission of Canada, Youth Council, 2010)

Transitional Age Youth

Characteristic of the Population

Access and

Navigating Services

Delivery of Services

Service Offerings

System Issues

Challenges for Transitional Age Youth with MHA

Developmentally-informed Practice

Consider sex & gender, trauma, culture Without support, youth with serious

mental health and substance use concerns face significant challenges in achieving developmental milestones Younger youth - school success, social skill

development Older youth – vocational success,

developing intimate relationships With support and/or early achievement,

positive outcomes are more likely

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Considerations in working with TAY

Need clinical services PLUS services that promote independent living AND coordinated care

Need services that address needs directly AND processes that reflect the needs of TAY

Need to consider youth goals re: adulthood

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Services for older youth to promote independence

Employment Education Housing Community involvement (social/recreational

activities) and social support Money management Training on basic living skills (cooking,

shopping, etc.), problem-solving and informed decision-making’

What exists in your community?

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Key attributes of service delivery Informal Flexible Individualized, youth involvement in goal

setting Involve supports Build on strengths Prepare youth for transition, across

services and sectors Support youth through transitions

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Parallel with MI principles Youth input Active listening Non-judgmental Avoid lecturing Express empathy Offer assistance Encourage, offer descriptive praise,

express enthusiasm

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Developmentally-specific services

Developmentally-specific services are targeted to meet the needs of youth considering their developmental stage (not, chronological age)

For example, developmentally-specific groups, services, residential programs, within child/adolescent and adult services

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Transitions: Challenges/Issues/Barriers

Lack of experience/difficulties addressing parental issues

Youth/family reluctance Lack of institutional support Lack of planning Lack of developmentally-informed adult

services Lack of two-way communication Confidentiality & consent issues

Brodie, Goldman & Clapton (2011), Davidson, S. & Cappelli, M. (2011), Singh, S. et al. (2008)

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Transitions: Challenges/Issues/Barriers

Time/Resources/high workload, staffing shortages, long wait lists

Training Differing perspectives (youth, family, providers) Attitudes/Discomfort/lack of confidence of providers Limited applicability of services Difficulty accessing resources Poor intra-agency & inter-agency coordination Individual vs. family approaches Developmental vs. diagnostic approaches Lack of flexibility Protective vs. responsibility approach

Brodie, Goldman & Clapton (2011), Davidson, S. & Cappelli, M. (2011), Singh, S. et al. (2008)

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Transitions: Challenges/Issues/Barriers

Limited specific research regarding how to prepare youth and family for transition – greater focus on policy & procedure, less focus on clinical practice

Inconsistent documentation/information systems/transfer systems

Organizational culture differences Lack of shared information about service

structures Different thresholds & eligibility criteria for service Lack of off-hours services

Brodie, Goldman & Clapton (2011), Davidson, S. & Cappelli, M. (2011), Singh, S. et al. (2008)

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Recommendations from the evidence

Youth and family perspectives should be considered in service planning generally & for their own care

Developmentally appropriate communication and information for youth

Accessible communication and information for families Worker support, co-located & multi-agency services Accessible & flexible services dedicated to youth (i.e.

community-based, friendly, informal, flexible venues, hours of service, types of service, & dealing with missed appointments)

Well-trained practitioners, advocacy, mentoring

Brodie, Goldman & Clapton (2011), Davidson, S. & Cappelli, M. (2011), Singh, S. et al. (2008)

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Example: A model of care for TAY

Transition to Independence Process (TIP)

“Discovery rather than Recovery”

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TIP Overview

TIP is a promising practice for: Transitional aged youth with

emotional/behavioural difficulties Appropriate for youth 14-29 years old Applicable across multiple services and

sectors in community-based settings Model operationalized through seven

guidelines & core practices

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Clark et al. (1995)

TIP Transition Domains18

Key Facts about TIP

Cross sectoral applicability Rooted in evidence based approaches

such as Motivational Interviewing and Cognitive Behavioural Therapy

Can integrate into existing worko TIP used intentionally and purposefully

Role of supervisor important to maintain fidelity

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Example: A model for transitions of care for TAY

TRACK

TRACK Criteria for Optimal Transition

Continuity of care – engaged with AMHS for 3 months or appropriately discharged (long-term continuity)

Period of parallel care – period of time when involved with both CAMHS & AMHS (relational continuity)

At least one transition planning meeting – meeting to discuss transition; involve youth, family, and key SPs, before transfer (cross-boundary/team continuity)

Optimal information transfer – referral letter, summary of services, current assessment (informational continuity)

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TRACK: Improving the Transition

Alignment Attitudinal adjustment to promote view of services as

complementary Map all services available to youth/TAY Interagency development of care pathways

Preparation of service users before transition Information/what to expect Differences re: services/confidentiality/parental

involvement

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TRACK: Improving the Transition

Transition process Flexibility “Age windows” Planned and occur at times of relative stability

Crisis is a contra-indication Improving info transfer

Specific protocol for information transfer Detailed info should go with youth

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TRACK: Improving the Transition

Improve liaison between the Child and Adolescent Mental Health System (CAMHS) and the Adult Mental Health System (AMHS) Improved knowledge, communication & understanding

between CAMHS & AMHS Joint training, continuous professional development re:

transition Changes to service structures & functioning Supervision, clinical accountability Designated transition workers

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What Youth Like! (YSSR, 2010-2014)

Positive relationships with service providers

IncentivesFlexibilitySupport for autonomyAddressing reasons for usingNon-judgmental treatment

(YSSR, 2010-2014)

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Essentials to building bridges with hospital (Heather’s perspective)

1. Align community practices to best practice/research

2. learn language and roles 3. know common client and need 4. build trust 5. formal MOU 6. lead a summit 7. learn together!

Complimentary services

Barrier free admission: GAIN Short Screener to screen for possible diagnosis

On the ground service coordination works: Taking youth to appointments, connecting them to primary care, crisis plans, finding and maintaining housing, etc.

Peer power: peer support workers, drop-in, groups, and opportunities for social connection

Crisis support– that is how young people re-engage with supports if they disengaged

Staff send on average 2500 texts/month Supportive housing

Being nervous is a normal part of the process. You are very passionate about your career, I think

that will show during your interview.

I’m just so nervous for the interview. I really want to get into this program.

Simple. The same way you just told me.

But how do I tell them that I really want this opportunity and I will wake up at 5am every morning if

I have to?

TAY TXT

Community and Peers

Peer support is a vital part of the program (paid vs unpaid)

Exploring new ways to have fun and learn: ex. Art therapy, visiting new places

Pathways to Recovery groups

Components of LOFT’s TAY MH and Addiction program

Weekly psychiatrist

Trained peer

mentors

Specialized Addiction program

Supportive Housing- low,

med , high support

Focus on tight referral

pathways

Care coordinatio

n pilot through

Health Links

Monthly psychologi

st staff consult

Focus on engagementPriority referral source is

hospitalOn the ground support

Evaluation framework (CAMH): GAIN SS

Formal partnerships with 3 hospitals

Research: Sean Kidd

Crisis phone/text

24/7

Staffing Mon-Fri

9am-9pmSat: 1-9pm

Groups and

recreational

activities

MCYS , TCLHIN

and donor funded

ACT Community Treatment project

Funded in 2013 For Transitional age youth (age 16-25)

with addictions (from harm reduction perspective)

Partners: CAMH, HSC and LOFT Focus on optimizing transitions from

hospital Team launch included people across

partners Education provided across sectors Offered in sites across Toronto

Optimizing transitions

Primary referral source is hospital (2 formal MOUs- Hospital for Sick Children and CAMH)

Robust evaluation framework Service gaps come at critical time when first onset of

mental health issues may occur; we use standard tools to start mental health care coordination

Partnership with Urgent Care clinic (CAMH) and psychiatry

Appreciative Inquiry: An exercise

Think of a time that you had the most amazing experience of either making a referral, receiving a referral or being referred.

Please talk about that experience in detail using the worksheets.

You will be asked to report back to the group what your partner said

What works in building bridges? Appreciative inquiry exercise: Make it

fun! Client or patient– who cares? Get it done. Pulled out principles of how we will work

together Contact list and intake flow chart in a

drop box ACT training together Regular team meetings to touch base

and open door to feedback

Our team!

Objectives to be evaluated

Improved access to evidence-based community addictions treatment for youth

Improved transitions from hospital to community, and from youth into adult care systems

Improved outcomes for youth with addictions issues

Components of our Evaluation Framework

Contemplation ladder (every meeting) GAIN Short Screener every 12 weeks Self-efficacy tool (every 12 weeks) Determinants of Health Outcomes (intake, 1

month, 3 month, 6 month, exit/discharge). Focus group annually Client satisfaction questionnaire annually Binder kept at program to keep anecdotal

feedback/comments

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GAIN-SS

brief screening tool for clients age 10+ identifies difficulties in 4 dimensions:

internalizing disorders (e.g. depression, anxiety) externalizing disorders (e.g. ADHD) substance use problems crime and violence

CAMH-version of GAIN-SS includes 7 additional items to screen for: eating-related issues trauma-related distress disordered thinking gambling, gaming and internet misuse

*GAIN-SS was developed by Chestnut Health Systems, Copyright © 2005

www.chestnut.org

Evaluation results Nov 2014

Total # of surveys collected to date = 231Domains assessed:

Mental health (GAIN-SS Revised) Internalizing Disorders Externalizing Disorders Substance Use Crime/Violence Screener Additional questions assessing disordered eating, traumatic distress,

disordered thinking, gambling, gaming, internet misuse

Social determinants of health (Transitional Age Youth Program Measure)

Motivation (Contemplation Ladder) Self-Efficacy (General Self-Efficacy Scale) Service User Feedback

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Transitional Age Youth Program Measures

64.7% male; mean age = 21.7 Scale 1 = Excellent, 2=Good, 3=Fair, 4 =Poor

higher scores = more difficulty in that domain

0

1

2

3

4

Means at Program Intake

PO

OR

ER

STA

TU

S

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GAIN Short-Screener: Summary

Percentage of youth endorsing severe problems in each domain (score of 3+)

Internalizing Disorders = 87.9% Externalizing Disorders = 75.7% Substance Use = 44.6% Crime/Violence = 15%

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Motivation – Contemplation Ladder

Pre-contemplation = 1 – 3Contemplation = 4 – 6Preparation = 7,8Action and Maintenance = 9,10

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Motivation – Contemplation Ladder

LOFT mean Ladder score = 8.5 Typical items youth selected

“I have made a plan to change my substance use, and have begun to make some of those changes”

“I have changed my substance use, but still worry about slipping back. I need to keep working on the changes I’ve made”

LOFT Importance score: “How important is it for you to change your

substance use?” Scale 1 (not at all important) – 4 (very important) Importance mean = 2.7

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Self-Efficacy

General Self-Efficacy N=43 Scale: 1 (not true at all) – 4 (exactly true)

Total scale: 10 (very low SE) to 40 (very high SE)

LOFT Youth mean = 28.1 “I can solve most problems if I invest the

necessary effort” 90% selected true or somewhat true)

“I can remain calm when facing difficulties because I can rely on my coping abilities”

57% selected true or somewhat true

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True/Somewhat

True

Not true/hardly true

0

20

40

60

True/Somewhat

True

Not true/hardly true

0

20

40

60

80

100

Service User Feedback

4-point scale 1 (Strongly Disagree) to 4 (Strongly Agree)

Total LOFT mean = 37.7, N= 24

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Satisfied with support from staff

Services relevant to needs

Have right to approve services

Know where to go if services not good

Staff interested in my improvement

Happy with living situation

Recommend program to others

My opinions/ideas count

Can influence MH/Social service system

Could work if given opportunity

Program offered opportunities to get involved

0 10 20 30 40 50 60 70 80 90 100

AgreeDisagree

Summary - Risk

LOFT youth Present with many social, health (mental and

physical), employment, and housing challenges (i.e., social determinants of health)

High internalizing problems (e.g., depression) and externalizing problems (e.g., difficulty paying attention)

Distressing memories/dreams about past Eating disturbances Substance use issues

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Summary - Resilience

HOWEVER, LOFT youth are also: Highly motivated to change problematic

substance use and maintain those changes Have a sense of self-efficacy to handle

challenges/stressors in their lives And, importantly, LOFT youth report

moderate to high satisfaction in most domains

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Thank-you for your time

Gloria Chaim, MSW, RSWAssociate Director, Child Youth and Family Services Centre for Addiction and Mental HealthGloria.Chaim@camh.ca

Heather McDonald, MSWDirector of Adult and Youth ServicesLOFT Community Serviceshmcdonald@loftcs.org