Child and Youth Collaborative Mental Health Care: A review of models and exchange of ideas

June 27, 2013

Blair Ritchie MD FRCPC Helen Spenser MD CCFP FRCPC

Brenda Mills CYW Cert Peter Kondra MSc MD FRCPC

Sari Ackerman BA BEd Paula Cloutier MA

Disclosures

• Blair Ritchie: none

• Helen Spenser: none

• Brenda Mills: none

Objectives

1. Review models of C&A collaborative care

2. Provide an update on the Child and Youth Mental Health Toolkit Project

3. Discuss audience experience

Background to Toolkit Project

• Original shared care conferences adult only

• Conference breakfast meetings re C&A projects

• Individual presentations of projects at conf

• Decision to combine with joint presentation

• Dr. Ritchie doing fellowship in shared care

• Development of toolkit project

• Calgary/Hamilton/Ottawa

Past Presentations

• Ottawa, Toronto, Hamilton, Kitchener

• Winnipeg

• Summerside, PEI

• Halifax

• Calgary

• Vancouver

Driving forces behind child and youth collaborative care

Isolation of rural primary care

physicians

Shortage of child and youth mental

health services

Youth prefer primary care BUT

practitioners lack training/confidence

~20% youth with MH prob and most

not identified

Only ~20% get treatment

75% MH prob onset before age

25

Early detection important

• Despite performing literature search many models still known only through word of mouth – need list of projects in Canada

• In US:

– nncpap.org

– Lists programs and tools throughout the US

– Tools are password protected

Models in C&Y MH Primary Collaborative Care

Education

Online

Direct Care

In Person Indirect Care

Telepsychiatry

School Youth Justice

etc

Prevention Early

Intervention

Primary Care

Specialty services

C&A MH Education in Primary Care: Online, In Person,

Telepsychiatry

Teaching family doctors

• CME to rural FPs in southwestern ON (pilot) – Involved didactic teaching, video vignettes, and

discussion on ADHD and behavioural probs

– 56 FPs attended and reported improved confidence in abilities to Dx and treat

• Needs assessment across the country with the goal of expanding this educational model (Steele, 2012; Stretch, 2009)

The Triple Board Training Program • First offered at U of Pittsburgh in 1980s as

pilot project

• Goal is to produce holistic clinicians trained in child and adult psychiatry as well as paediatrics

• Program became permanent in 1986 but low numbers of graduates

• www.thereachinstitute.org/

• Dr Peter Jensen et al

• Primary care physicians attend 3-day training program followed up by 6 mo regular teleconferences amongst themselves and specialists

• Mainly in US but there have been training groups in Canada too

• Resources also listed through site

• Gov initiative in Finland in 2000 group implemented 1-day training course (n = 303)

• 1-day PBL (ADHD, MDD, PCRP, CD, family substance prob) with group discussion in AM followed by discussion with multidisciplinary team in afternoon held at 56 clinics

• Competence assessed before and 6 months after

• Conclude that one-off sessions not that helpful (Heikkinen et al., 2005)

Papers and books published as tools

• Example:

Papers by Sarvet & Brewer (2011) describing

approaches to anxiety in primary care

• Dr. Amy Cheung was a leader in the development of the Guidelines for Adolescent Depression in Primary Care (GLAD-PC)

• http://www.shared-care.ca/toolkits

• Survey update: ~50% SW, 75% in practice >10 yrs, ~80% had training in MH while ~40% had C&A MH training

• Visits substantially increased this year with almost 50,000 visits since 2010

– Visits from US, Vietnam, China and India

• Anxiety most viewed, followed by ADHD

Child and Youth Toolkit Project

Teen Mental Health – Drs. Kutcher and Garcia – Ortega et al

• http://teenmentalhealth.org/

• Information for patients and families, educators, and professionals

• Packages for professionals on depression, ADHD, anxiety

• Info on substance use and psychosis

• Drs. Kutcher, Davidson and Garland: Child and Youth Mental Health (CYMH) module in BC through the Practice Support Program (PSP)

• http://www.gpscbc.ca/psp-learning/module-overview/child-and-youth-mental-health

(Kallstrom, 2013).

UK has multiple similar programs

• Therapeutic Intervention in Depressed Youths (TIDY) program

• Royal College of Paediatrics and Child Health developed adolescent e-learning project

• Toolkit developed by “Headstart” program in NE England

(Vallance et al., 2011)

Telepsychiatry: indirect or/and direct but not in person

• TeleLink: telepsychiatry to rural/remote ON

• Psychiatry, psychology, SW, admin

• Between 2000 and 2010 >7000 consults with 1/5 requiring f/u

(Pignatiello et al., 2011)

Healthy Minds/Healthy Children

• Provides education and consultation for Southern AB professionals (health care and educators)

• Largely education and indirect consultation but direct consultation also available

• Large online education component

(Lipton & Donsky, 2012)

• 6 specialist teams provided support to over 350 primary care clinics

• Provide:

– immediate telephone consultations

– in-person telepsychiatry consult if required

– coordinating community mental health services

– professional education

• After 3.5yrs PCC reported inc competence, minority sent on for consult

(Sarvet et al., 2010; Sarvet et al., 2011)

PAL - Partnership Access Line

• Washington state

• Primary care call C&A psychiatrist for indirect consult and written recommendations (faxed), parent handouts, possible telepsychiatry consult

• 70% were one-time phone consult avg 15 min

• High satisfaction

(Hilt et al., 2013)

• Training and Education for the Advancement of Children’s Health (TEACH): New York state initiative with telephone, telepsychiatry, or in person contact to primary care and their patients

(Kuehn, 2011)

• REACH institute teaching

• CAP PC consultation 9-5 Mon-Fri

• Coordinator if referral to specialist required

Minnesota

• Minnesota: Sulik et al (2005) reported that shared care model cost offset by decreased need for admission and inappropriate med use

• Now Minnesota has similar telepsychiatry to PAL, MCPAP and others

(Reinke et al., 2011)

Telehealth RCTs are ongoing

• Ongoing RCTs:

– Cincinnati Children’s Hospital ADHD Study

– Seattle Children’s Research Institute ADHD study

(Myers et al., 2011)

In-person direct care

Ottawa, ON

• 2 shared care clinics running out of academic family medical centers with resident involvement – Residents pleased with learning

• Pediatrician was incorporated into tertiary mental health clinic through the children’s hospital – Learning opportunity for mental health and peds

(Spenser et al., 2009)

Collaborative program in Montreal

• Dr. Lucie Nadeau and team (2012) have emphasized how challenging and important communication is in a multidisciplinary collaborative team working with multicultural population

Hamilton Family Health Team

• Variety of Services – Flexible

• Professional Development in C&A MH

• Develop resources and clinical “tools”

• Support practices in system redesign and full team care of C&YMH

• Evaluate

Hamilton Family Health Team Model

• Coordinator of C&YMH

– program development, implementation, professional development

• Child & Youth Mental Health Counsellors (2.3fte)

– co-located at large practices

– consultation, assessment, treatment

• General Mental Health Counsellors

– across the life span – access to support for C&YMH

– build capacity and comfort

British Columbia

• Clinical Projects

– Dr. Terry Isomura: 12 family doctors in 2 practices, 2 mental health workers

Increasing prevention and collaboration with schools

• Co-chaired by Drs. Kutcher and Manion

• Meet mental health needs of all youth

– improve access with location (e.g., schools and primary health care) and format (e.g., electronic, in addition to face-to-face)

– include groups traditionally overlooked (e.g., 18-25, rural or economically disadvantaged, First Nations youth)

– Focus: common mental illnesses

P4C=

• McMaster University: Program for DCD whereby OTs intervene with teachers and parents to provide education and strategies

• School-wide intervention

(Missiuna et al., 2012)

• Telepsychiatry programs to schools to provide clinical support and education to students and teachers

• Conclude that more study of outcomes needed

(Grady et al., 2011)

• Penn Resiliency Program:

• Goal to prevent MDD in youth

• ~270 11-12 yr old enrolled to receive PRP

• Depression not prevented compared to controls at 2 yr f/u

• Some positive secondary findings (Hamilton et al., 2006)

Prevention programs

• Cullen and Cullen 1996: Australia showed that PCP counselling mothers of preschool children resulted in favourable MH outcomes 6 yrs later and f/u 20 yrs later also favourable

(Cullen & Cullen, 1996)

• Department of Health 2011 UK: “no health without mental health” aims at ensuring new parents and their children offered support

(Vallance et al., 2011)

Barriers

• Limited access (geographic and online)

• Funding for programs

• Compensation for time spent

• Middle management/coordinators

• No common list of projects in Canada

Future Directions / Questions

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• Cullen KJ & Cullen AM. Long-term follow-up of the Busselton six-year controlled trial of prevention of children's behavior disorders. The Journal of Pediatrics 1996; 129(1):136-139.

• Grady BJ, Lever N, Cunningham D, Stephan S. Telepsychiatry and school mental health. Child Adolesc Psychiatr Clin N Am 2011; 20(1):81-94.

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• Heikkinen A, Puura K, Niskanen T, Mattila K. Improving GPs’ skills and competencies in child psychiatry. Nord J Psychiatry 2005; 59:114-120.

• Hilt RJ, Romaire MA, McDonell MG, Sears JM, Krupski A, Thompson JN, et al. The Partnership Access Line: evaluating a child psychiatry consult program in Washington State. JAMA Pediatr 2013; 167(2):162-168.

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