Increasing Access to Mental Health and Addictions Services in Rural Areas.

Increasing Access to Mental

Health & Addictions (MH&A)

Services in Rural Areas

BC Patient Safety & Quality Council

Quality Forum, Vancouver, Feb 2015

Presenters: Kathleen Collins, Selina Tsang

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Rural Setting: Pemberton

Pemberton is located• 25 min north of Whistler

• 2 hours from Vancouver

Health Services

• Served by 4 to 5 GP’s

• No local hospital

• Only emergency in

local health centre

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Community Mental Health

• Acute and community mental health services

divided into adult stream (19y & older) and a

children and youth stream (< 19y)

• Variation in who delivers community MH

services.

Note: Vancouver Coastal Health (VCH)

Child Youth Mental Health (CYMH)

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Stakeholders

• Family doctors

• MCFD / CYMH – community mental health

services

• Emergency (community and acute)

• BC Ambulance Transport

• Secondary level of acute care

• Tertiary level of acute care

A fractured youth mental health

system in B.C. that is confusing

and frustrating for youth and their

families to navigateCommunication lapses

between service providers

Long waits to see

mental health

professionals or

to receive

treatment

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Lack of coordination between systems and providers

have left many vulnerable youth unsupported

• GP calls CYMH to request help with risk assessment

• CYMH recommends to certify under Mental Health Act

• GP, based on previous experience with LGH, decides

not to take this route (not confident that certification will

result in care)

• GP confused why they can’t refer directly to BCCH

(CAPE unit) Child & Adolescent Psychiatric Emergency

• CYMH later learns that youth is released to community

with no request for follow up from CYMH

• GP; CYMH; and Youth are all frustrated

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Current State Issues• CYMH services not well understood -- often

confused with Child Protection Services and Adult

MH Services

• CYMH services generally available only during

weekday office hours

• Inadequate child psychiatrist coverage – only

available in Squamish; up to 2 months’ wait.

• GP not following protocol to certify kids under the

MH Act

• Nearest hospital (LGH) not staffed with child

psychiatrist

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Project Goals

Establish standardized process for Pemberton

children, youth and families to access psychiatric

assessment

• Emergent need

• Urgent need

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Lean Approach• Assembled design team

GP, psychiatrists, nurses, leadership from Regional Mental Health,

Lion’s Gate Hospital, CYMH

• Established clarity and shared understanding

• Clarified roles and responsibilities

within MCFD and between VCH vs CYMH

• Provided education Certification under MH Act

• Document standard process between CYMH and

VCH re: urgent psychiatric assessment clinic

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Current State Map

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An emergent patient may be…Refused transport to secondary hospital

if ER Doc refuses to accept patient

Typically only accepted for medical

issues

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.

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An urgent patient

• Ideally accesses local help

• But when local resources are unavailable /

inadequate

• Cannot escalate to Emergency (do not fit

Emergent criteria)

Take their chances to get seen by

BCCH Urgent Assessment Clinic

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Future State Map

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Emergent Cases

LLTO Policy Revisions

• Receiving sites must

accept the transfer of a

patient in a LLTO situation

when the services needed

for the patient do not exist

at the sending site

• Policy specifically

references MH&A patients

Resulting Changes

Certified children and

youth receive

psychiatric

assessment at LGH

(by adult psychiatrist

in the interim)

Addition of child

psychiatrist at LGH

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What does it take to …

• Create a New Urgent Assessment Clinic?

• In a rural setting (aka lack of resources)?

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Unleash the Power & Passion

of a Committed Team

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PEOPLE

Combination

of adult &

child

psychiatrists

CYMH +

VCH staff

Psychiatrist

bills MSP

for seeing

patient

COST

CYMH

covers

transcription

costs

VCH covers

cost of

psychiatrist

time for no-

shows

Same

space

used by

adult MH

- VCHPLACE

CYMH

office

space

(child

psych)Private

office space

in Whistler

(child

psych)

CONSULT

NOTES

Charts

held by

CYMH

TIME

Clinic

available

every 1–

2 weeks

Hold time

or book

lunch

time slots

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Referral Process• Accept referrals from

Self / Family

Schools

General Practitioner

Emergency Clinic

• CYMH Intake coverage 7 days a week

• Referral triaged by CYMH leader

Standard process documented in Pemberton Child and

Youth Urgent Assessment memorandum of understanding

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LGH liaison notifies

Community of

impending

discharge

Community Mental Health

Pemberton emergency

medical centre

Urgent Ax Clinic

LGH

GP / Referring

MD

Partners …

for the Benefit of the Kids

* If patient gets transferred

to BCCH, CAPE doctors

invite CYMH in discharge

planning

Psychiatrist consult

notes sent to GP /

referring physician

CYMH shares specific

strategies for high risk

youth in anticipation of

future patient visits.

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Measures of SuccessUrgent Psychiatric Assessment Clinic

Established urgent assessment clinic in

Dec 2013

Guaranteed appointment within 2 weeks,

often seen as soon as next day

8 urgent cases seen to date

8 urgent cases receiving psychiatric

assessment within target of 1 week

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Voice of Providers

We know we can call

CYMH when we need

help with a patient

Knowing there are local

psychiatric services we can access

makes it much easier to make

decisions about urgent patients.

We now have much more

confidence that patients will

receive the urgent care they need

in their own community within a

quick time frame.

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Voice of Patient

They were going to send me to the city...to Lion's Gate...

They phoned someone from the Ministry and found out I could see a psychiatrist in Pemberton.

Then someone came to the clinic to help my parents understand how to help me. My parents let me come home with them...

I am doing much better now. I am glad I didn't have to go to the city."

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Design Team• Project Sponsors:

– Yasmin Jetha, Regional Director, MH&A Program

– Dr. Steve Mathias, Regional Youth Medical Lead

– Olga O’Toole, Regional Manager, CYMH Vancouver Coastal

Region

– Rena van der Wal, Executive Director, Lean Transformation

Services

• Process Champion: Elizabeth Stanger, Director MH&A Coastal

• Project Owner: Kathleen Collins, CYMH Team Leader

• Physicians: Dr. Lance Patrick, Dr. Apu Chakraborty,

Dr. Rebecca Lindley, Dr. Helen Rosenauer,

Dr. Bobbie Rathbun

• Health Centre: Tracey Kavanagh, Janet Hamer

• Lean Advisor: Selina Tsang