Priority Health Innovation Challenge

Team lead: Jasneet Parmar, Physician Medical Lead, Home Living and Transitions, AHS EZ Continuing Care 

Patient/family representative: Brenda Bell 

Senior officer/director: Anita Murphy 

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home 

• Supplementary outcome indicators: Caregiver distress 

• Patient/population reach indicator: All primary caregivers of long-term supportive and maintenance home care clients 

The Edmonton Zone Enhanced Home Living Supports Pilot Program 

Alberta Health Services developed this program to ensure caregivers and home care clients with complex chronic conditions have a real choice to remain in their homes in the community and caregivers are supported to sustain care and maintain their own wellbeing. Home care staff are educated to provide Caregiver Centered Care. Case managers use the Carer Support Needs Assessment Tool (CSNAT) to complete a person-centered assessment of family caregivers’ support needs, and the Caregiver Risk Screen (CRS) to identify “at risk” caregivers. Home care staff help caregivers access the support they need and navigate health and community systems. Enhanced respite care and supports for independent activities of daily living are available for caregivers at high risk of burnout and/or being unable to sustain caregiving. The program was piloted in multiple settings – urban, rural, suburban and inner city – and rolled out to the entire Edmonton Zone from late 2019. 

Connect: @AHS_YEGZone @jatiprin

Team lead: Kathleen McQueen, Manager of Clinical Excellence, Therapy 

Patient/family representative: Curtis Hiemstra 

Senior officer/director: Omar Aboelala 

Indicators: 

• Primary outcome indicator: Caregiver distress 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Caregivers who are all ages 

Care for the Caregiver Program 

CBI Health Group, the largest provider of community healthcare services in Canada, has developed the Care for the Caregiver Program – a three-tiered program offering varying levels of support for caregivers. Tier 1 provides referral to the appropriate services or programming. Tier 2 provides caregiver support needs assessment (via the Caregiver Strain Index [CSI]). Tier 3 provides a self-management approach to wellbeing, supporting and connecting caregivers to a comprehensive suite of resources and tools. The program was initiated for caregivers involved in the enhanced palliative program and restorative care program in the South West Local Health Integration Network, with plans to spread next to Erie St. Clair Local Health Integration Network. 

Connect: @KatMcQueenOT and @OmarAboelelaPT

Team lead: Carlie Brown, Case Manager, Home Ventilation Program 

Patient/family representative: Teresa Macmillan 

Senior officer/director: Sherri Katz 

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home 

• Supplementary outcome indicators: 

• Wait times for home care services, referral to services 

• Caregiver distress 

• Death at home/not in hospital 

• Patient/population reach indicator: Paediatric home ventilation patients (age newborn to 18), including tracheostomy dependent and invasive ventilation patients, patients on non-invasive ventilation for life support, complex patients on positive airway pressure devices and patients requiring lung airway clearance devices such as LVR and cough assist. Secondary reach includes caregivers (RN’s, PSW, school staff and family members) via caregiver competency checklists and number of providers trained. 

Complex Respiratory Care for Paediatric Patients 

Through this program, the Children’s Hospital of Eastern Ontario’s (CHEO) intensive care unit addressed the length of stays and admission rates by improving home care services for paediatric patients so they can remain at home. The program was funded by the Local Health Integration Network (LHIN) and modelled on the Somerset West complex respiratory care program, which has demonstrated success for moving adult patients with complex respiratory needs and technology from the acute care setting back to the community. A community paediatric respiratory specialist offered home visits as needed for complex respiratory patients – addressing home equipment issues and creating a more seamless transition between patients and hospital teams. The program team also delivered training and education to home care agencies, to decrease wait times to home care services and decrease length of stay for inpatients requiring home care services. 

Learn more: CHEO

Team lead: Amelie DesLauriers, Social Worker-System Navigator 

Patient/family representative: Lillian Kitchen; Teresa MacMillan 

Senior officer/director: Michele Hynes, Director; Chantal Krantz, Manager 

Indicators: 

• Primary outcome indicator: Caregiver distress 

• Supplementary outcome indicators: N/A      

• Patient/population reach indicator: Parents in the Champlain region experiencing caregiver distress who have children and youth under the age of 18 with medical complexities and are receiving support from the Children’s Hospital of Eastern Ontario (CHEO) 

Navigator Program 

Parents of children and youth with medical complexities experience many challenges when caring for their child. Among the highest concerns are the effects on parents’ physical and mental health, and their increased social isolation.   
The Navigator Program helps to address critical gaps in supports and connections, and promote social and emotional health, for these families.

Two Parent Navigators help families to socialize, share ideas and connect with others, through workshops, wellness and social events, social media, and supporting them during admissions and clinic visits. In addition, a System Navigator can help families with needs beyond social isolation to navigate the complex care system, by finding resources and through one-on-one counselling, family counselling and workshops. Parents decide what their goals are and meet with Parent Navigators and/or System Navigators depending on their needs. 

Team lead: Zayna Khayat 

Patient/family representative: Randy Filinski 

Senior officer/director: Zayna Khayat 

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home 

• Supplementary outcome indicators: Wait times for home care services, referral to services, caregiver distress, (in)appropriate move to long-term care, death at home/not in hospital. 

• Patient/population reach indicator: Home care clients in London-Middlesex and Englemount Lawrence neighbourhoods 

The H.O.P.E. Model® (Home Opportunity People Empowerment) 

The H.O.P.E. Model addresses many of the gaps identified in the current transactional fee for service model of home care. Through combining both the health and social aspects of clients' lives, H.O.P.E aims to reduce clients’ use of high cost acute services while delivering a community-based care model whereby nurses provide a more integrated and holistic approach to care. Clients are supported to meet their goals by self-managing teams of nurses that take care of a person's full set of needs, including the majority of care services (nursing, PSW, therapies, etc.), care coordination and connections to both formal and informal care. The empowered teams of nurses work to their full scope to manage complex patients in the community with a lean infrastructure and management backbone. 

Team lead: Christina Dolgowicz, Lung Health Coordinator 

Patient/family representative: Christine Love 

Senior officer/director: John Jordan 

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Clients over the age of 40 with a diagnosis of chronic obstructive pulmonary disease (COPD) 

Lanark Renfrew Lung Health Program 

North Lanark Community Health Centre worked to integrate and enhance three of its regional chronic obstructive pulmonary disease (COPD) related programs: lung health, community-based pulmonary rehab and primary care outreach for seniors. The aim of integrating these programs was to improve early screening of COPD, enhance appropriate referral and care, and identify patients requiring palliative care supports. The team targeted four key areas for improvement to increase access, with the goal being to keep patients at home: 

• Increasingly early screening and detection for people at risk of COPD 

• Implementation of a 1-833 phone number to connect patients with a respiratory therapist to manage care from home 

• Connecting patients to primary care outreach programs and providing education sessions to rehabilitation participants 

• Early identification of palliative care clients based on specific indicators of decline 

Learn more: ConnectWell 

Team lead: Carolyn Freeman, Chair of the MUHC Clinical Pertinence Coordinating Committee 

Patient/family representative: Susan Szatmari 

Senior officer/director: Martine Alfonso 

Indicators: 

• Primary outcome indicator: Death at home/not in the hospital 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: All stage IV lung cancer patients referred to palliative support within 60 days of initial visit to the MUHC for diagnosis or care. 

Integrating Palliative Support as Routine Care for Patients with Stage IV Lung Cancer 

The McGill University Health Centre (MUHC) is rolling out a program to integrate early referral to palliative support as part of routine care for all patients with stage IV lung cancer treated at the MUHC. A feasibility study will be undertaken by conducting stakeholder interviews to assess readiness of clinicians and the institution/network and identify preferences of patients and caregivers. The program involves: 

• All patients with stage IV lung cancer presenting at the MUHC will be referred to palliative care within 60 days of initial visit. 

• In order to implement this policy, we plan to organize several focus groups with the various stakeholders including physicians, patients and caregivers, allied health care providers, as well as hospital managers and senior administrative staff. 

• Qualitative data from these focus groups and interviews that will help evaluate feasibility and stakeholder preferences and identify current gaps and areas to target (for example, patient and physician education about end-of-life discussions and need for methodical and transparent recording of advance care directives). 

Learn more: McGill University Health Centre  

Connect: @cusm_muhc   

Team lead: Laurel Stretch 

Patient/family representative: Judy Brown 

Senior officer/director: Max Jajszczok 

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home. 

• Supplementary outcome indicators: Caregiver distress, (in)appropriate move to long-term care. 

• Patient/population reach indicator: All home care clients in Alberta 

Provincial Seniors Health Project 

The Provincial Seniors Health team designed a quality measurement framework and performance monitoring process for home care within Alberta. They identified quality measures/key performance indicators (KPIs) and developed a reporting process to drive quality and measure progress. The team established accountability for quality in a consistent, standardized and transparent way which supports collaboration and sharing. 

Learn more: Alberta Health Services Continuing Care Quality Connect: continuingcare.quality@ahs.ca

Team lead: Tammy O’Rourke, Nurse Practitioner 

Patient/family representative: Pearl Todd 

Senior officer/director: Tammy O’Rourke 

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home. 

• Supplementary outcome indicators: N/A. 

• Patient/population reach indicator: Homebound seniors. 

Collaborative Community Care (C3) for Seniors: Health Services @ Sage 

Collaborative Community Care (C3) for Seniors: Health Services @ Sage was a senior focused/senior friendly clinic providing all the services that a traditional health team provides, with additional services not typically offered by traditional community primary care teams. For example, clients could access housing assistance or purchase a meal during their visit. Seniors who were homebound had home visits to integrate them into a social services program, helping them to stay at home. C3 Nurse Practitioners and other team members saw seniors in their home for both ongoing primary care and urgent care requests. Both of these types of visits contributed to seniors’ ability to stay at home, which decreased the number of non-urgent visits to emergency rooms, avoided hospitalizations and potentially decreased 911 calls for non-emergency concerns. 

Learn more: Sage 

Connect: @SageYEG

Team lead: Dennis Natembeya  

Patient/family representative: Tiara Driedger 

Senior officer/director: Zahid Merali  

Indicators: 

• Primary outcome indicator: Home care services helped the recipient stay at home. 

• Supplementary outcome indicators: Wait times for home care services, referral to services. 

• Patient/population reach indicator: Clients in the community on polypharmacy, discharged from the hospital, GP, or referral from case managers and community health nurses. 

Naz Wellness Campus 

Wellness Campus was a robust service for patients who were on a complex medication regime, had compliance issues, were non-mobile and/or required additional assistance. It was an innovative initiative under the Wellness/Naz pharmacies located in Vancouver, Surrey and Langley, British Columbia. The team facilitated care transitions from the hospital to the client’s home as well as supporting older adults to stay healthy at home, therefore reducing emergency and primary practitioners' visits. The service supported clients around their immediate and long-term medication needs, wellness checks and reducing social isolation. The Wellness Campus’s innovative services helped clients with medication compliance such as insulin administration, daily injections and smart medication dispensation, as well as case managing and facilitating GP consultations to keep clients at home. 

Learn more: Wellness Pharmacy

Team lead: Brad Pollman 

Patient/family representative: Nora Lilligreen 

Senior officer/director: Cheryl Dowden, Executive Director 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Those living with, and at the greatest risk of acquiring, HIV/AIDS and/or HCV, who have difficulty obtaining services elsewhere, especially due to substance use, mental illness, sexual orientation, gender identity, race and ethnicity, and/or other social barriers:  

• Number of individuals who access the SMRT 1 Pod who click on the “find support” functionality. 

Mobilizing Technology to Reduce Harm 

ANKORS, a local harm reduction agency serving Nelson, British Columbia, partnered with technology firm SMRT1 to increase accessibility to harm reduction supplies, support and resources. The SMRT1 Pod provides interactive touchscreen vending technologies that increase point of care access for substance use and harm reduction services. By adding a 24/7 access “SMRT1 POD (Personalized On-Demand)” at ANKORS, the organization has increased access to the service’s existing content, resources and related services by providing on-demand, self-service locations in the community. Real-time measurement and reporting can be generated through anonymous data collection accessed by both clients and providers, which increases population reach and program effectiveness. Interaction points are at the large format touchscreen located at ANKORS and through personal devices such as cell phones, tablets or computers, which can provide continuity of care simultaneously. 

Learn more: ANKORS and Smrt1Health  Connect: @ANKORSWest  #SMRT1TECH  

Team lead: Jennifer Kuntz, Project Facilitator 

Patient/family representative: Kerri Conner 

Senior officers/directors: Avril Deegan; Andrea Perri 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Caregivers, clients and service providers. 

Connection in the Community – Empowering Families Affected by Trauma 

The Child and Adolescent Addiction, Mental Health and Psychiatry Program (CAAMHPP) aims to improve the transition from psychiatric emergency department/urgent care to community care for children and youth who have experienced trauma. The service pathway created through this project connected Calgary families with mental health and psychiatry outreach support and helped in developing a crisis plan. The service also coordinated a case conference for the child, youth and family’s informal and formal supports (including primary care teams, education, government agencies and other health professionals). An important component of the pathway was regular reviews of the intervention/support plan as well as follow-up with the client, family and services providers. 

Connect: @AHS_YYCZone 

Team lead: Bronagh Morgan, Executive Director 

Patient/family representative: Denise Ludrigan 

Senior officer/director: Bronagh Morgan 

Indicators: 

• Primary outcome indicator: Early identification for early intervention in youth aged 10 to 25. 

• Supplementary outcome indicators: 

• Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Awareness and/or successful navigation of mental health and addictions services. 

• Patient/population reach indicator: Children and youth aged 5 to 17 in the London, Ontario region (including Middlesex, Elgin and potentially Oxford counties) who self-identify as needing support after the death of someone close to them, their parents/caregivers and other adults seeking support for the children and youth they serve (including teachers, social workers, psychologists and youth case workers). 

Designing Support Programs to Support Bereaved Children and Youth 

In this project, the Bereaved Families of Ontario: Southwest Region served children, youth and young adults who had experienced the death of a close family member by offering services and programs with safe spaces and peer support. The team designed programs to target children aged 5 to 9 and youth aged 10 to 17, and worked on scoping additional support to better address the needs of First Nations and LGBTQ+ communities facing societal barriers. The team also evaluated programs and services to determine opportunities for improvement and ensure programs are engaging, inclusive and effective in supporting their targeted groups. 

Learn more: Bereaved Families of Ontario: Southwest Region Connect: @BFO_SW 

Team lead: Sonia Seguin, Executive Director, Body Brave 

Patient/family representative: Becca Bishop 

Senior officer/director: Shaleen Jones, Executive Director, Eating Disorders Nova Scotia 

Indicators: 

• Primary outcome indicator: Wait times for community mental health services. 

• Supplementary outcome indicators: Awareness and/or successful navigation of mental health and addiction services. 

• Patient/population reach indicator: Individuals who register for the electronic platform. 

e-Peer Support Initiative 

Eating Disorders University was a social learning e-platform designed by and for organizations across Canada that support individuals impacted by eating disorders. Through this platform, those impacted by eating disorders could access educational modules, peer support groups, workshops and treatment delivered by community organizations and treatment providers from across Canada. The individual looking for support was truly in the driver’s seat, able to create their own support network. By removing geographic and other barriers to care, the e-platform addressed existing inequalities that impact those in rural and under-served areas. From live classrooms to discussion forums, individuals had options to connect with healthcare providers and trained peer supporters. The e-platform served as a community space, knowledge hub and service delivery tool – increasing access to mental health care. 

Connect: @bodybravecanada, @nsedrecovery

Team lead: Jackie Aufricht, Program Manager 

Patient/family representative: Farah Anastas 

Senior officer/director: Allison Fielding 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator:  

• Children and youth aged 5 to 20 with complex addiction, mental health and related psychosocial needs and their families in the Cochrane area. 

• Older adults with complex addiction, mental health and related psychosocial needs in the Bowness area. 

Case Collaborative Models 

A joint initiative between the Calgary Foothills Primary Care Network and Alberta Health Services, the Case Collaborative Model has been tested as a method for better coordinating care for individuals challenged by mental health and addictions issues. The Case Collaboratives support patients in successfully navigating mental health and addiction services by immediately connecting them to the most appropriate services in their community based on their needs. The model brings together providers from multiple organizations to problem-solve complex patient situations and improve continuity of care. 

Learn more: Case Collaboratives Connect: @foothillspcn

Team lead: Karen Leung 

Patient/family representative: Shane Hooshmand 

Senior officer/director: Ashley Hogue 

Indicators: 

• Primary outcome indicator: Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: New BounceBack referrals, that are screened eligible for the program (adults and youth aged 15+). 

Improving Access to BounceBack

BounceBack: Reclaim Your Life is a skill-building program designed to help adults and youth 15+ manage low mood, depression and anxiety, stress or worry. In this project the team created improvements, using quality improvement methodologies, to improve wait-times to service, from date of screening through to the date of the participant’s first coaching session. The team also focused on reducing the number of participants that become unreachable before an assessment, to impact the wait-time. 

Learn more: BounceBack    Connect: @CMHAOntario 

Team lead: Cyndy Forsyth 

Patient/family representative: Mary Boersma 

Senior officer/director: Krista Sibbilin 

Indicators: 

• Primary outcome indicator: Early identification for early intervention in youth aged 12 to 25. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Youth between the ages of 12 and 26 who participate in the B-Together Talk Series. 

Integrated Youth Services Network 

Youth wellness hubs are designed to provide youth with the right services, at the right time, in the right place. Youth wellness hubs provide centralized service at a single site in a geographic area, thus reducing barriers in accessing care. In Wellington County and the city of Guelph, the Integrated Youth Services Network planned to create seven sites: four in Guelph and three in rural Wellington County. The project’s goal was to make it easy for youth to access youth related services, and for them to be involved in all stages of development. Reflecting the collaborative model on which youth wellness hubs are designed, the project was led by the Rotary Club of Guelph, with partners including the Canadian Mental Health Association Waterloo Wellington, the Guelph YMCA/YWCA, the University of Guelph, Shelldale Family Gateway, Big Brothers Big Sisters of Centre Wellington, Minto Mental Health, East Wellington Community Services and the Guelph Community Foundation. 

Connect: @CMHAWW

Team lead: Christine Tomori 

Patient/family representative: Joanne Finnegan 

Senior officer/director: Doctor Joanna Cheek 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addiction services. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Adults (aged 17.5 to 75) with mild to moderate mental health conditions who attended the Cognitive Behaviour Therapy (CBT) Skills Group program following a referral from primary care. 

Cognitive Behaviour Therapy (CBT) Skills Group Program 

The CBT Skills Group program is an eight-week, publicly-funded, evidence-based intervention for adults with mild to moderate symptoms of anxiety or depression. Designed by psychiatrists and taught by physicians, this course integrates neuroscience, mindfulness and cognitive behavioural therapy skills and concepts. In groups of 15 patients, this trans-diagnostic program teaches patients self-management skills and practical tools to recognize, understand and manage patterns of feeling, thinking and behaving. They learn to be conscious of their choices as they respond to life stressors, and explore options for living a fuller, richer life, more aligned with what they value most. To adapt to these unprecedented times and to support the mental wellness of the communities it serves, the program has successfully moved online with hundreds of patients being served at any given time through virtual groups. 

Learn more: CBT Skills Groups  
Connect: cbtskills@divisionsbc.ca 

Team lead: Captain Anna Harpe 

Patient/family representative: Colonel Heather Morrison 

Senior officer/director: Major Health Robson 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Members of the Canadian Armed Forces (CAF) in Edmonton, Alberta (experimental group) and Petawawa, Ontario (control group) who have attended a residential addiction treatment program for a substance use disorder and subsequently enrolled in the 12-month Aftercare Program. 

Attitudes & Perceptions with the Addictions Aftercare Program 

This study investigated the impact of social support networks, and system wide education and awareness initiatives, on CAF members initiating and maintaining recovery from addiction. It examined perceptions and attitudes toward mental health and addictions aftercare services and the related effects on individuals’ recovery capital, engagement and overall well-being. Participants used aftercare services in two settings, CFB Edmonton (the experimental group) and CFB Petawawa (the control group), and completed a questionnaire to compare pre- and post-project attitudes and perceptions about addiction and the Aftercare program.  

Learn more: National Defense  Connect: @NationalDefense 

Team lead: Dakota Drouillard, Licensed Practical Nurse 

Patient/family representative: April Bullchild 

Senior officer/director: Shelby Young 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: The target population was individuals using programs, treatments or support services to overcome challenges and barriers they faced due to mental health and addictions, and to assess if treatment is easily accessible. 

Introducing Electronic Medical Records (EMR) to preventative and primary care resources 

Through environmental scanning and distribution of surveys, Indigo Harm Reduction compared the population of Albertans who identify personal challenges with mental health and addictions to utilization of services, as reported by Statistics Canada. The aim of the project was to unite programs in such a way that referral of services is easier and clients know the criteria for utilizing services – to create a way in which individuals can find appropriate services that match their needs almost fully. 

Connect: @indigoHRS @dakotaleee 

Team lead: Bila Sabra, PHAST Charge Nurse 

Patient/family representative: Lynn Gallagher 

Senior officer/director: Cheryl Gustafson 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: 

• Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Rates of repeat emergency department and/or urgent care centre visits for a mental health or addiction issue. 

• Patient/population reach indicator: The target population for PHAST is transitional age youth, adults and seniors (aged 16 to 99) who experiencing acute instability of a mental health and addiction concern. 

Prioritizing Health through Acute Stabilization and Transition 

Joseph Brant Hospital has led the development of a multi-agency Mental Health and Addictions (MH&A) model in Burlington called PHAST (Prioritizing Health through Acute Stabilization and Transition). PHAST is an innovative, system-wide integrative ’hub and spoke’ service delivery model. Its goal is to provide the most appropriate urgent MH&A care through timely access, assessment and intervention while preventing unnecessary emergency room visits and hospital admissions. The stabilizing interventions will help to reduce recidivism to the emergency department while the warm transfers, i.e. those transfers occurring from service to service, are designed to improve an individual’s initiation into community treatment, particularly for more complex situations. 

 Connect: @Jo_Brant 

Team lead: Rossana Astracio-Morice 

Patient/family representative: Rebecca McDermott 

Senior officer/director: Analyn Einarson 

Indicators: 

• Primary outcome indicator: Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Supplementary outcome indicators: Awareness and/or successful navigation of mental health and addictions services. 

• Patient/population reach indicator: Children in Manitoba aged 12 and under, along with their families and support systems (guardians, extended family, teachers, aides, paediatricians, nurses, coaches, faith leaders, community leaders, instructors, neighbors, and a variety of other adults who support children). 

KIDTHINK: Providing Evidence-Based Mental Health Treatment Services 

KIDTHINK offers clinical and outreach services that aim to improve mental health services, with a focus on early intervention and prevention for children aged 12 and under. KIDTHINK leverages technology to remove geographical barriers to accessing timely services, by offering services through a rapid screening process without requiring a diagnosis. The program offers additional supports to improve childrens’ access to treatment, including financial aid, home visits to meet families or communities, and partnerships with public schools to facilitate referrals from school psychologists and guidance counsellors. Using InterRAI’s Child and Youth Mental Health Screener (ChYMH-S) and Child and Youth Mental Health Community Based Assessment Form (ChYMH), clients are directed to the appropriate treatment stream within a corresponding timeframe according to the urgency of their presenting concerns. 

Learn more: KIDTHINK

Team lead: Ryan Andres, High Risk Therapist 

Patient/family representative: Sarah Cannon 

Senior officer/director: Bill Helmeczi, Director of Strategic Initiatives, Standards and Practices 

Indicators: 

• Primary outcome indicator: Rates of self-injury, including suicide. 

• Supplementary outcome indicators: 

• Rates of repeat emergency department and/or urgent care centre visits. 

• Wait times for community mental health services. 

• Early identification for earlier intervention in youth aged 10 to 25. 

• Awareness and/or successful navigation of mental health and addictions services. 

• Patient/population reach indicator: Children and young people aged 0 to 18 in Niagara who present a serious risk to harm themselves or others. 

Violence Threat Risk Assessment Care Pathway Project 

Pathstone Mental Health’s High Risk program provides mental health assessment and therapy for children and youth who have been identified as being at an elevated risk to harm themselves or others. Often these children and youth are identified and referred to Pathstone by community partners including police, schools, hospitals or child welfare. They are provided with intensive individualized services designed to reduce the imminent risk they pose to themselves or others. Once risk has been reduced, the individual is referred to a more appropriate and less intense service or program. T  
he team participated in the Quest Continuous Quality Improvement Program with a goal of improving care pathways into the High Risk program. Using Six Sigma QI methodology, the team reviewed and worked to improve the Violence Threat Risk Assessment (VTRA) care pathway. They also aimed to establish ongoing quality improvement initiatives that improve all care pathways into the High Risk program (for example, hospital admission referral to High Risk program).  

Learn more: Pathstone Mental Health’s High Risk Services 

Connect: @PathstoneMH

Team lead: Tacie McNeil, Clinical Nurse Educator 

Patient/family representative: Jesse Dobson 

Senior officer/director: Lois Ward, Senior Operating Officer 

Indicators: 

• Primary outcome indicator: Hospitalization rates for problematic substance use. 

• Supplementary outcome indicators: Rates of repeat emergency department and/or urgent care centre visits for a mental health or addictions issue. 

• Patient/population reach indicator: People who use substances (primary stimulants such as crystal methamphetamine) and are admitted to the Peter Lougheed Hospital. 

Contingency Management Programs for Inpatients with a Stimulant Use Disorder 

With the aim of developing strong evidence-informed medical treatment to support individuals with reducing or stopping stimulant use at the Peter Lougheed Hospital, the team implemented Contingency Management (CM) to support individuals experiencing a stimulant use disorder. Stimulants can have profound effects on mental and physical health, thereby contributing to increased visits to emergency departments and admissions to hospital. Stimulant use also makes it difficult for some patients to remain in hospital for the full course of their medical treatment, which contributes to multiple presentations for the same and worsening health problems.   
The CM group created opportunities for people who use stimulants to make positive changes including reducing or stopping their use of the substance, participating in addiction treatment and attending to their health and social needs.  
 
While CM has been evaluated in the outpatient setting, it had not been implemented and formally studied in Alberta in an inpatient setting and in the context of wraparound supports from an addiction medicine consult service. Using patient-centered objectives, rather than simply abstinence-focused outcomes, enabled additional important and meaningful outcomes to be evaluated. 

Connect: @ahs_yyczone

Team lead: Alex Gosselin, MSW, RSW, RYT, Clinical Manager 

Patient/family representatives: Lucie Langford; Samantha Ledamun 

Senior officer/director: Nzinga Walker, Director of Program Operations 

Indicators: 

• Primary outcome indicator: Early identification for early intervention in youth aged 10 to 25. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Youth aged 16 to 25 who attend the Dialectical Behaviour Therapy (DBT) skills group. 

Dialectical Behaviour Therapy (DBT) Skills Program 

This evidence-based program run at Stella’s Place identifies and teaches young adults aged 16 to 29 skills in distress tolerance, emotion regulation and recovery. The 14-week program has a group component one day a week for two hours, along with one session of individual counselling per week. In each cycle of the program, 12 participants are registered. Clinicians and peer supporters facilitate the DBT Skills groups. DBT has been shown to be effective for individuals living with a borderline personality disorder diagnosis, and has also been proven effective in treating self-harming behaviors, suicidal behaviors, post-traumatic stress and depression. Stella’s Place has been offering the program in person since 2017 and online since May 2020. A co-design focus group with young adults and a survey with participants who received in-person and virtual services through Stella's Place help with better understanding how each mode of service delivery makes an impact, and what can be improved. 

Learn more: Stella’s Place 

Connect: @stellasplaceca 

Team lead: Roula Markoulakis, Research and Evaluation Lead 

Patient/family representative: Julie Cowan 

Senior officer/director: Sugy Kodeeswaran 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: 

• Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Early identification for early intervention in youth aged 10 to 25. 

• Patient/population reach indicator: Youth aged 13 to 26 with Mental Health and Addictions (MHA) concerns and their families living in the City of Toronto, Peel Region, York Region, Durham Region and Halton Region (i.e., Greater Toronto Area). Family is broadly defined to include biological family members and those of significant importance to the youth. 

Family Navigation Project 

Sunnybrook’s Family Navigation Project (FNP) is a non-profit, free-of-charge service for youth aged 13 to 26 with Mental Health and Addictions (MHA) concerns. It is designed to guide patients through care plans and reduce barriers to timely access and transition of services. Services are designed to be responsive and accessible. Upon initial intake through a screening assessment, cases are assigned to Navigators. These are graduate-level clinicians in mental health and/or addictions care, social work, psychology, child development, Parent Advocates with Lived Experience (PAL) and psychiatrists, who work one-on-one by phone or email with patients and/or their families to assist in untangling the web of the MHA system and design care plans around the youth’s medical, social and family goals. The model is designed to reduce barriers to access by creating meaningful relationships with families to engage them throughout the care process, and in some cases, working with families where youth are not motivated to access care or are unwilling to engage in care. 

Learn more: Family Navigation Project Connect: @Sunnybrook 

Team lead: Andrew Reyes, Project Coordinator 

Patient/family representative: Community Engagement Advisory Network (CEAN) 

Senior officer/director: Monica McAlduf 

Indicators: 

• Primary outcome indicator: Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Number of patients (with depression and anxiety) successfully referred to Kelty’s Key – VCH Online Therapy. 

Kelty’s Key 

Kelty’s Key is a free online psychotherapy platform that enables therapists to incorporate Therapist Assisted Internet-Cognitive Behavioural Therapy (TAI-CBT) into their practice. TAI-CBT is as effective as face-to-face therapy and gives clients added flexibility. Kelty’s Key can help therapists treat more clients and reach individuals who may otherwise be unable to access treatment. The program is based on email therapy and online courses. The modules are evidence-informed and developed by clinical CBT experts at Vancouver Coastal Health and Providence Health Care. Courses offered include: Anxiety, Chronic Pain, Complicated Grief, Depression, Insomnia, Panic and Substance Use. 

Connect: @VCHhealthcare 

Team lead: Monty Ghosh 

Patient/family representative: Rebecca Morris-Miller 

Senior officer/director: Kim Ritchie 

Indicators: 

• Primary outcome indicator: Rates of self-injury, including suicide. 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Our primary target population is:  

• Anyone who uses substances alone. 

• Individuals who have a landline or mobile phone. 

• Individuals who live in communities outside of the 500 meter therapeutic radius of supervised consumption sites. 

• Clients who are self-isolating due to COVID-19 but still using substances. 

Virtual Overdose Response Line 

The Virtual Overdose Response Line (now National Overdose Response Service) provides peer-supported supervision for individuals who use substances alone. Clients call a phone number to have a peer supervise them virtually. If the client becomes unresponsive, the peer calls 911 to send an ambulance to the client. Physical supervised consumption sites reduce mortality rates to a maximum of 500 meters around them, but the majority of overdoses (80-95%) occur outside of this therapeutic radius, in suburban communities and rural communities, where individuals often use substances alone. The goal is to support clients who use substances alone, and refuse to utilize services like supervised consumption sites due to fear of being seen or stigma, to use with remote supervision. The overall goal is to reduce mortality outcomes (especially rates) among these individuals as well as reduce morbidity outcomes. In addition, the service provides clients with access to community-based resources that treat addiction and mental health concerns. 

Learn more: Grenfell Ministrieshttps://www.grenfellministries.org/

Team lead: Claire Doherty 

Patient/family representative: Irene Toy, Providence Health Care’s Care Experience Advisory Committee;  Lyn Brooks, Patient Voices Network;  
Mario Gregorio, Providence Health Care’s Care Experience Advisory Committee ( 
note: one additional patient partner did not wish to be identified) 

Senior officer/director: Margot Wilson 

Indicators: 

• Primary outcome indicator: Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Supplementary outcome indicators: N/A 

• Patient/population reach indicator: Adults in Vancouver who require a psychiatric consultation or short-term intervention for a mood or anxiety disorder, or stable schizophrenia. 

Virtual Psychiatry Collaboration with Vancouver Primary Care (VPC2) 

In the Vancouver City Centre area, there is limited access to adult psychiatry for non-acute mental health concerns, but significant need and long wait times. Many people with moderate mental health conditions cannot access a psychiatrist at all, resulting in family physicians providing all of their mental health care without advice from a specialist. This project aimed to improve access to psychiatric care for Vancouver residents aged 19 to 64. The team developed a shared care model of managing non-acute cases virtually on an outpatient basis in conjunction with primary care providers, so psychiatrists could provide patients with efficient short-term care without assuming ongoing responsibility for care or utilizing office space. Access improvements were assessed on an ongoing basis by comparing the median wait time from referral to first appointment for the virtual psychiatry prototype, versus existing psychiatry models of care in British Columbia. The team also evaluated patient-reported health outcomes. VPC2 was an initiative of Providence Health Care, supported with funding from the Shared Care Committee. 

Learn more: Patient Voices Network  

Team lead: Nicole Schween 

Patient/family representative: Sarah Precious 

Senior officer/director: Flora Ennis 

Indicators: 

• Primary outcome indicator: Awareness and/or successful navigation of mental health and addictions services. 

• Supplementary outcome indicators: Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Patient/population reach indicator: Youth aged 12 to 25. 

Youth Hub 

Woodview in the Square is a one-stop Youth Hub offering multiple services under one roof to youth aged 12 to 25. We aim to offer the right service, at the right time, in the right place. This is made possible through our partnerships and integrated services with multiple sectors including Education, Mental Health and Addictions, Youth Justice, Indigenous Services, Public Health, Recreation, Social Services, the City and Municipality, and non-profit organizations. Woodview goes above and beyond to engage individuals and families by providing high quality mental health and autism services and supports that inspire hope and strengthen lives. 

Learn more: Woodview in the Square  

Connect: @WoodviewMHAS

Team lead: David O’Brien 

Patient/family representative: Keon Reid-Charles 

Senior officer/director: David O’Brien 

Indicators: 

• Primary outcome indicator: Rates of repeat emergency department and/or urgent care centre visits for a mental health or addiction issue. 

• Supplementary outcome indicators: Wait times for community mental health services, referral/self-referral to services (services provided outside of emergency departments, hospital inpatient programs and psychiatric hospitals). 

• Patient/population reach indicator: Individuals aged 12 to 29 with moderate and above clinical mental health and addiction issues transitioning from Humber River Hospital (Emergency Department/Inpatient/Outpatient) to the West Toronto Youth Hub. 

West Toronto Youth Hub 

Yorktown Family Services operates the West Toronto Youth Hub. The Hub is an integrated youth services site for youth 12 to 29, with an interdisciplinary team that provides rapid and seamless access to mental health, social service and primary health support. The team facilitates the care pathway navigation to increase access to services and enable wraparound support. The outcomes for youth are strengthened mental health functioning, increased social participation and support in acquiring the social determinants of health so they can live healthy lives.  

Learn more: Yorktown Family Services 

Connect: @YorktownFamily