‘‘CE to Go’CE to Go’Building capacityBuilding capacitythrough accredited through accredited distance education in distance education in Northern OntarioNorthern Ontario

Paula Ravitz MD FRCPC

NO INDUSTRY RELATIONSNO INDUSTRY RELATIONSDisclosure:

With AppreciationWith AppreciationOur team: Robert Cooke, Barb Crawford , Annette Katajamaki, Therese Millette, Scott Mitchell, Paula Ravitz, Scott Reeves, Ana Rogers, Bhadra Sthankiya, Robert Swenson, John Teshima

Our partners: Northern Psychiatric Outreach Program – CAMH; Canadian Mental Health Association northern branch participants, executive directors & small group facilitators; Ontario Psychiatric Outreach Program; University of Toronto Faculty of Medicine CE Office; the U of Toronto and U of Ottawa department of psychiatry faculty; Mae Productions

Funding from: CAMH AFP The Innovation Fund & Ministry of Health and Long term Care

CE to Go: GoalsCE to Go: Goals• Improve access to professional development

by mental health practitioners in underserviced settings

• Facilitate dissemination of evidence supported clinical practices for clients with mental illness through the provision of expertise and evidence supported teaching with standardized materials

• Foster collaboration between psychiatric outreach consultants & community mental health services through a coordinated knowledge transfer program

Desired OutcomesDesired Outcomes

(i) Indirectly improve mental health of patients in under-serviced communities, by

(ii) improving the knowledge and skills of front line mental health workers in areas identified through learning surveys, key informant interviews and consultation requests, via

(iii) application of teaching, with

(iv) comprehensive mixed evaluative methods

Psychiatric services in Northern Ontario

Psychiatric services in Northern Ontario

• Average ratio of psychiatrists to patients 1:30,000 (Berntson et al, 2005)

• Care delivered by inter-professional clinicians• Social workers, nurses, mental health clinicians,

MDs – Family physicians and psychiatrists• OPOP – 60 consultants from 6 university-based

programs whom provide a LOT of care• Telepsychiatry• Majority of time: direct care

MENTAL HEALTH SERVICES IN SMALLER NORTHERN ONTARIO COMMUNITIES: A SURVEY OF PSYCHIATRIC OUTREACH CONSULTANTS (2010)

MENTAL HEALTH SERVICES IN SMALLER NORTHERN ONTARIO COMMUNITIES: A SURVEY OF PSYCHIATRIC OUTREACH CONSULTANTS (2010)

Jill E. Sherman Raymond W. Pong J. Robert Swenson Margaret G. Delmege Abraham Rudnick Robert G. Cooke Paula Ravitz Phyllis Montgomery

Capacity BuildingCapacity Building• An identified objective of outreach to

underserviced areas: increase the capacity of local providers to provide appropriate assessment, care, and referrals.

• Many consultants do not spend any time providing education and of those who do, 2/3rds provide informal educational activities (65%), and 1/3 provide some formal education (31%).

Opportunity to strengthen the education component of outreach

Opportunity to strengthen the education component of outreach

• Identified gap and need for the OPOP model to go beyond the delivery of clinical care, to increase local capacity

“I think an education/training component is important ... So that there is something in addition left in the community. So that it shouldn't perhaps all be patient‐focused. It should have an education, training focus.”

“This survey helped me realize all the teaching I don’t do.”

Recommendations Mental Health Services in Smaller Northern Ontario Communities:

A Survey of Psychiatric Outreach Consultants

Recommendations Mental Health Services in Smaller Northern Ontario Communities:

A Survey of Psychiatric Outreach Consultants

Recommendations• develop a tool to aid in

prioritizing patients; • strengthen between‐visit

support services;• increase the use of

education as a capacity building tool;

• develop multidisciplinary outreach;

• create a sub-specialty support service for northern psychiatrists.

Response

• Local capacity building in community mental health providers may result in strengthened support services

THE PROBLEM: • Front-line mental health clinicians who work in under-serviced remote

settings, in Ontario and other places…such as Ethiopia, have minimal training yet see ++complex patients

• Geographic barriers & time constrains learning of these mental health clinicians

• Outreach consultants do little formal teaching yet recognize the potential benefit of building capacity in the communities where we provide outreach clinical services

A POTENTIAL SOLUTION: • Increase the educational role of outreach consultants and experts

through the creation of distance education materials to support these community agencies and build capacity

CE to Go – Methods ICE to Go – Methods I• Assembled team & advisory committee

• Northern Psychiatric Outreach Program-CAMH CE Committee, CMHA KT Director, Northern Branch ED,

Wilson Centre for research in education

• Created preliminary “menu” of evidence supported educational offerings from learning needs surveys, informants and consultation requests

• Recruited faculty experts

Methods IIEvidence based teaching of evidence based clinical practices

Methods IIEvidence based teaching of evidence based clinical practices

• Learning needs verified and ranked with CMHA northern branch clinicians and executive directors

• Formatted skills-based distance education modules based on CME best-practices : • Oral presentation with power point • SP demonstrations • Case-based, interactive learning guide • Practice reminders • ‘Commitment to Change’ exercise• Mentored local opinion-leader facilitators

Methods IIIMethods III• Invited nominations for & recruited opinion

leaders

• Following REB approval, recruited front-line mental health workers in 7 CMHA branches (north of Parry Sound) assigned to • self-directed v. facilitated small group learning

“Opinion Leaders”“Opinion Leaders”• A trusted professional colleague whom you

would turn to for advice on a difficult clinical matter

• Selected those with multiple nominations, verified with executive directors

- Community Support Worker

- Therapist

- Director of Clinical Services

- Social Worker/Psychotherapist

CONTEXT: Canadian Mental Health Association (CMHA)

CONTEXT: Canadian Mental Health Association (CMHA)

• CMHA : a national organization, with provincial divisions and local branches in 135 communities across Canada• Provides public education • Does applied research and policy analysis, • Advocates for healthy public policy and an effective

and efficient health system

SETTING: CMHA Ontario BranchesSETTING: CMHA Ontario Branches

• Provide direct services to 33 communities• case management, supportive housing, social

rehabilitation / recreation, employment support, assertive community treatment, crisis intervention, peer support, primary care, health promotion and public education and more...

• Clients served include • Youth, adults, seniors with serious mental illness,

concurrent disorders, dual diagnosis • Plus families

Learning Needs Survey Results (N = 102 from 7 Northern CMHA Branches)

Learning Needs Survey Results (N = 102 from 7 Northern CMHA Branches)

1. What is your Role?

Director 10 Registered Nurse 12

Clinician/Practioner 17 Case Manager 19

Program Manager 11Mental Health Worker

33

Learning Needs Survey ResultsLearning Needs Survey Results2. Please indicate your top 3 choices of topics listed.

  FIRST SECOND THIRD

Interpersonal Psychotherapy (39) 18 21 9

CBT on the Fly (38) 28 10 15

Concurrent Disorders (32) 18 14 18

Law & Mental Health (27) 14 13 10

Bipolar Disorder (18) 5 13 11

Psychopathy (14) 3 11 8

Psychiatric Emergencies (11) 7 4 10

Psychosis (7) 0 7 0

Delirium in the Elderly (5) 3 2 2

Assessing Driving (1) 0 1 3

Learning Needs Survey ResultsLearning Needs Survey Results3. Please indicate your level of interest for each topic.

  HIGH MODERATE SOME NO

Interpersonal Psychotherapy 60 30 3 2

Concurrent Disorders 57 22 15 0

CBT on the Fly 52 32 9 3

Law & Mental Health 39 30 22 2

Bipolar Disorder 38 31 20 2

Psychosis 36 32 18 2

Psychiatric Emergencies 34 32 22 3

Psychopathy 31 28 24 4

Delirium in the Elderly 19 29 30 13

Assessing Driving 8 17 30 36

The CE to Go: opening ‘Menu’ offerings

The CE to Go: opening ‘Menu’ offerings

CBT for Depression Zaretsky & Fefergrad

CBT for Anxiety Fefergrad & Richter

IPT Ravitz, Watson, Grigoriadis

Working with clients with Concurrent Disorders using Motivational Interviewing

Skinner & Chamberlain

Depression & Disability in Medically Ill

Swenson & Gillies

Planned…working with clients who are emotionally dysregulated using Dialectical Behaviour Therapy skills

McMain & Wiebe

The Educational InterventionThe Educational Intervention

Self-Directed• Taped presentation with Taped presentation with

Power Point & captioned Power Point & captioned simulationssimulations

• Focus: Skills-basedFocus: Skills-based• Learning Guide w/ Case Learning Guide w/ Case

Based Reflection and Based Reflection and Practicing ExercisesPracticing Exercises

• Practice RemindersPractice Reminders• Commitment to Change Commitment to Change

ExerciseExercise

Facilitated• All elements of Self-All elements of Self-

Directed Arm Directed Arm PLUSPLUS• Small Group Learning Small Group Learning

with Local Champion, with Local Champion, mentored by mentored by consultant/faculty expertconsultant/faculty expert

A Mixed Methods DesignA Mixed Methods Design

Pre-Course Measures1. Readiness for Inter-professional Learning Scale

(RIPLS; Parsell and Bligh) • This 19-item scale is used to explore differences in students'

perception and attitudes towards multi-professional learning. 2. Counselling Self-Estimate Inventory

(COSI; Larson 1992) • 42 self-assessment items measure the clinician’s ability to

track, respond and work with difficult patients. 3. Multiple-Choice Knowledge Questionnaires

(CE to Go faculty; 2010)• 25 MCQ items, some of which are case-based on each topic

A Mixed Methods DesignA Mixed Methods Design

Post-Course Measures1. Counselling Self-Estimate Inventory (Larson 1992) 2. Multiple-Choice Knowledge Questionnaires (CE to

Go faculty; 2010)3. Commitment to Change Exercise – an intervention

and a measure (Fox, Mazmanian & Putnam 1989)• shown to result in greater practice changes from continuing

education research4. Interviews/Focus Groups with learners

Demographics of Learners (N=52) Demographics of Learners (N=52)

Age 42.2 years

GenderFemale – 46 (88%)

Male – 6 (12%)

Previous CBT TrainingYes – 16 (31%)

No – 36 (69%)

Previous Concurrent Disorders Training

Yes – 23 (44%)

No – 29 (56%)

# of Years of Clinical Work 11.2 years

# of Years at CMHA 5.7 years

# of Years of Training 4.3 years

CMHA’s 7 Northern BranchesCMHA’s 7 Northern Branches

Facilitated Small-Group• Cochrane-Timiskaming (11)• Kenora (8)• Sault Ste Marie (4)• Sudbury-Manitoulin (8)

Self-Directed• Fort Frances (7)• North Bay (3)• Thunder Bay (15)

CE TO GO:CBT FOR DEPRESSIONCE TO GO:CBT FOR DEPRESSION

Ari Zaretsky & Mark Fefergrad; Series Editor: Paula Ravitz

The Learning Guide ‘Lessons’The Learning Guide ‘Lessons’

5 hours5 hours1.1. Watch the 1-hour presentationWatch the 1-hour presentation

• 30 minutes didactic 30 minutes didactic • 3 x ~10 minute captioned simulations3 x ~10 minute captioned simulations

2-4. Watch each of Role Plays #1-3 (one/session) 2-4. Watch each of Role Plays #1-3 (one/session) • Questions for Reflection or DiscussionQuestions for Reflection or Discussion• Role plays or exercisesRole plays or exercises• Home workHome work

5. Case-based consolidating session5. Case-based consolidating session

CBT for Depression: Learning Guide example

CBT for Depression: Learning Guide example

A. Questions for Discussion• Define “hot thought”? List 3 techniques to help a patient identify a hot

thought.• What are ways to empathically respond to distress or tearfulness during a

session?

B. Experiential Tasks• Set an alarm to go off six minutes into the video. At that moment pay

attention to and write down your feelings and thoughts. Be thorough. What do you notice? Connection between the thoughts and emotions?

C. Homework• Complete the first three columns of the thought record on at least three

different occasions when you notice a change in emotion. Attend to what you notice about patterns that may emerge between the three thought records.

Pocket Guide Pocket Guide of Practice of Practice RemindersReminders

Future Steps & OpportunitiesFuture Steps & Opportunities• Modules in various stages of progress

• Translation of modules

• +/- add modules on other topics or build upon current modules (part II)

• Complete evaluation of 1st two modules• Focus Groups

Adjust intervention/protocol in response to results

• Use parts or whole modules with • differing groups of learners & facilitators including

visiting consultants

• in differing settings ( i.e. shared care, undergrad, post-grad, CME, inter professional education)

Thank you for Thank you for your attentionyour attention

Paula.ravitz@utoronto.ca