Putting the pieces oget ther...2. A blueprint to consider for the redesign of the MHA system and a practical example to illustrate its application. 3. How to set the conditions for

October 2019

kpmg.com/ca/MHA

Putting the pieces togetherVolume 3Re-imagining the Future of Mental Health & Addictions System

http://kpmg.com/ca/MHA

Our mental health and

addictions (MHA) system is

ripe for transformation: new

models of care and cutting-

edge technologies have the

potential to reduce costs

and help us re-think how

we deliver care. Embedding

modern digital solutions

into legacy service delivery

models is not enough; we

need to think bigger and re-

imagine a MHA system that

can push through existing

barriers and accelerate the

adoption of digitally-enabled

service delivery models.

This is the third and final MHA Issue Brief in a series aimed at exploring MHA in the context of the client seeking care (see Issue Brief I) and the broader MHA system (see Issue Brief II). In this Issue Brief, we focus on:

1. How we might think differently about re-imagining MHA given advancements and disruptions in technological trends across other industries;

2. A blueprint to consider for the redesign of the MHA system and a practical example to illustrate its application.

3. How to set the conditions for success.

Taking a new perspective: re-imagine

1. Also see: Britnell, In Search of the Perfect Health System, 2015 https://home.kpmg.com/xx/en/home/insights/2015/09/in-search-perfect-health-system.html

2. Source: Reuters (2018). Mental health crisis could cos the world $16 trillion by 2030. [Online] Available from: https://www.reuters.com/article/us-health-mental-global/mental-health-crisis-could-cost-the-world-16-trillion-by-2030-idUSKCN1MJ2QN

© 2019 KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.

2 Putting the pieces together Vol.3

https://home.kpmg.com/xx/en/home/insights/2015/09/in-search-perfect-health-system.html

In today’s digital age, there are more connected devices than people on Earth.1 All types of industries are using technology to rethink traditional models of service delivery.

But what does this mean for mental health and addictions?

It is no secret that many industries are being threatened by innovative and disruptive business models that are built upon digital breakthroughs. Changing customer expectations are driving companies to think differently about how they leverage technology and evolve their traditional business models. Whether technology is driving new business models or new business models are demanding more digital innovation, data is becoming the new currency that is completely changing our experiences. The innovators who have found ways to drive value to consumers through the intelligent use of data have become the pioneers of new, disruptive business models.

Well-documented examples like Uber, Airbnb, and Netflix show that no industry is safe from disruptors, and that a superior customer experience will always triumph. What all of these examples have in common is that the technology was not forced into the status quo – rather, it was the key enabler for creating new ways of doing business.

While adoption of new business models in healthcare seem to be years behind other industries, the conditions for this type of disruptive change have never been better:

— There are significant cost pressures for healthcare: Canadian health systems cannot sustain health care spending at the current rate and are looking for ways to do more for less.

— The stigma surrounding mental health and addictions is decreasing: While the stigma surrounding mental health and addictions continues to exist today, reduced stigma and increased awareness is motivating governments to focus their health system priorities on the MHA sector.

— The digital world we live in demands modern, digitally-enabled experiences: Technology is no longer a barrier to keeping pace with the demand for digitally-enabled experiences. Solutions exist today, but health system leaders need to find ways to increase the pace of innovation to re-imagine how we deliver healthcare services for Canadians.

We propose that health system leaders and innovators think big. MHA is a critically important part of our healthcare system and deserves more than incremental improvement. We need to think about how we can leverage new digital solutions to benefit the 1 in 5 Canadians experiencing a mental illness or addiction problem in any given year. 2

Re-imagining MHA

1. https://www.cisco.com/c/dam/en_us/about/ac79/docs/innov/IoT_IBSG_0411FINAL.pdf.

2. https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics



LONG TERM CARE REHAB

IN-PATIENT CARE EMERGENCY CARE & CRISIS

SERVICES

Acute Care

Primary Care

Tertiary Care

Community Partners

COMPLEX SURGICAL INTERVENTIONS

SPECIALIZED CONSULTATIVE CARE

RESEARCH

REFERRAL CENTRES

Occasionally

Rarely

Very Rarely

COMMUNITY MENTAL HEALTH & ADDICTION

AGENCIES

EDUCATIONAL INSTITUTION

SOCIAL JUSTICE AND CHILD WELFARE

Frequently

WORKPLACE

Client Accessing Care from Home

Often

RETAIL CLINICS

Making the impossible possible in MHA

New service delivery models

A paradigm shift is needed in healthcare to improve accessibility and coordination. Systems must move from the traditional approach of building and organizing around providers to organizing around clients. This will mean looking beyond care boundaries and silo working, and organizations will have to look for new ways to create exceptional client experiences like we see in other industries around the globe.

The current mental health system can seem impossible to navigate given:

1. Information siloes leading to barriers in providing a truly integrated service delivery

2. The attempt to focus on mental health or substance use versus the needs of the individual who may live with both

3. The need for services go beyond traditional health services and into other supportive social services including housing

These gaps, amongst others that are discussed in the first Issue Brief of this three-part series, ultimately result in clients ‘falling through the cracks’. At the same time, these gaps also highlight

opportunities to rethink traditional models of care. In Canada, the current economic burden of mental illness is estimated at $51 billion per year, and includes costs related to health services utilization, short-term and long-term work loss, and decreased health-related quality of life. As described in the second issue brief, the investment in MHA might just be the best economic investment given the direct and indirect benefits to developing a strong, vibrant economy.

So, how do we make the impossible, possible? We reimagine a whole new way of bringing the pieces together –not only from a technological perspective, but through developing a truly integrated approach designed to do things differently to improve individual and health system outcomes.



The traditional MHA model uses the healthcare system as the first point of access, often requiring clients to travel to physical locations with restricted scheduling and potentially long wait lists. These services are also limited by a traditional mix of services in places where healthcare is traditionally delivered. As we reimagine MHA, it will be important to think differently about the traditional limitations of existing services and locations. Whether in community-based or acute care settings, these settings limit how we can create experiences for clients, family members and caregivers as they move through their personal challenges with MHA.

The figure above shows new service delivery models in which the client first accesses MHA services in their own “home,” which refers to anywhere a client frequents and feels comfortable in. In their home, the client can access care virtually, without the inconvenience of attending an appointment at a certain time in a certain place. For clients where virtual care will not suffice, the client’s point of access could be in the community (e.g. community centres, religious institutions), and their care should be closely tied to social services and primary care as needed. Community Partners can offer a coordinated and comprehensive set of services delivered across both traditional and new types of partnerships. For many clients who are able to manage well in the community, this may be the only service delivery model they need, especially as innovation brings care closer to home. Some clients who have higher intensity needs may need to occasionally access primary care, or in crisis, access acute care. Reliable acute care services should help deal with crisis and provide smooth, quick transitions to the relevant part of the system. For the small subset of the population who need higher intensity levels of care, they can access tertiary care for specialized MHA services.

The following section introduces a blueprint based on the concept of bringing care closer to the client to enable more efficient and effective use of healthcare resources while improving the client experience. The blueprint will further explore new funding and service ideas.



A blueprint for the redesign of the MHA system



Introducing the blueprint to a client-centered system design

Building on the components of the perfect MHA system in the second issue brief, we have constructed a blueprint (Figure 1) for a modern (digitally enabled), high performing mental health and addictions system that we believe can help healthcare system leaders, re-imagine the design of MHA service delivery across Canada. This blueprint introduces the foundation to build new ideas, incorporate new insights and implement new technologies to deliver comprehensive MHA services for Canadians.

Key drivers for change

Figure 2. Blueprint for re-imagining the MHA system

Blueprint A client-centered system design powered by digital.

Goals and ObjectivesCreate exceptional client experiences that enhances efficiency and effectiveness for healthcare providers and payers.

Ambition Set a bold ambition (e.g., eradicate wait times, reduce suicide rates, eliminate opioid deaths, etc.)

Innovation Policy and Funding Principles

Promoting Client-Centered Navigation

Building New Types of Partnerships

Leveraging the Digital Mental Health and Addictions Solutions Spectrum04

01 02 03

Artificial Reality (AR)/ Virtual Reality (VR)

Tele-medicine/Virtual care

Internet of Things (iOT)

Artificial Intelligence

Population Health

Analytics

Wearables Smart CitiesWeb-based / Mobile provider

solutions

Proven Tech Emerging Tech Forward-Looking

Personalized Care

Design around a specific population segment.

Seniors(over 65 years old)

Adults(18 to 64 years old)

Children and Youth

(0 to 18 years old)

Transitional Youth(16 to 24 years old)

Re-imaging the Future Mental Health & Addictions System

Lack of alternative health and culturally-grounded service options

Underutilized assets for families and caregivers

Disparities in rural communities Inconsistency in care and unclear outcomes



Blueprint for redesigning the MHA system

Each element introduces a component of the blueprint that will together help to create the right environment to enable new service delivery models.

1. Building New Types of Partnerships

Traditional approaches to MHA do not always meet client needs and/or expectations. There is often disconnect between client needs and the ways that services are offered, including existing models that are unable to service the volume of client demand.

This first component of the blueprint identifies the opportunity to consider which providers can best enable the desired outcomes. Existing MHA leaders play an important role in providing high quality, compassionate care for vulnerable populations, and we must consider how we can complement their work through new partnerships with including non-traditional partners.

Unconventional partnerships are already happening - for example, Hudson’s Bay Company and WE Charity are partnering to develop a mental health campaign, WE Well-Being, to empower young people across Canada to promote positive well-being within themselves and within their and communities. Together, they are collaborating to produce a limited-edition bracelet to build awareness and raise funds for WE Well-Being. Similarly, brands like Kate Spade and Bell have donated millions of dollars to mental health initiatives. How can these types of unconventional mental health partnerships bring more value to the MHA system?

These types of partnerships can contribute to building capacity for suicide prevention, creating more accessibility to crisis services using private partnerships and integrating the reduction of stigma directly into the foundations of unconventional forums. Non-traditional MHA system-wide partners such as start-ups, insurance companies, and retail could be woven into the fabric of a seamless system design to contribute to a holistic and cost-effective foundation for MHA services, bringing care right to the fingertips of the client.

Program Builder Tips: Consider where the natural environment of your targeted populations is and identify who has a trusted brand that can be marketed synonymously with MHA needs.

The following pages provide a breakdown of the elements of the blueprint:

Now Imagine...

If a well-known coffee shop chain partnered with community

service centres in hot spot, low income neighbourhoods where the proportion of people suffering from Mental Health or Addictions issues is high. Imagine a 19 year old with depression walking into a local coffee shop and as they are ordering their coffee on an electronic kiosk, finds out information about MHA services offered in their neighbourhood for the first time. He is able to sign up for a screening assessment which he can later complete on his phone and be directed to the service that best suits his needs.

As you read through the blueprint components below, a call-out box will share a 'Now Imagine' scenario to consider. Additionally, 'Program Builder Tips' are included for individuals who are designing and building new models of care.

!



2. Promoting Client-Centered NavigationClients, community and clinical service providers often have trouble navigating the complexity of which MHA service should be accessed, hours of operation, and who to contact to request an appointment. When even clinicians struggle to determine who to contact to refer a client to a service, navigation for the client can be close to impossible, especially if there are additional barriers (e.g. not speaking the same language).

The second component of the blueprint proposes developing central intake models, supporting clients and providers with a central up-to-date directory of services, and developing a standardized library/repository of tools for providers. Through standardizing the intake models and tools with best practices, we can help maximize resources for better client outcomes. While in practice, standardization is often agreed to, stakeholders often struggle with the change of adopting another method. How can we shift this mindset to be more receptive to developing better processes that positively impact the client experience?

Ultimately, making strides towards improving system navigation can immensely improve the client experience. Other industries have been offering this seamless experience for years (e.g. online hotel booking, flights, beauty services), and it is not unrealistic for this to be translated to the MHA system. System navigation and coordination could similarly be designed on data-driven insights and allow for client-centered navigation, ultimately improving the overall accessibility of care.

Program Builder Tips: Create a current state client pathway to understand how your clients are navigating the system now. Then, design a future state client pathway that addresses pain points in the process.

Now Imagine...

If there was a single source of truth, (such as a central mobile app)

to search for services nearby, view hours of operation, and/or contact the service directly. Even more, let’s imagine if based on data-driven insights, the app could recommend appropriate, personalized services based on a client’s individual needs before they even realized they needed to go searching for it. If we imagine a client who visits a methadone clinic regularly for witnessed ingestion, the app can map out the easiest path to the most convenient location with the lowest wait times with the various transit options presented in real time.



3. Innovative Policy and Funding PrinciplesAcross Canada, pockets of innovation exist which have proven successful in their communities. However, these types of solutions struggle to scale up across the broader MHA system, often due to restrictions in policy and funding backbone that limit their growth.

To foster a culture of innovation in the delivery of MHA services, key policy and funding principles should be considered, including:

– Integrated System Governance and Leadership: Reducing complexity of system governance by simplifying the layers in the MHA system and empowering leaders who are ready to make bold changes together

– Holistic Client Information: Promoting legislation that balances security and privacy with access to shared data and anonymized databases for secondary use purposes

– New Payment Models: Creating flexible payment structures that align incentives and allow funds to be directed to innovative, high-impact interventions and technologies (e.g. innovation grants, self-directed funding, social impact bonds, etc.)

– Continuous Improvement Principles to Manage Risk: Using rapid assessment evaluations instead of year-long studies to allow innovation to scale and manage risk.

– Workforce Development: Developing a workforce that can support the capacity demands of the MHA system

– Published quality indicators: Defining client satisfaction results and other performance indicators will help drive certain system-level behaviors

New policy initiatives such as Social Impact Bonds embody these principles and are one of the potential solutions to fuelling innovation in the MHA sector. Social Impact Bonds are social finance tools based on pay-for-performance contracting that enables government to work collaboratively with service providers and private investors.3

Innovative policies and new funding structures can create incentives to work towards designing the “perfect” MHA system that will push Canada to become a global leader in this space.

Program Builder Tips: Consider co-design principles when considering policy and funding changes. Ensure that the client voice is represented. Review global leading practices and innovations that have shown improvement in patient outcomes and let these inspire out-of-the-box thinking.

4. Leveraging the Digital Mental Health and Addictions Solutions SpectrumIf we reflect upon the way in which digital has been viewed as a method to drive advancements in the MHA sector, it has been largely underwhelming and without broader design considerations. Where discourse has centered on electronic health records and “cool apps”, delivering MHA services in a digital world requires a high functioning, integrated digital ecosystem which integrates a broader architectural design to data governance to enable a better client experience and improved outcomes. .

There are a spectrum of forward-thinking technologies that can be used to augment MHA care. As we move along the spectrum, there are increasingly better artificial intelligence-driven capabilities. These more forward thinking technologies provide a fully integrated view of the various technologies that will become more seamlessly integrated in day-to-day life. This will allow care to be accessible to a greater population, but also decrease the overhead costs of brick and mortar organizations, with these savings being reinvested to front line care.

Now Imagine...

if providers were incentivized to use new technology like Orbita which helps

organizations design, build, manage, and optimize artificial intelligence-driven voice and chatbot applications. Clients with dementia who experience a lack of social support may benefit from these solutions. Innovative policies can create flexible funding structures where clients diagnosed with dementia can have this AI-driven voice companion covered by insurance. This type of solution can help provide clients with emotional support, voice reminders to take medications, and story-telling functions to show improved patient outcomes.

3. https://www.ontario.ca/page/piloting-social-impact-bonds-ontario-development-path-and-lessons-learned



In the future, when technology is more seamlessly integrated into day-to-day life, smart cities will be able to consider elements such as lighting, sound, spatial design, as well as leverage population health analytics to predict trends and behaviour patterns to inform MHA services. How can we plan strategically so that these types of innovations have the right environment to be able to accelerate the MHA system exponentially?

Program Builder Tips: Think deeply about the root of the problem you are trying to solve, and consider not only the requirements needed to address the problem from a technology perspective, but also consider how technology may impact people and processes. Technology itself may not solve the problem, but it can act as an enabler for changes in people and processes to create new solutions.

Now imagine...

A client who experiences anxiety in crowds can use virtual or augmented reality to simulate anxiety-causing situations like a crowded subway or shopping mall. Now

imagine that as she ventures into one of these situations in real-life, the earphones she is wearing can detect the crowd and plays a CBT track to help her calm down. Then this data is leveraged to start to predict when she will have an anxiety attack even before she enters this environment and activates the appropriate strategies to help her with her treatment.

Artificial Reality (AR)/ Virtual Reality (VR)

Tele-medicine/Virtual care

Internet of Things (iOT)

Artificial Intelligence

Population Health

Analytics

Wearables Smart CitiesWeb-based / Mobile provider

solutions

Proven Tech Emerging Tech Forward-Looking

Personalized Care

― Web-based and mobile provider solutions: eCBT solutions that provide cognitive behavioural therapy (CBT) using mobile or web applications.

― Telehealth/virtual care: These technologies enable care to be provided remotely in which the client does not need to go to a physician location.

― Virtual reality (VR): Leading Canadian hospitals are starting to use virtual reality to improve pre-operation anxiety and reduce stress.

― Artificial reality (AR): AR products already exist to show clients with addiction augmented images of their addiction to trigger a more realistic sensation of craving to create more powerful therapy sessions. 4

― Wearables: Smart electronic devices worn on the body allow users to collect their own data. New emerging technology such as wireless emotion sensors are fueled by artificial emotional intelligence and can read and analyze not only skin conductance, breathing and heart rate but also eye movements, facial expressions, changes in voice.

― Internet of things (iOT): Devices embedded in everyday objects allowing them to connect to the internet to send and receive data. iOT can be used for data collection to support personalized medicine.

― Artificial intelligence: Computerprograms that can learn without being explicitly programmed. New emotion detection technologies can be used to capture emotional reactions to certain data and facts analyze situations accordingly and come up with appropriate recommendations.

― Personalized care: Using healthcare data that includes genetics, genomics and other biologic information to help predict risk for disease or how a client will respond to treatment.

― Population health analytics: Extract information from large datasets to predict trends and behavior patterns

― Smart cities: Using information and communication technologies to improve the quality of government services and citizen wellness

Digital Mental Health & Addictions Solutions Spectrum



Bringing the model to life



How can this blueprint be brought to life?

Experience tells us that a “one-size-fits-all” approach is not effective in creating high performing health systems. Yet, a fragmented approach that attempts to serve a narrow population may create silos and duplication, making it exponentially more difficult to navigate the system.

Below, we consider how the blueprint can aid policymakers and health system leaders in building high performing MHA systems by balancing the needs of individual clients, families and caregivers with the needs of a larger population. While there are certainly a number of system challenges, our exemplar begins with the following problem statement: how do we improve access to crisis services?

Note in reality, the complexity of this planning is even more of a challenge because there are many more than this example population to consider.

Re-imaging the Future Mental Health & Addictions System

Innovation Policy and Funding Principles

― Fully supporting the needs of clients with chronic depression requires tackling difficult challenges. Thus, new policy initiatives will need to address the current policy and funding restrictions in order to foster a culture of innovation. Embedding the right funding incentives in the sector (e.g., pay-for-performance social finance tools) could enable more service providers to work collaboratively towards the right outcomes.

Promoting Client Centered Navigation

― With multiple providers in the system, clients with chronic depression may find it overwhelming to navigate through too many points of access. As a result, clients are getting lost in transitions of care in a system that is difficult to navigate. By creating a single directory of all mental health and addictions services and a central intake and coordinated access model (e.g., via a mobile app), clients will have better connection to the services they need the most.

Building New Types of Partnerships

― Clients with chronic depression may have poor access to transportation which could lead to social isolation, anxiety and missing important appointments; as a result, symptoms may get aggravated. By building a partnership with a leading on-demand transportation app, clients can have access to convenient and free roundtrip rides to therapy, psychiatry, and medication management appointments; clients will no longer have to miss out on the help they need because of transportation issues.

01 02 03

Leveraging the Digital Mental Health and Addictions Solutions Spectrum04

Population Segment: Chronic Depression in Transitional YouthCurrent Challenges for this population― Clients may be managing well for months or years on

end and may not require regular attention from healthcare professionals, and by the time the client, their family members or caregivers identify the need to seek help, they are not able to easily identify or access the right services which could result in a crisis or use of expensive acute care resources.

“The Individual”Ahmed, 19 years old, university student in his first year. He has begun feeling extremely lethargic and is starting to lose interest in daily activities.

“The Population”This subset of the population suffers from depression and if not treated, increases the risk of suicide. One of the challenges in managing this population is to understand and be able to respond to early warning signs that might be a predictor of an episode of depression.

― Innovative technology solutions have a lot of potential for clients with chronic depression and MHA providers alike. Throughout the solutions spectrum, these technologies can provide improvements across the continuum of care from the point of identifying early signs of an episode of depression to therapy treatment, monitoring of symptoms, and recovery. Developing solutions such as AI-driven analytics provide the ability to alerts providers and family members when there appears to be change in regular habits or behaviors, especially for client with chronic depression. Another solution is access to an integrated virtual Mental Health team who are reachable via text or video for consultations as required anywhere anytime while providing a level of outreach through remote monitoring.



Final thoughts...

The blueprint is meant to inspire and stimulate new ideas for what could be possible in a mature state MHA system. Moving small pieces is no longer enough to transform our current system –it is time to push for large scale change. In the existing Canadian MHA system, there are pockets of innovation, but they lack the system-wide scale needed to augment change. In order to truly set the conditions for success, we suggest that MHA leaders across Canada focus on the following five considerations:

– Define the Problem: Define the problems we want to tackle and truly understand them – what is the problem? Who is it a problem for? What specifically is not working today?

– Be Digital: Build a platform that embeds the digital tools (and ultimately data) to drive new ways of working and engage with an ecosystem of innovators who are motivated to build the next generation of MHA solutions.

– Measure what you want to change: If we define the right performance measure and are transparent about expected performance against those measures, we will create a focus on solutions that help drive towards achieving a defined set of outcomes.

– Redesign the System: Simplify the system for clients and families. Bring a design-thinking approach to system design. If structure is impeding our ability to achieve better quality and experience at a lower cost, simplify the structure.

– Create a Movement: Set the conditions for success and incent the market to adopt business models that provide better outcomes. MHA stakeholders of all types – rather than government alone – have a role to play to create a broader movement to create best in class systems for Canadians living with MHA challenges.

We challenge you to re-imagine the MHA system, let’s do this.

The call to action





The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the particular situation.

© 2019 KPMG LLP, a Canadian limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. 20893 / 24954

The KPMG name and logo are registered trademarks or trademarks of KPMG International.

kpmg.com/ca/MHA

Aaron BerkPartnerHealthcare AdvisoryT: 416-777-3217E: [email protected]

Vivian DemianExecutive Director Healthcare AdvisoryT: 416-777-8555E: [email protected]

Douna Al SayyariSenior Consultant Healthcare Advisory T: 647-777-5177E: [email protected]

Contact us

http://kpmg.com/ca/MHA

https://twitter.com/KPMG_Canada

https://www.linkedin.com/company/kpmg-canada

https://www.youtube.com/user/KPMGCanada

http://www.google.com/+KpmgCa

Documents

Putting the pieces oget ther...2. A blueprint to consider for the redesign of the MHA system and a practical example to illustrate its application. 3. How to set the conditions for