Systems Improvement through Service Collaboratives(SISC)

Brian Rush, PhD(on behalf of the Performance Measurement & Implementation Research Team)

Centre for Addiction & Mental HealthOntario, Canada

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Outline• Background and Context

• Ontario• CAMH• Systems Improvement through Service Collaboratives (SISC)

Initiative

• Implementation Framework • Background • Adaptation of the National Implementation Research Network

(NIRN) Active Implementation Framework to SISC

• Balancing between Science & Pragmatism • Implementation research dilemmas

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Ontario, you say?

Source: http://www.fmcsa.dot.gov/intl-programs/canada/index.htm

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Ontario, you say?

What Ontario is…

What Ontario isn’t…

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Ontario: Population density

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What is CAMH?The Centre for Addiction and Mental Health (CAMH) is Canada's largest mental health and addiction teaching hospital, as well as one of the world's leading research centres in the area of addiction and mental health.

CAMH combines clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues.

CAMH has been recognized internationally as a Pan American Health Organization and World Health Organization Collaborating.

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Background: Open Minds, Healthy Minds

• CAMH has been asked by the province of Ontario to lead several key provincial activities which are now underway as part of Open Minds, Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strategy.

• The Strategy begins with a three-year-plan that focuses on children and youth.

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Starting with Child and Youth Mental Health Our Vision: An Ontario in which children and youth mental health is recognized as a key determinant of overall health and well-being, and where children and youth reach their

full potential.Provide fast access to high quality

serviceKids and families will know where to go to get what they need and services will be available to respond

in a timely way.

Identify and intervene in kids’ mental health needs early

Professionals in community-based child and youth mental health agencies and teachers will learn how to

identify and respond to the mental health needs of kids.

Close critical service gaps for vulnerable kids, kids in key transitions, and those in

remote communitiesKids will receive the type of specialized service they need

and it will be culturally appropriate

TH

EM

ES

IND

ICA

TO

RS • Reduced child and youth suicides/suicide

attempts

• Educational progress (EQAO)

• Fewer school suspensions and/or expulsions

• Decrease in severity of mental health issues through treatment

• Decrease in inpatient admission rates for child and youth mental health

• Higher graduation rates

• More professionals trained to identify kids’ mental health needs

• Higher parent satisfaction in services received

• Fewer hospital (ER) admissions and readmissions for child and youth mental health

• Reduced Wait Times

Ontario’s Comprehensive Mental Health and Addictions Strategy OVERVIEW OF THE THREE YEAR PLAN

Provide designated mental health workers in schools

Implement Working Together for Kids’ Mental

Health

Hire Nurse Practitioners for eating disorders program

Improve service coordination for high needs

kids, youth and families

INIT

IAT

IVE

S

Implement standardized tools for outcomes and

needs assessment

Amend education curriculum to cover mental health promotion and address

stigma

Develop K-12 resource guide for educators

Implement school mental health ASSIST program and

mental health literacy provincially

Enhance and expand Telepsychiatry model and

services

Provide support at key transition points

Hire new Aboriginal workers Implement Aboriginal Mental

Health Worker Training Program

Create 18 service collaboratives

Expand inpatient/outpatient services for child and youth

eating disorders

Reduce wait times for service, revise service contracting, standards, and reporting

Funding to increase supply of child and youth mental

health professionals

Improve public access to service information

Pilot Family Support Navigator model

Y1 pilot

Increase Youth Mental Health Court Workers

Provide nurses in schools to support mental health services

Implement Mental Health Leaders in selected School

Boards

Outcomes, indicators and development of scorecard

Strategy Evaluation

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“Create 18 Service Collaboratives”

Systems Improvement through Service Collaboratives (SISC) is one initiative encompassed within the Comprehensive Strategy. 18 Service Collaboratives established across Ontario will focus on addressing system gaps related to mental health and addictions services.

SISC’s GoalTo support local systems to improve coordination of and enhance access to mental health and addiction services.

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Which Ministries are involved?

The Centre for Addiction and Mental Health (CAMH) is working with six provincial ministries to ensure the Service Collaboratives’ success. They are:

• Ministry of Health and Long-Term Care;• Ministry of Children and Youth Services;• Ministry of Education;• Ministry of Training, College and Universities;• Ministry of the Attorney General, and;• Ministry of Community Safety and Correctional

Services.

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Advisory and Accountability Structures

Systems Improvement

through Service

Collaboratives (SISC)

Project Sponsor:

CAMH

Ministry of Health and Long-Term Care

Service User Expert PanelProvincial Collaborative

Advisory Group

Scientific Expert Panel

Related Services and Stakeholders

Provincial Government Oversight Committee

Advice and

Communication

Accountability

Communication

Advice, Communication and Approvals

Communication

Other Expert Panels

Minimum Specifications

• Focus on improving transitions• Multi-sector partnerships• Use of Implementation Science & Quality Improvement

tools• Focus on Equity• Evaluation

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What is a Service Collaborative?

Statement of Purpose

Service Collaboratives will bring together service providers and other stakeholders from various sectors that interact with people who have mental health and/or addictions problems, in particular children and youth agencies, justice programs, health providers, and education organizations. By working together to identify and implement system level changes, the Collaboratives will improve individuals’ ability to access services, their service experience, and their health outcomes.

(Government of Ontario, 2011)

A group of local service providers who work together to improve access to and coordination of mental health and/or addiction services.

• Membership in Collaboratives reflects the cross section of sectors that provide service to children and youth with complex needs.

• 14 Service Collaboratives are geographically based, and 4 focus on transitions between the health and justice systems.

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Key Transition Points

E.g. Clients transitioning from inpatient to community based services.

E.g. An individual with mental health and/or addiction issues moving between health and justice services.

E.g. Youth transitioning to adult services.

Health Justice System

Child Services

Adult Services

Hospital Community Services

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Community-ledService

Collaborative

Service Users

Children & youth

services

Mental health and addictions

Justice Programs

Communityservices

Hospital services

Culture-specificservices

Family health

care centres

Educational institutions

Who is participating?

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Service Collaborative Rollout

4 demonstration sites have been established (Cluster 1).

8 Service Collaboratives

(6 geographic and

2 justice + health)(Cluster 2).

The Strategy’s First 3 Years – Children & Youth

2011-2012 2012-2013 2013-2014

6 Service Collaboratives (4 geographic and 2 justice +

health) (Cluster 3).

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Service Collaborative Locations (to date)

Thunder Bay

London

Simcoe/Muskoka

Ottawa

Cluster 1 2011/2012

Champlain (J)

Cluster 2 2012/2013

Hamilton

Kingston, Frontenac, Lennox & Addington

Waterloo/Wellington Peel

DurhamToronto (J)

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Implementation FrameworkImplementation

• A specified set of purposeful activities at the practice, program, and system level designed to put into place a program or intervention of known dimensions with fidelity.

• A “make it happen” process, as opposed to diffusion or dissemination, which can be more passive in nature (Greenhalgh, Robert, Macfarlane, Bate, and Kyriakidou, 2004).

Implementation Science• The study of the methods to implement research findings (i.e. evidence-based

research) into routine practice to ultimately improve client outcomes;

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Adaptation of the National Implementation Research Network (NIRN) Active Implementation Framework to SISC

1. Implementation Stages – SC sites phased in by 3 clusters- Exploration- Installation- Initial Implementation - Full Implementation

2. Implementation Teams - Central and regional resources

3. Implementation Cycles - QI tools (i.e. PDSA and practice-policy communication loop)

4. Implementation Drivers – - a) Leadership; - b) Competency; - c) Organization (e.g. program evaluation / decision support data systems).

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Implementation Science in a Community Development Context

Science

Pragmatism

Where we land depends on the issue, stakeholder

perspective and perceived costs and benefits

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Balancing between Science & Pragmatism• Developmental evaluation (Patton, 2011) has

been applied from the beginning of the SISC initiative and aligned with the implementation stages. – Seeks to balance the gold standards of

evaluation practice, policymaking and implementation science with the realities of community development

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• Health equity • Key transitions• Partnership/collaboration • Implementation progress• Intervention outcomes

Performance Measures Provincial

Level

• Strengths, Weaknesses, Opportunities, Threats (SWOT)

• Semi-annual

Internal Interim

Assessments

• In-depth analysis to understand the factors associated with the implementation of the Service Collaboratives and their impact.

• 4 sites

Case Studies of Selected

Service Collaboratives

SISC Evaluation Plan

Performance Measures – Local level

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Local Evaluation

• Logic model / Evaluation Framework / Contribution Analysis – Linking activities, processes and outcomes

• Evaluation Plans with Key Principles– Distinction between process and outcome objectives – Stakeholder-based – Consistent with developmental evaluation

• Local indicators developed after decision on interventions

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• Meeting provincial expectations while supporting community development process- Intervention + context = outcome- NOT a linear process

• Developmental Evaluation- Evaluation is part of the development of SISC, not above or

outside of it

• Time constraints- Timeline for SISC program development, including for PMIR (e.g.

hiring Regional Evaluation Coordinators) - Timeline for intervention and short to medium term outcomes –

what is measurable and when?

Evaluation Challenges I

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• Holding space for Implementation Science - Tremendous opportunity but needs time and resources

• ‘Levels of evidence’ – Implementation Science for EBPs compared to reality of lack of evidence

• Moving timelines – Challenges with fidelity to stages with moving timelines

(community reality)

• Data sharing - Sharing of client info, confidentiality, legal issues…etc

Evaluation Challenges II

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Balancing between Science & Pragmatism

Science

Pragmatism

Not an easy balancing act but it’s exciting and we

don’t think we’re alone!

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About SISC- The Strategy- FAQ- Who we are- Implementation Framework

News & Resources

- Project Updates- Upcoming Events - Resources- Newsletters

Service Collaborative Communities

- Map of active Service Collaboratives

- A page for each Collaborative

ServiceCollaboratives.ca

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For more information about the Systems Improvement through Service Collaboratives (SISC) initiative, contact:

Brian Rush Director, Performance Measurement and Implementation Research Team Provincial System Support Program (PSSP) CAMH brian.rush@camh.ca

Fiona Thomas Research Coordinator, Performance Measurement and Implementation Research Team Provincial System Support Program (PSSP) CAMH fiona.thomas@camh.ca

Appendix: Cluster 1 Gaps & Interventions

System Gap Intervention

London Continuity of care for children and youth with complex needs during transitions between services and/or sectors.

The intervention is informed by:•The Transitional Discharge Model•The Emergency Department Clinical Pathways for Children and Youth

Thunder Bay

Community linkages that increase access to care and supports for Dennis Franklin Cromarty (DFC) High School students, and a service delivery plan that coordinates access of services for youth at DFC.

The Fostering School, Family, and Community Involvement: Effective Strategies for Creating Safer Schools and Communities model (Adelman and Taylor, 2002) to bring together the family, community, and school to improve the student’s chance of success.

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System Gap Intervention

Ottawa Access to services for transition aged youth (14-24) that are coordinated, youth-centred, timely, consistent, effective and evidence-based, least intrusive, innovative and community driven.

The implementation of a formalized care plan including critical components:1.Formalized Care Plan2.Interagency and Cross sectoral Collaboration‐3.Meaningful Priority Population Involvement4.Meaningful Child and Youth Involvement5.Meaningful Family and Supporter Involvement

Simcoe/Muskoka

Youth with mental health and/or addiction concerns transitioning between youth services (e.g., community services, justice and education) and Emergency Department and Hospital mental health services.

The Transition to Independence Process (TIP) model to:•Engage youth in their own future planning process;•Provide youth with services and supports that are developmentally appropriate, non stigmatizing, ‐culturally competent, and appealing;•Involve youth, their families, and other informal key players.

Appendix: Cluster 1 Gaps & Interventions

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