Recommendation Accountability Response and Action Leads: Regional Emergency Department Head (Dr. Eric Grafstein) and Mental Health Physician Program Director/Department Head Psychiatry, Providence Health Care (Dr. Maria Corral) Recommendation 1: All patients brought into St. Paul s Hospital under a Form 4 Mental Health Act certificate should receive a psychiatric assessment. Those patients brought in under Section 28 of the Mental Health Act should be held long enough to complete an appropriate assessment and arrange disposition and have, when indicated, a psychiatric consultation. Although this recommendation is focused on St. Paul s Hospital and Providence Health Care the development of solutions and their subsequent implementation will be completed across the Vancouver Coastal Health Region. This recommendation will be brought to the Emergency/Mental Health Improvement Committee at St. Paul s Hospital. The details of this implementation will be further discussed at the committee taking into account a number of points highlighted in the body of the report. The recommendation that all patients brought into St. Paul s Hospital under a Form 4 Mental Health Act certificate receive a psychiatric assessment will be addressed at the Emergency Department (ED) and council level and the Department of Psychiatry and MHA program, and will take in consideration best practices regionally, provincially and nationally. Regional consultation and collaboration will be sought in order to ensure that protocols for the assessment of patients brought in under Section 28 of the Mental Health Act are consistent within the region. The assessment of risk remains a largely a clinical one within the acute care setting. While a number of risk assessment tools, such as the COVR or HCR 20 have been studied extensively in the forensic psychiatric 1
Recommendation 2: The following resources should be implemented and accessible to St. Paul s Hospital: a) An evaluation of the current 4 bed secure observation unit within the ED that includes ascertainment of appropriate number of beds (more than 4) and adequate multi disciplinary staffing. These beds would fulfill the function of a Crisis Stabilization Unit. b) The secure observation unit in the ED should be managed and overseen by Psychiatry (in close collaboration with the ED to ensure efficient use of resources) so that the individuals with expertise are front line in the assessment and management of complex psychiatric patients. c) An enhanced capacity of a low barrier rapid access clinic (Urgent Care Clinic) with outreach into the community that can support the immediate follow up of patients discharged from the ED. Leads: Mental Health Program Director, PHC (Jennifer Duff), Mental Health Physician Program Director/Department Head Psychiatry, PHC (Dr. Maria Corral), Program Director Acute and Access Services, PHC (Miriam Stewart) and Emergency Physician Program Director, PHC (Dr. Dan Kalla) Reporting to: Regional Mental Health and Addictions Council (RMHAC) setting, they have not been validated in the emergency setting. The HCR 20 contains a specific risk management component that rates five items. These items, namely, feasibility of discharge plans, exposure to destabilizers, lack of personal support, non compliance and stress will be considered in the context of assessment and when considering discharge planning in high risk individuals. This recommendation is accepted and will be addressed in conjunction with recommendation 5 and 6. The response and actions to recommendations 2, 5 and 6 need to focus on the broad continuum of services that reaches both upstream and downstream from those recommended under recommendation 2. There is a need to look at the alignment of resources across the continuum and determine how we may be able to better utilize the resources to match capacity with demand of those served. There are already structures and roles in place to support this: for example, the creation of the Regional Mental Health Program and the formation of the Regional Administrative and Physician Director roles promote greater system wide planning and coordination of services. Actions will require both internal work within PHC/St. Paul s Hospital as well as extensive regional work in order to implement these recommendations given the need for standardization of practice across the region. a & b) As an initial step, the issue of evaluation of the 4 2
d) A dedicated ACT or similar team (i.e. Acute Home Based Treatment) to follow frequent and persistent patients at highest risk for readmission to the ED and to inpatient care; e) Access to ambulatory mental health and addiction services and supports for individuals who do not require the intensity of services delivered by ACT (e.g. case management programs) beyond that provided by APAC. bed secure observation unit will be addressed at the Emergency/Mental Health Improvement Committee at St. Paul s Hospital. c) The Department of Psychiatry and Mental Health Program are involved in a number of initiatives to improve access to urgent psychiatric assessments and which will support the discharge of patients from the ED. Specifically, funding has been applied for to support a full time Social Worker and Nurse Practitioner Emergency Psychiatry. The availability of a dedicated psychiatric social worker in the ED will be crucial in the ability to engage in efficient discharge planning. Additionally, a redesign of the Outpatient Psychiatric clinic is underway that will enhance capacity for urgent referrals via the Acute Psychiatry Assessment Clinic (APAC). Emergency Psychiatric Nurse Leaders are now able to directly refer to APAC. The impact of this practice on resources will be assessed on a monthly basis for the next 3 months. Based on the results, consideration will then be given for Emergency and Community Physicians to access APAC directly for urgent assessments. d and e) St. Paul s is already able to access a regional Acute Home Based treatment program which increases the options for patient and family disposition after assessment. More regional work will be undertaken to standardize access to ACT Teams. The feasibility of a dedicated ACT Team for St. Paul s will require discussion at the Regional level. 3
A considerable amount of work is already being done within the Region to understand the gaps in services that are barriers to the provision of services across a continuum of care for our patients. It will be important to ensure that St. Paul s is involved in these discussions with Vancouver Community Mental Health and Addictions Services given its prominent role in the care of this at risk population. In addition to the foregoing, it is the view of the steering committee that there needs to be greater standardization and clarity around criteria for accessing Community Mental Health Team services and forensic services in relation to providing services to this population. Recommendation 3: Given the increased volume of clients taken to St. Paul s Emergency for psychiatric assessment, there needs to be clearer means of communicating with the many involved community agencies. Specifically, there should be an identified contact person in the ED or Department of Psychiatry to manage information received from outside agencies and to inform other treatment staff regarding decisions affecting admission and discharge. Leads: Mental Health Program Director, PHC (Jennifer Duff), Mental Health Physician Program Director/Department Head Psychiatry, Providence Health Care (Dr. Maria Corral) This recommendation is accepted and will be implemented. Although this recommendation is focused on St. Paul s Hospital and Providence Health Care the development of solutions and their subsequent implementation will be completed across the Vancouver Coastal Health Region. Some of the work involved in implementing this change has already begun. There have been numerous discussions at the Emergency/Mental Health Improvement Committee at St. Paul s regarding the need to consistently fill the Psychiatric Clinical Nurse Leader (CNL) position. This person should be the identified contact person with which community 4
agencies communicate around the clock, in addition to acting as a contact point for families for collateral information gathering as well as discharge planning. The addition of a nurse practitioner role would also serve to enhance communication with outside agencies, as the NP would also be involved in liaising with the community in order to ensure continuity of care. Within the Department of Psychiatry, the recent assignment of a dedicated cadre of psychiatrists to cover Psychiatry Emergency has enhanced and streamlined communication within the hospital (with EPs) and outside agencies (Community Mental Health Teams). A focus on communication at points of transition is a key priority. Recommendation 4: The Mental Health Act allows for extended leave, which allows patients to reside in the community providing they adhere to certain conditions such as treatment. The appropriate use of this extended leave provision should be clarified and optimized to facilitate clinical outcomes, and an educational program about this provision should be undertaken with patient and family involvement. Leads: Regional Director, Mental Health & Addiction Program (Yasmin Jetha) and Regional Dept Head, Mental Health & Addiction Program (Dr. Lakshmi Yatham) A review of existing protocols related to communication and transfer of care between Mental health emergency services, mental health team and addiction teams and emergency department/acute care will be reviewed to ensure a standard protocol and practice is adopted across the region. This recommendation is accepted. The extended leave provision within the mental health act is utilized to optimize clinical outcomes. To that end, along with Mental Health Act education sessions that have been implemented across the health authority, the regional program will incorporate education related to the use of the extended leave provision as part of ongoing education provided to our clinical teams. 5
Additionally, as noted in the review, consumer and family engagement and education is an important aspect of care provision. Accordingly, the regional program will also work with our consumer and family advisory groups across the health authority to provide education and discussion sessions related to the mental health act and the extend leave provision. Recommendation 5: Regular access and flow into and out of the Burnaby Centre as a component of a fully integrated system for the complex concurrent disorder population should be streamlined and expedited. Recommendation 6: System integration must include, in addition to the Burnaby Centre, Mental Health and Addiction teams, ACT teams and other low barrier case management teams. Leads: Operational Director, Burnaby Center (Laura Case) and Medical Director Burnaby Centre ( Soma Ganesan ) Reporting to: Regional Mental Health and Addictions Council (RMHAC) Leads: Regional Director, Mental Health & Addiction Program (Yasmin Jetha) and Executive Director, Vancouver (Joanne Bezzubetz) This recommendation is accepted and will be addressed in conjunction with recommendation 2 and 6. The response and actions to recommendations 2, 5 and 6 needs to focus on the broad continuum of services that reaches both upstream and downstream to include the services provided within the Burnaby Centre. Over the past year, the Burnaby Center has been better integrated within VCH. The intake process has been integrated within a centralized structure and a lean process has been used to redesign the referral and flow process. The result has been increased utilization and flow of VCH residents. As part of a continuous quality improvement process, the referrals and utilization is continually monitored to ensure timely access. This recommendation is accepted and will be addressed in conjunction with recommendation 2 and 5. The response and actions to recommendations 2, 5 and 6 needs to focus on the broad continuum of services that reaches both upstream and downstream encompassing those services recommended here. An integrated, coordinated, and accessible healthcare 6
delivery system across primary, secondary and tertiary services is a priority for VCH. As a result, VCH has created the regional program structure to enable planning across the health authority and to support system and clinical integration. Over the last year, VCH has developed a regional centralized access and discharge process inclusive of all tertiary programs for mental health and addiction. The Burnaby Center access has now been integrated as part of this process. VCH is continuing to develop its tertiary capacity as well as collaborating with the divisions of family practice to identify joint initiatives to support the mental health and addiction needs of clients within the primary care setting. Recommendation 7: Collaborative task groups comprising key providers in the health related sectors (justice, corrections, housing) should be established. These should be structured with clear terms of reference and meet regularly. Their initial development should be supported by professional facilitation. Leads: Co Chairs of Project Link Committee from VPD (Inspector Ralph Pauw) and VCH ( Joanne Bezzubetz) and/or MHAP and RESC leads The mental health and addiction services are engaged in processes to ensure timely, low barrier services are provided to clients. The includes mobile intensive wrap around services like the primary care outreach team, Assertive Community Treatment, and reviewing ambulatory programs. This recommendation is accepted and will be addressed in conjunction with recommendations 11, 15, 16, 17 and 19. There is currently an opportunity to streamline the work involved within this grouping of recommendations under the already existing Project Link Structure. Project Link which is the coordinated group of VPD, ACT and VCH that meets on a regular basis with the mandate to 7
review and solve issues arising between the parties and engage with relevant stakeholders who extend beyond this group to create more efficient and effective problem solving. Terms of reference and membership will have to be adjusted to accommodate this. Alternatively, a new multi sectoral coordinated Task Group will be formed to undertake all or part of this initiative, while ensuring full alignment with Project Link. Recommendation 8: Information management system development should proceed as soon as reasonably possible and a task group should be established involving all relevant stakeholders to promote alignment of information systems. Recommendation 9: A process should be undertaken to clarify the consistent use principle of the Freedom of Information and Protection of Privacy Act and to develop protocols for consistent application of this principle. It should include education on privacy issues, consistent use, and education on the requirements of 2 way flow of Leads: Vice President, Clinical and Systems Transformation VCH/PHC (Susan Wannamaker), Regional Emergency Department Head (Dr. Eric Grafstein) and Regional Department Head, Mental Health and Addiction Program (Dr. Lakshmi Yatham) Lead: Regional Mental Health Program Director (Yasmin Jetha) This recommendation is accepted. VCH, PHC and PHSA are embarked on a process that will see the implementation of a region wide Cerner electronic medical record and information system. This is rolling out over the next three to five years and will engage all regional programs and departments in clinical systems transformation. The Regional Emergency Services Council and the Regional Mental Health and Addictions Program will be fully engaged in this project to ensure that the information management system meets the needs of all MHA clients. addressed together with recommendations 18, 20, 21 and 22. An Inter sectoral Collaboration and Information Sharing Working Group needs to be coordinated to address these recommendations. Key members of this group 8
information (family to caregiver, and caregiver to family). would include but not limited to Legal Counsel at PHC and VCH, the Vancouver Police Department (VPD), patient/family representatives, and members of RESC and RMHAC. The mandate of this group will be to clarify the consistent use principles of the Freedom of Information and Protection of Privacy Act, as well as other legal authorities for sharing information, to develop protocols for consistent application of these principles and to conduct education sessions with patients/families, care providers and other sectors (i.e. VPD) to ensure that the correct information can be shared with the right people at the right time and reduce misinformation. Both VCH and PHC have policies and guidelines around disclosure of information to law enforcement and family members. We also have in place a privacy education program addressing these issues. However, we recognize the need to make this information more accessible and user friendly so that front line staff are familiar with our policies and have appropriate guidance on hand when they need it. Recommendation 10: The Steering Committee should establish an implementation and accountability framework to address the identified themes and recommendations (see figure 2). Lead: Vice President, Regional Programs and Service Integration VCH ( Jeff Coleman) and President and CEO PHC (Dianne Doyle) We accept this recommendation but will modify the framework provided in figure 2 to better reflect the key stakeholders currently engaged in this work and the approach being taken to address the recommendations. 9
The membership of the current Executive (and intersectoral) Steering Committee who led this review process will be reviewed to ensure that we have adequate representation from relevant sectors involved in addressing the recommendations from the external review and providing direction to the working groups. Terms of Reference will be drafted to guide the work of this group. This group currently has representation from Forensics, Community Court, VCH, PHC, VPD, Patient/Family representation, the Ministry of Health. Task Groups formed for the purposes of addressing recommendations and existing groups accountable for recommendations will report to the Executive Steering Committee to ensure that recommendations are addressed in a timely way. Recommendation 11: A task group should be established involving all relevant stakeholders to identify opportunities for enhancing coordination and integration of services and to develop and implement strategies for achieving this goal. This may include: a) development of consistent standards for discharge planning and coordination of care at points of transition and handoff, b) exploration of opportunities for cross appointments between organizations c) exploration of a central access model for individuals with concurrent disorders. addressed in conjunction with recommendation 7, 15, 16, 17 and 19. 10
Recommendation 12: The Vancouver General Hospital, St. Paul s Hospital and the Department of Family Medicine should continue to explore promising practices in other jurisdictions to organize care with community partners to better serve the concurrent disorders population. Leads: Regional Director, Mental Health & Addiction Program (Yasmin Jetha), Executive Director, Community Health Services Vancouver (Joanne Bezzubetz), Executive Director, Primary Care (Carole Gillam) This recommendation is accepted and there already exist a number of early strategies to better organize care as between primary care providers, clinics, community services, Mental Health & Addictions and the Emergency Departments. For example, Rapid Access Consultative Expertise program (RACE) has been developed to provide real time tele health support to primary care physicians in their office. The program enables family physicians to consult with specialists such as psychiatrists for emergent matters including medication prescription, guidance and advice regarding assessment, management and treatment. VCH has developed a primary care outreach team that supports mobile primary care, mental health and addiction services within the downtown eastside for clients that are vulnerable and do not access traditional health services. This team also works with St Paul s and VGH emergency departments to identify clients that require outreach support. VCH is also supporting our primary care clinics to provide coordinated and comprehensive services through the integration of mental health and addiction services at our primary care sites. Recommendation 13: Expand on the integration of the Vancouver Police Department with the health Lead: Regional Director, Mental Health & Addiction Program These recommendations are accepted. 11
care sector as is occurring with ACT teams. Recommendation 14: Include police representation on the existing ED committee. Recommendation 15: The VPD & Vancouver Mental Health and Addictions Collaborative should work to have a clearly articulated and timely dispute resolution protocol between the police department and EDs to handle differences arising from the management of patients apprehended under the Mental Health Act. Recommendation 16: There is a need for formal and informal venues for medical, legal, mental health, police and social support staff working in different agencies to meet and clarify roles, expectations and working relationships. It is recommended that such meetings should be organized through the task group on coordination. Given that there will be inevitable staff changes over time, these meetings need to be scheduled on a regular basis. Recommendation 17: Establish formal contact between liaison staff at Community Court and a designated contact person in St. Paul s Hospital (Yasmin Jetha), VPD (Inspector Ralph Pauw), Regional Medical Director, Mental Health & Addiction Program and Regional Department Head, Department of Psychiatry (Lakshmi Yatham) There are currently two committees that integrate VPD with Vancouver health sector teams: the SPH ED/MH Committee and the VCH MH Committee. However, these address site specific issues only. To support better regional sharing and planning, a joint VPD/SPH/VCH forum will be established. We will also pursue stronger linkages between the established ACT teams and SPH clinicians. addressed in conjunction with recommendation 7, 11, 16, 17 and 19. addressed in conjunction with recommendation 7, 15, 16, 17 and 19. addressed in conjunction with recommendation 7, 11, 15, 16 and 19. 12
Department of Psychiatry or Department of Emergency Medicine to review people sent from jail or the Mental Health Program through Community Court. Recommendation 18: It is recommended that legal counsel clarify privacy issues as part of the task group on FIPPA and consistent use provisions. Written guidelines regarding release of information should be available in the ED, Department of Psychiatry and the VPD as part of standard procedure to provide trainees and staff with ready access to relevant policies and procedures. Recommendation 19: There is a need for clarification of the roles and responsibilities of ED and Department of Psychiatry staff in decisions involving discharging clients sent in by community mental health agencies and communicating with those agencies especially outside of business hours. It is recommended that the task force on coordination organize this process. Recommendation 20: Provide education about permissions and restrictions that privacy legislation enables regarding communicating information between family members and the health care sector. Recommendation 21: Provide education that information can be released for continuity of care addressed with recommendations 9, 20, 21 and 22. addressed in conjunction with recommendation 7, 11, 15, 16, and 17. There is also a need to clarify what can be communicated to patient and family members and this will be addressed with recommendations 9, 20, 21 and 22. addressed with recommendations 9, 18, 21 and 22. addressed with recommendations 9, 18, 20 and 22. 13
and there is no legislation that prevents receiving information from families and others Recommendation 22: A process/protocol should be developed to ensure that the patient and family voice is included in the care delivery process. Education to ensure staff and care providers are open to engaging patient and family participation is required. addressed with recommendations 9, 18, 20 and 21. 14