Mental Health and Substance Use Strategic and Operational Priorities 2015 2020 Achieving optimal mental wellness for all October 2014
CONTENTS ACKNOWLEDGEMENTS... iii EXECUTIVE SUMMARY...iv INTRODUCTION... 1 CONTEXT FOR THIS DOCUMENT... 5 Strategic Context and Principles Guiding This Document....................... 5 MHSU Purpose, Values, Vision and Guiding Principles...6 Conceptual Frameworks Guiding This Document...7 Strategic and Operational Planning Process....11 Priority Actions for MHSU Services......................................... 12 COMMUNITY SERVICES... 13 Community Mental Health Services (CMHS)................................. 14 Psychosis Treatment Optimization Program (PTOP)...15 Child, Youth and Young Adult (CYYA) Services...17 Older Adult Mental Health and Substance Use Services...19 Substance Use Services...21 Outreach and Outpatient Substance Use Services.... 21 Withdrawal Management Services.... 22 Residential Substance Use Programs.... 24 Primary Care Substance Use Services.... 25 ACUTE SERVICES... 28 Acute Mental Health Services....28 Seclusion Room Practice................................................... 31 TERTIARY SERVICE STREAM................................................33 HOUSING AND RESIDENTIAL SERVICE STREAM... 35 SERVICE QUALITY AND SAFETY............................................37 Quality and Performance Monitoring...37 Rehabilitation and Recovery (R&R) Services...38 Lived Experience and Family Involvement................................... 40 Trauma-Informed Practice (TIP)...42 SPECIALIZED SERVICES... 44 Reproductive Mental Health Services...44 Concurrent Disorders Services....45 Eating Disorders Services.................................................. 47 Co-occurring Developmental Disabilities and Mental Health Disorders (DDMH) Services...49 MHSU Strategic and Operational Priorities 2015 2020 i
SPECIFIC POPULATIONS.....................................................51 Severely Addicted, Mentally Ill (SAMI) Population........................... 51 Aboriginal Communities....53 Diverse Communities..................................................... 55 PUBLIC HEALTH...............................................................57 Health Promotion and Prevention.......................................... 57 Reducing Opioid Overdose and Improving Client/Patient Safety................ 58 STAFF AND PHYSICIANS... 61 Academic Affairs......................................................... 61 Knowledge Exchange (KE) to Support Clinical Excellence....63 NEXT STEPS....................................................................65 Appendix 1: Works Consulted..................................................66 Appendix 2: Alignment with Fraser Health Priorities..............................76 Appendix 3: Alignment with BC Ministry of Health Priorities...84 Appendix 4: List of Key Stakeholders Consulted by Working Groups during the Planning Process...90 Appendix 5: Environmental Scan Key Informant Interview Themes...91 Appendix 6: IAP2 Framework..................................................93 Appendix 7: Summary of Priority Actions........................................94 Appendix 8: Acronyms Used in This Document...................................97 TABLE OF FIGURES Figure 1. Current Continuum of Care at MHSU....................................4 Figure 2. MHSU Purpose, Values, Vision and Guiding Principles.....................6 Figure 3. Integrated Care Model across FH MHSU Services...13 Figure 4. Levels of Care within MHSU Tertiary Services...33 Figure 5. The Recovery Journey...39 ii MHSU Strategic and Operational Priorities 2015 2020
Acknowledgements ACKNOWLEDGEMENTS On behalf of the entire Mental Health and Substance Use (MHSU) team at Fraser Health, we are pleased to present the strategic and operational priorities for MHSU services for the next five years. The collective wisdom of all the MHSU staff, service providers, clients, families, partners and stakeholders who were involved in the planning process is captured in these pages. As a team, we are confident that this document will be a cornerstone that supports our efforts to continuously and progressively develop our system of care, address challenges of access and demand, improve client experience, and enhance the delivery of safe, effective and sustainable services for all residents in the Fraser Health region. We extend our sincerest thanks to everyone individuals and groups who generously gave their time, commitment and energy to making this document a reality, and for having a truly invaluable impact on the future of MHSU services across the region. Andy Libbiter Executive Director Mental Health and Substance Use Langley Memorial Hospital and Community Dr. Nigel Fisher Program Medical Director Mental Health and Substance Use MHSU Strategic and Operational Priorities 2015 2020 iii
Executive Summary EXECUTIVE SUMMARY Mental illness and substance use disorders can profoundly impact all aspects of an individual s life and that of their family, regardless of age, social and economic status, physical well-being and psychological functioning. MHSU Strategic and Operational Priorities 2015 2020 is founded on the belief that with proper treatment and support, people who experience mental illness and substance use disorders can recover and have productive and engaging lives. To fulfill this aim, it is essential that MHSU services be accessible, responsive, seamless, coordinated and evidence-informed. With both the region s demographic pressures and the ever-improving, research-based insights into the complexities of mental health and substance use issues, MHSU is constantly striving to be innovative and adaptable. This document presents the priority actions and strategies that Fraser Health Mental Health and Substance Use Services (MHSU) will undertake in order to realize the vision of achieving optimal mental wellness for all individuals living within the Fraser Health region. This document presents a map of where we are today and where we need to be in 2020. Here we describe the current system of care, identify gaps in the system, and provide clear, high-level direction that responds to those gaps and aims to enhance the overall level and quality of services we provide. The document is also firmly aligned with the directions articulated in the Ministry of Health s Setting Priorities for the BC Health System and Fraser Health s Strategic and Operational Plan 2014/15 2016/17. The strategic and operational priorities identified here are the result of an extensive process of review, research and consultation that has resulted in the development of 27 priority actions (Appendix 7). These priority actions focus on system-wide change that will facilitate and improve person-centred care through the individual s journey of recovery. The priority actions are informed by seven strategic frameworks: population health, health equity, trauma-informed practice and recovery-oriented services, integration of mental health and substance use services, integrated primary and community team-based care, and change management. Embedded throughout the document are the principles of partnership, sustainability and accountability. Priority actions are high level and will be used by teams and partners to develop detailed implementation work plans, outcome measurements and accountability frameworks. The next step in putting these strategic and operational priorities into action is to develop a service plan and work plans with timelines and tangible measures. The service plan will lay out clear deliverables, action items, budgetary guidelines, outcome measures and other operations-related details required for the phased implementation of these priority actions. iv MHSU Strategic and Operational Priorities 2015 2020
Introduction INTRODUCTION The region served by Fraser Health is home to about 1.7 million people. Fraser Health is the largest and the fastest-growing health authority in British Columbia. Demographic pressures, combined with ever-better insights into the complexities of mental health and substance use issues, make it essential for the work of the health authority s Mental Health and Substance Use (MHSU) services to be innovative and adaptable. Furthermore, given the priorities of the BC Ministry of Health and Fraser Health, these services must undergo a system-wide change to ensure the provision of person-centred, community-based services that are built around inter-professional teams with increased linkages between primary and specialist care. MHSU services are built along a continuum of care that is shaped by: the integration of mental health and substance use services; support of client recovery and rehabilitation; seamless provision of quality care; and safe, evidence-informed practices. In line with the strategic direction set out by the BC Ministry of Health 1 and Fraser Health 2 in 2014, this document outlines the strategic and operational priorities that will guide the provision of MHSU services from 2015 to 2020. Regional Demographics Demographics are a key driver of MHSU services in Fraser Health. Understanding the distribution of regional populations by location, demand for services, age and cultural diversity is integral to ensuring that MHSU services meet the needs of current and future clients. In addition to being the largest and fastest growing health authority in British Columbia, Fraser Health has a population that is rapidly aging, with seniors making up the fastestgrowing age group. This trend is expected to continue for the next several decades as a result of low fertility rates, increasing life expectancy, and the aging of the baby boom generation. The proportion of seniors in Fraser Health s population is expected to increase from 14.7 per cent (250,000) in 2014 to 21.1 per cent (472,000) by 2030. 3 Driving MHSU service needs is the fact that Fraser Health has: the highest population growth of any health authority in BC; an aging population and fast growth in the 65+ age group; the largest child and youth population in BC; and an increasingly culturally diverse population. 1 2 3 BC Minsitry of Health (2014b) Fraser Health Authority (2014) BC Stats. Population Projections. BCStats. [Online] May 28, 2014. www.bcstats.gov.bc.ca/statisticsbysubject/demography/populationprojections.aspx MHSU Strategic and Operational Priorities 2015 2020 1
Introduction Fraser Health is also one of the most culturally diverse health authorities in the province, with one-third of the population identifying as a visible minority. Of this population, the two predominant visible minority groups are South Asian (39 per cent) and Chinese (27 per cent). First Nations totalled 54,460 in 2006, representing about 4 per cent of the Fraser Health population. Understanding the diversity of the Fraser Health population is key to the delivery of patient-centred services. Prevalence of Mental Health and Substance Use Disorders in the Region Fraser Health has the highest number of people affected by mental health and substance use disorders of any health authority in British Columbia. About 230,000 people (17 per cent of the region s adult population) live with some form of mental illness. An additional 160,000 200,000 people are in need of withdrawal management or treatment services for substance use. As Table 1 shows, these numbers are projected to increase by 2020. About 14 per cent of youth (aged 13 18 years) in Fraser Health experience mental health problems. Table 1. Estimated Prevalence of Mental Health and Substance Use in Fraser Health s Adult Population (2014 2020) Measure Prevalence rate (%) 2014 2020 (projected) Adult population a (age 19+) 1,342,580 1,497,361 Having mild, moderate or severe mental 17.2 230,900 257,500 illness b Mild mental illness 10.2 136,900 152,700 Moderate mental illness 4.3 57,700 64,400 Severe mental illness 2.7 36,200 40,400 In need of withdrawal management and/ 12 15 161,100 201,400 179,700 224,600 or treatment services for substance use c Those seeking assistance 15 24,200 30,200 27,000 33,700 a BC Stats, Population Projections. BCStats. [Online] May 28, 2014. www.bcstats.gov.bc.ca/statisticsbysubject/ Demography/ PopulationProjections.aspx. b Kruger and Associates Inc. (2013). Tertiary Mental Health Services: A Review. [unpublished document] c Fraser Health Authority Mental Health and Addictions. (2007). Data at the provincial level shows that 50 80 per cent of people aged 15 64 years who are receiving treatment for substance use issues are also receiving mental health services. These complex clients with dual diagnoses, together with other individuals who are severely addicted and mentally ill (commonly referred to as the SAMI population), total about 50,000 in Fraser Health,4 representing 35 per cent of the provincial total. 4 H. Kruger and Associates Inc. (2013). Tertiary Mental Health Services: A Review. [unpublished document] 2 MHSU Strategic and Operational Priorities 2015 2020
Introduction Furthermore, a recent study 5 identified a subset of SAMI individuals who: have complex co-occurring disorders; are also involved with the justice system, hospitals and social welfare services; and are homeless or at risk of homelessness. These individuals are at high health risk and require ongoing, comprehensive services from multiple agencies to maintain their lives in the community, as they have often lost vital social connections. Of the 2,202 clients identified within this subset in British Columbia, 577 reside in the Fraser Health region. Current Continuum of MHSU Services The present continuum of care provided by MHSU services includes a variety of treatments and interventions. This service continuum is based on providing integrated services for individuals. MHSU services range from health promotion, harm prevention and community-based care to more intensive services such as inpatient/day treatment, tertiary care and housing supports (see Figure 1). This complex continuum of care is built around the guiding principles that underpin effective service delivery, namely: the provision of person-centred services sensitive to family and cultural diversity; a focus on quality and safety; integration of hospital, primary, specialist and community services; integration of mental health and substance use services; collaboration in working relationships; and seamless care. 5 Somers et al. (2014) MHSU Strategic and Operational Priorities 2015 2020 3
Introduction Figure 1. Current Continuum of Care at MHSU Fraser Health - Mental Health and Substance Use (MHSU) Continuum of Care Health Promotion and Prevention activities Information on Mental Health and Substance Use Early Psychosis Intervention (EPI) Mindcheck.ca website Collaborative Mental Health Care Rapid Access Clinic Primary Care Clinics Nurse Practitioners Police & Mental Health Partnerships Child & Youth Crisis Programs Psychiatric Liaison Staff in all FH Emergency Departments 32 Community Residential Short Stay Treatment Beds Regional Crisis Line Intake/Urgent Response 17 Community Mental Health Centres: ACSS/ACM - Outpatients - Group Program - Geriatric - EPI - Eating Disorders - Adult Concurrent Disorders Therapists - ASTAT Rehabiitation Recovery Services: Vocational/Rehabilation - Club Houses - Peer Support - Life Skills Training - Therapeutic Volunteers - Supported Employment Co-occuring Developmental Disabilities and Mental Health Teams (FH/VCH) Psychosis Treatment Optimization Program (PTOP) Acute Home Treatment Program (Langley/White Rock) Adolescent Day Treatment (MCFD, SMH, ARH) Adolescent Psychiatric Unit (10 Beds) Adult Psychiatric High Acuity (16 Beds) Adult IPU (8 Sites, 176 Beds) Tertiary Services: Older Adult # Beds Acute 24 Rehab/Specialized Residential 71 Adult # Beds PICU (FH & VCH) 12 Assessment & Treatment 30 Intensive Tertiary Rehab 37 Community Tertiary Rehab 45 Specialized Residential 44 Neuropsychiatry (VCH) 10 Assertive Community Treatment (ACT) (4 Teams) Mental Health Services Health Promotion/ Prevention and Harm Reduction Primary and Collaborative Care Urgent/ Emergent/Withdrawal Management Community/ Counselling/Outpatient/ Outreach Inpatient/ Day Treatment/ Short-Term Residential Tertiary Care/ Long-Term Residential Substance Use Services Health Promotion and Prevention activities Information on Mental Health and Substance Use School-based prevention workers in primary schools and high schools Community based prevention/ promotion Primary Care Clinics Nurse Practitioners Creekside Withdrawal Management Unit (24 adult + 6 dedicated youth beds) and Daytox program Riverstone Home/Mobile Daytox/Detox Quibble Creek Sobering Centre Direct services outpatient/outreach counselling programs (Surrey and Burnaby) Outpatient/Outreach services contracted with 20 Health Service Providers Specialized Youth Outreach Program Youth Concurrent Disorder Therapists Maple Ridge Treatment Centre - 60 beds (male) Kinghaven - 52 beds (male) Peardonville - 28 beds (women) Day, Evening, Weekend Youth Program Elizabeth Fry Short Term Stabilization - 4 beds (women) 11 Stabilization & Transitional Living Residence Facilities (support recovery) - 127 beds 10 Youth beds in Keremeos Mental Health and Substance Use Housing Supported Housing Units Minimum Barrier Housing Family Care Homes Second Stage Addictions Housing Supported Independent Living Program (SIL) Mental Health Licensed Residential Youth Supported Living Program (YSLP) Mental Health Assisted Living ARH: Abbotsford Regional Hospital ACSS: Adult Community Support Services ACM: Assertive Care Management ACT: Assertive Community Treatment ASTAT: Adult Short Term Treatment EPI: Early Psychosis Intervention IPU: Inpatient Unit MCFD: Ministry of Children & Family Development PICU: Psychiatric Intensive Care Unit PTOP: Psychosis Treatment Optimization Program SMH: Surrey Memorial Hospital STLR: Stabilization and Transitional Living Residence VCH: Vancouver Coastal Health FHA-201-005 fraserhealth@kochink.com 4 MHSU Strategic and Operational Priorities 2015 2020
Context for This Document CONTEXT FOR THIS DOCUMENT Strategic Context and Principles Guiding This Document Two key documents set the foundation for the development of this document: The BC Ministry of Health s Setting Priorities for the B.C. Health System, released in February 2014 This document outlines eight priority areas and seven strategies for achieving sustainable, effective and high-quality health services across the province. The Ministry s priorities call for health authorities and agencies to collaborate in achieving system-wide change that will result in patient-centred, communitybased care. Health care services are to be built around inter-professional teams that have increased linkages between primary and specialist care, increased access to residential care services, and targeted and effective health promotion and harm prevention (see Appendix 3). The Fraser Health Authority s Strategic and Operational Plan 2014/15 2016/17 Following the release of the Ministry of Health s priorities document, Fraser Health underwent a review as part of creating a three-year strategic and operational plan. This plan responds to the changing population health needs and demands within the region, and aims to deliver sustainable, effective and high-quality health services as mandated in Setting Priorities for the B.C. Health System (see Appendix 2). Fraser Health s plan presents 10 priority areas to achieve meaningful change in population and patient outcomes: capacity for care; quality and safety; public health measures; accountability; staff and physicians; patient centredness; governance; operational organization and management; Lower Mainland collaboration; and budget accountability. The priorities for MHSU services are closely aligned with those of Fraser Health, particularly with regard to system-wide change as described by the Ministry of Health (shown in Appendix 3). MHSU Strategic and Operational Priorities 2015 2020 5
Context for This Document MHSU Purpose, Values, Vision and Guiding Principles Essential to the planning process are MHSU s purpose, values, vision and guiding principles, all of which guide the organization in providing the residents of Fraser Health with compassionate care through sustainable, dynamic, person-centred and evidence-informed practices (Figure 2). These values and principles align with those in the Ministry of Health s priorities document and Fraser Health s Strategic and Operational Plan 2014/15 2016/17. Figure 2. MHSU Purpose, Values, Vision and Guiding Principles Purpose To achieve excellence in the wellness and recovery process for people living with mental illness and/or problematic substance use, and for their natural supports, through a commitment to quality, safety, partnership, accessibility and efficiency. Values Our services are based on mutual respect, compassion, integrity and accountability. Vision Achieving optimal mental wellness for all. Guiding Principles Recovery-based practices Person-centred care Seamless and safe care Evidence-informed practices Timely, accessible, appropriate and effective services Commitment to ongoing workforce development Reduction of harm and building of resiliency Equity, efficiency, accountability and sustainability Partnerships and collaborative working relationships Systems inclusive of families and/or other natural supports Promotion, prevention and early detection Monitoring, evaluation and quality improvement 6 MHSU Strategic and Operational Priorities 2015 2020
Context for This Document Conceptual Frameworks Guiding This Document Seven overarching frameworks informed MHSU s strategic planning process, across the continuum of care for MHSU services. Population health In the context of MHSU services, a population health approach aims to reduce the burden of mental illness and substance use by strengthening protective factors such as self-esteem, personal coping skills, social support, inter-personal relationships, resilience, a sense of belonging, and optimism through multiple and inter-sectoral collaborations and partnerships. This important harm prevention approach is highlighted by the strategic priorities of both the Ministry of Health and Fraser Health. Population health reflects a shift in our thinking about how health is defined. It aims to maintain and improve the wellbeing of an entire population, and views health as a capacity or resource rather than a state of being, allowing people to pursue their own health goals, acquire skills and education, and grow. MHSU considers an integrated population health approach to be the best way to meet client needs. For this approach to be effective, intersectoral collaborations are necessary to bring the key stakeholders and service providers together. MHSU is continuing to invest in a more holistic approach that recognizes the interconnectedness of physical, emotional and mental health. Holistic, evidence-informed service planning and delivery will help create supportive environments that will lead to improved outcomes for patients and clients. Health equity The cumulative effect of stigmatizing behaviours is the most powerful contributor to health inequities among people with mental health and substance use issues. In the context of MHSU services, a health equity approach aims to prevent and reduce unfair and avoidable differences in health outcomes that negatively affect patients, clients and families. Reducing stigma has been a focus in many policy-influencing documents, including Healthy Minds, Healthy People: A Ten-Year Plan to Address Mental Health and Substance Use (2010) by the BC Ministries of Health Services and Children and Family Development, and it is a funding priority of Health Canada s Drug Treatment Funding Program (DTFP). In this document, health equity is both a concept and an approach to addressing stigma and discrimination related to mental health and substance use. MHSU Strategic and Operational Priorities 2015 2020 7
Context for This Document Health equity is a person-centred approach that recognizes and responds to the different needs of diverse individuals and groups in order to achieve good health outcomes. Examples of programs and approaches within MHSU that promote health equity include housing services for people with mental health challenges, suicide risk management clinical practice guidelines, and feedback-informed treatment. Adopting a health equity approach ensures that everyone has an equal chance at better health across MHSU services and supports, regardless of socio-economic status, age, gender, sexual orientation, race, ethnicity, neighbourhood, social history, medical diagnosis or assessed mental health and substance use needs. Trauma-informed practice In the context of MHSU services, trauma-informed practice aims to ensure that anyone who has witnessed or personally faced violence, abuse, neglect and other traumatic experience is treated compassionately and effectively at the practice, organization and system level. Recognizing and addressing trauma are essential to meeting the complex needs of the majority of patients, clients and families who access MHSU services. When service providers do not sufficiently understand trauma, its effects, and the coping mechanisms that people adopt, the results can be misdiagnosis and inadequate treatment. At the same time, it is essential to recognize that health practitioners exposed to the trauma of clients can also be affected, and that their ability to help can be compromised. A traumainformed practice approach provides the basis for compassionate and effective mental health and substance use treatment planning. Trauma results from experiences that overwhelm an individual s capacity to cope. Trauma can happen early in a person s life and may result from witnessing violence or suffering child abuse, neglect or disrupted attachment. It can also happen later in life when someone suffers a traumatic experience such as an accident, violence, natural disaster, war, personal injury or loss, sudden death of a loved one, or other such life event. Intergenerational trauma describes the psychological and emotional effects that can be experienced by people who live with trauma survivors. Historical trauma is cumulative emotional and psychological wounding across generations from massive group trauma. To become more trauma informed in all aspects of service planning, delivery, monitoring and evaluation, MHSU is investing in evidence-informed change management designed to support all MHSU services and supports. This initiative is based on the BC Ministry of Health s Trauma-Informed Practice (TIP) Guide and TIP Organizational Checklist. 6 Furthermore, trauma-informed practice is one of the four 6 BC Mental Health and Substance Use Services Planning Council (2013) 8 MHSU Strategic and Operational Priorities 2015 2020
Context for This Document priorities for the next phase of the Drug Treatment Funding Program (DTFP) in British Columbia. Evidence supports the continuing and urgent need for MHSU services to address trauma through an evidence-informed, systematic approach. 7 Recovery-oriented services The traditional view of mental illness and substance use issues puts mental wellness at one end of a spectrum and mental illness at the other, implying that mental wellness requires the absence of illness. The recovery model supported by MHSU services proposes that impairment related to the symptoms of illness or substance use does not preclude flourishing mental health but, rather, that the two can co-exist. Recovery in mental health refers to living a satisfying, hopeful and contributing life even when there are ongoing limitations caused by mental health problems and illnesses. Mental Health Commission of Canada (2014) Complete mental health incorporates two aspects of recovery emotional well-being and positive functioning each viewed as occurring in a separate dimension rather than as both being seen as part of one dimension. MHSU s commitment to a recovery-oriented service is evidenced by the integration of the Recovery-Centered Clinical System (RCCS) into Tertiary service programs in 2007 and the Community Residential Program in 2010. MHSU substance use services are equally as committed to the recovery model, acknowledging the multi-dimensional aspects of addiction. The bio-psycho-socialspiritual model used by MHSU addresses problematic substance use while also recognizing the many dimensions of recovery, including physical and mental wellness (bio-psychological), healthy relationships, productive vocation and community involvement (social); and meaningful engagement with life (spiritual). Recovery, then, is not narrowly defined by the absence of substance use, but by improved global wellbeing. This framework underscores the importance of using recovery-based outcome measures and benchmarks such as the capacity of individuals to participate and contribute in their community. MHSU services are dedicated to helping clients develop well-being rather than simply manage their symptoms, in this way allowing clients to take control of their own recovery journey. 7 Ibid. MHSU Strategic and Operational Priorities 2015 2020 9
Context for This Document Integration of mental health and substance use services MHSU services deal primarily with three population groups: those with substance use disorders; those with mental health disorders; and those with both types of disorders (identified as clients with concurrent disorders). An integrated system of programs and services is essential for assisting individuals with concurrent disorders. An integrated system requires high levels of communication and collaboration, not only among providers of MHSU services but also between those service providers, clients and family members (as permitted). Integration is an approach that combines elements of mental health treatment with elements of substance use treatment, creating a unified and comprehensive service. When individuals appear at a facility that is not qualified to provide some type of needed service or support, they are guided to appropriate, cooperating service delivery agencies, with follow-up by staff to ensure they receive proper care. An integrated approach can involve single-site service delivery, treatment teams, or collaborative partnerships across more than one provider. To best serve individuals with concurrent disorders, MHSU will focus on integrating services at the right level, for the right people. Integration of primary and community team-based care In the context of MHSU services, integrated primary and community team-based care aims to achieve improved health outcomes and support for MHSU s most vulnerable clients, including the severely addicted and mentally ill (SAMI) population. Team-based care is widely accepted throughout North America as an effective way to increase access to, and continuity and integration of, services for clients with mental health or substance use disorders. 8 Within inter-professional, integrated care teams, GPs (general practitioners) work with primary and community care professionals to provide support to a shared client base. Stable clients are identified and supported through their transition to primary care, with assured access to recovery-based community services and fast-track crisis management when necessary. Team-based care has been shown to decrease the need for hospitalization and other high- Team-based care places the client at the centre of an interdisciplinary team of mental health and substance use professionals, enabling highly coordinated, supportive, skilled and efficient care. Inter-professional teams create closer linkages between clients and the continuum of health services, improving client access to primary and community services and reducing their readmission rates to acute facilities. Team-based care stresses efficient care coordination and a culture that encourages parity among all team members. Teams are used to promote clinical excellence, continuous improvement and real-time feedback. 8 Drake and Latimer (2012) 10 MHSU Strategic and Operational Priorities 2015 2020
Context for This Document intensity, high-resource services such as residential care. Successful inter-professional team-based care requires a strengthening of the relationship between community-level specialists and primary care or family practitioners. This interface is critical in mitigating risk during post-discharge transitions and ensuring that clients are provided with continual support, seamless care and timely access to primary mental health care and recovery services. Integrated care teams focus primarily on moderate to severely ill clients with high needs. MHSU will build the capacity to respond to the increasing complexity and prevalence of severe and concurrent disorders. Change management The priority actions presented in this document have the capacity to transform MHSU s continuum of care. They respond to Fraser Health s growing and diverse population; to our increased understanding of the complexity of mental health and substance use problems; and to the Ministry of Health s newly established priorities. For the proposed changes to be implemented successfully in a way that is accepted by and appropriate for the organization, staff, clients and their families/supports MHSU is committed to adopting a change management framework that is ethical and supportive and that uses evidence-informed processes to implement the priority actions. MHSU s change management strategy includes identifying stakeholders, establishing clear communication channels, implementing training and education, evaluating the process, developing shared change management approaches, and ensuring timely, open communication with staff. MHSU s change management strategy aligns with the Ministry of Health s strategy for skilled change management. Strategic and Operational Planning Process Mental Health and Substance Use Strategic and Operational Priorities 2015 2020 was developed through a well-informed, collaborative and inclusive process. It is aimed at guiding decision making about priority areas and directions for MHSU. The process began in March 2013 and was completed in November 2014. This document was shaped by a review of previous planning documents, evidenceinformed practices and clinical benchmarks, consultations with internal and external stakeholders, and assessment of current issues and priorities. MHSU Strategic and Operational Priorities 2015 2020 11
Context for This Document Environmental scan To ensure that the priority actions presented in this document would build on current MHSU service strengths in practice as well as align with existing policy-driving documents and evidence-informed practices, an environmental scan was conducted between January and March 2014. The scan process also stimulated thoughtful analysis of gaps and challenges in the provision of, and access to, quality MHSU services. This scan involved key informant interviews and a review of planning and policy documents (see Appendix 5). Review of planning and policy-driving documents In addition to Setting Priorities for the B.C. Health System and Fraser Health s Strategic and Operational Plan 2014/15 2016/17, several other internal and external documents were reviewed. A number of MHSU documents were used to provide a foundation for planning and to guide the development of the 2015 2020 priorities. These included MHSU service plans, evaluations and reviews of current practices, and documents at the ministry and health authority level. Additional external sources served as useful references by providing policy direction, evidence-informed practices and current and emerging conceptualizations and frameworks for health care service delivery. External reference materials consulted included those from the BC Ministry of Health, the Canadian Mental Health Association, the Mental Health Commission of Canada, and other materials from both the provincial and federal governments. Common themes that emerged related to capacity building within the community, quality, collaborative service delivery within MHSU, and evidence-informed practices. A list of major external guiding documents is presented in Appendix 1. Key informant interviews In early 2014, one focus group and 13 interviews were conducted to determine MHSU core service elements, strengths, obstacles and future prospects from the perspectives of key informants who hold positions that involve most MHSU services and supports. Five themes emerged from these key interviews, and are summarized in Appendix 5. Priority Actions for MHSU Services The following sections describe MHSU services across the continuum of care and outline 27 priority actions for 2015 2020. A brief description of the service area precedes each priority action and sets the context for the stated action. Details about how the action will be achieved and the signs of success then follow. 12 MHSU Strategic and Operational Priorities 2015 2020
Community Services COMMUNITY SERVICES A robust system of community-based care can provide a significant level of care to individuals with mild, moderate and complex disorders within the community. An effective communitybased system of care is characterized by a high degree of integration between services and service providers, and by a continuum of stepped care, with appropriate service intensity to match clients service-level needs. Figure 3 shows how MHSU services can be organized to achieve this objective. Community-Based System for Health (CBSH) is an approach that provides a comprehensive array of distinct services networked together in an activated community where teams of professionals collaborate seamlessly, patients and providers are partners, and patients are informed and engaged. Figure 3. Integrated Care Model across FH MHSU Services This section highlights areas of service delivery that are highly congruent with the vision of building a robust community of care. These service delivery areas include community mental health services (CMHS); the Psychosis Treatment Optimization Program (PTOP), a prominent example of the Community-Based System for Health (CBSH); child, youth and young adult services; older adult mental health and substance use services; and four sub-areas of substance use services: outreach and outpatient services, withdrawal management, residential services, and primary care services. MHSU Strategic and Operational Priorities 2015 2020 13
Community Services Community Mental Health Services (CMHS) Population pressures and capacity challenges are compelling drivers for the transformation of community mental health services. Redesigned services have the potential to build capacity, reduce hospitalizations, and create a safer, more effective and accessible system of care for all MHSU clients. The transformation of CMHS towards a strengthened Community-Based System for Health (CBSH) provides an opportunity to increase our capacity. The MHSU priorities focus on building integrated community mental health services around effective inter-professional teams and partnerships with primary care, specialist care, mental health teams and other care providers at the community level. This strengthened interface between acute, community and primary care will allow MHSU to build capacity in order to care for its severely addicted and mentally ill clients while also providing its stable and mildly to moderately ill clients with accessible, effective and supportive care that promotes recovery and self-management and provides support during post-discharge transitions. Restructuring in this way will facilitate better care for all Fraser Health clients, including the most vulnerable SAMI population. Priority Action Increase timely access to community mental health services for MHSU clients through redesigning and rebalancing community mental health services. We will achieve this by: creating an integrated system of primary and community care built around interprofessional teams and functions; placing clients at the right level of care with the help of a decision support tool; ensuring that primary care providers are supported to care for mildly to moderately ill clients, and that clients continue to have access to recovery services; expanding hours of operation to enable access to community-based care and specifically crisis response capacity in the evenings and on weekends; developing and improving protocols to support client transitions between primary, acute, residential, tertiary and community mental health services; and rebalancing and maximizing acute and community capacity by increasing assertive outreach capacity, early intervention and crisis response. 14 MHSU Strategic and Operational Priorities 2015 2020
Community Services Signs of success: Mildly to moderately ill clients receive accessible, effective support from their primary care provider through fast-track crisis management. Clients receive timely access to the level of service that best meets their care needs. Clients experience timely, seamless and safe transitions to community services, and from community services to other types of services. Psychosis Treatment Optimization Program (PTOP) The Fraser Health Psychosis Treatment Optimization Program (PTOP) has had demonstrated success in developing community-based services that have reduced reliance by a vulnerable population on acute care services. PTOP offers communitybased services to clients affected by treatment-resistant psychosis (TRP). PTOP s inter-professional teams provide comprehensive services that include assessment, treatment and monitoring of the medical, physical and psychological wellbeing of clients on clozapine, an antipsychotic medication. Rigorous evaluation of PTOP over the past three years shows it has achieved marked improvements in clients social and mental functioning. It has resulted in a 67 per cent reduction in acute care bed days, a reduction in readmission rates, and a 39 per cent reduction in emergency room visits for mental health issues. As well, PTOP has increased the number of clozapine starts in community settings, averting 1,701 hospital bed days. One of the challenges being addressed in Fraser Health is the underutilization of clozapine for TRP due to differences in physician practices and prescribing. Since its inception in 2011, PTOP has reached about 10 per cent of the estimated 5,000 clients affected by treatment-resistant psychosis (TRP) in Fraser Health (one-third of the estimated 15,000 individuals with schizophrenia). A person is defined as having TRP if he or she has had two or more unsuccessful trials with antipsychotic medications. Failure to properly manage TRP can lead to lost productivity, increased hospital admissions with longer stays, and increased levels of medical and psychiatric complications (including harm to self and others and suicide). In response, PTOP has developed a standardized protocol for the safe use of clozapine, with the goal of having the protocol implemented by all physicians across Fraser Health. The opportunity exists to increase awareness of the program, improve current services, and share knowledge with other health care professionals through partnerships with community mental health, primary care and other community agencies. MHSU Strategic and Operational Priorities 2015 2020 15
Community Services Priority Action Increase timely access to Psychosis Treatment Optimization Program (PTOP) services to improve care for individuals with treatment-resistant psychosis (TRP). We will achieve this by: promoting inter-professional collaboration; improving PTOP integration with primary and community services; increasing clinical data collection, evaluation and monitoring; establishing a secondary hematological monitoring system across Fraser Health for clients on clozapine; establishing an improved discharge process to support client reintegration into the community by partnering with primary care; strengthening and streamlining PTOP workflow and standardizing clinical practices and information processes; increasing participation with the Professional Support Program and developing curricula and materials for TRP and clozapine management training; collaborating with health care professionals with expertise in TRP and health authorities to promote a provincial quality framework and shared learning system, and to consider opportunities to develop a province-wide TRP management service; and creating a knowledge-based repository of PTOP best practices and clinical information lessons that can be shared with other health authorities and stakeholders involved in managing TRP. Signs of success: Clients in the PTOP program experience seamless care from inter-professional teams with expertise in TRP care. Treatment and assessment tools and procedures are standardized across Fraser Health. Clinical processes and information among caregivers are strengthened, streamlined and standardized across Fraser Health. The number of TRP clients receiving safe, effective and high-quality clozapine treatment increases. 16 MHSU Strategic and Operational Priorities 2015 2020
Community Services Child, Youth and Young Adult (CYYA) Services Mental health and wellness is the most significant health issue for young people, and the long-term impact of mental illness on personal and family health and wellness cannot be understated. The population of children and youth (0 18 years) and young adults (19 24 years) within Fraser Health is growing, and so is the prevalence of existing and emerging mental health and substance use issues. Without early intervention, psychiatric disorders frequently persist into adulthood. While the existing substance use services in Fraser Health have developed a reputation for excellence, gaps exist in the ability of MHSU to meet the increasing demand for youth-oriented services and address the needs of clients with co-existing complex disorders such as eating disorders, mental health issues, behavioural issues and lack of safe housing. About 25 per cent of youth (10 24 years) who are currently accessing substance use services are under the age of 15. Adolescence and young adulthood is a time of profound change that can include emotional, biological, spiritual and social shifts. The introduction of substance use during these times of transition can result in significant biological, psychological and social impairments. Overwhelmingly, evidence suggests that early intervention is a successful tactic to delay or offset the initial use of substances by young people. a a McGorry et al. (2011) The need for these youth-specific services is expected to increase. The number of children and youth with mental health concerns presenting to Fraser Health hospitals and the crisis response program has been dramatically rising in recent years. Waitlists for the Ministry of Children and Family Development s (MCFD) Child and Youth Mental Health Services are increasing, putting additional pressure on an already burdened system. Young people with mental health and substance use issues often cannot obtain timely treatment or have difficulty finding age-appropriate services. A responsive, integrated and comprehensive continuum of well-resourced services that are appropriate to the developmental needs of young people will help to ensure that the least intrusive and most effective interventions are provided. Collaboration with family physicians and other key stakeholders such as MCFD, schools and families is essential for developing and sustaining a system that meets the needs of young people. MHSU Strategic and Operational Priorities 2015 2020 17
Community Services Priority Action Increase timely access to specialized psychiatric stabilization, crisis response and substance use services for children, adolescents and young adults as resources allow. We will achieve this by: developing a 10-bed Child and Adolescent Psychiatric Stabilization Unit (CAPSU) based out of Surrey Memorial Hospital; improving access to the Early Psychosis Intervention (EPI) Program; aligning the EPI Program with British Columbia s standards and guidelines for early psychosis services 9 ; developing services in the EPI Program, Adolescent Day Treatment Program and outpatient clinics for assessing young people s cognitive skills and supporting those clients in improving those skills and the ability to function in daily life (e.g., at school or work); developing Headspace a youth-friendly, multidisciplinary and sharedcare service through partnerships between Fraser Health s various services (substance use, primary care, population and public health, maternal/infant/ child/youth) and those of the MCFD; and redesigning child and youth crisis response services. Signs of success: A 10-bed CAPSU for Fraser Health is established. Children, youth, young adults and their families have access to enhanced and comprehensive EPI Program, day treatment and outpatient psychiatry services. Children and youth in acute psychiatric crises receive an improved response that matches their needs with services provided in the most appropriate location. Children, youth and young adult service providers collaborate effectively with other MHSU services, community agencies and MCFD s Child and Youth Mental Health Services to provide improved integrated care and effective transition and aftercare services. The rate of readmission to MHSU services by substance-using and substanceaffected children, youth and young adults is reduced. 9 BC Ministry of Health Services (2010) 18 MHSU Strategic and Operational Priorities 2015 2020
Community Services Older Adult Mental Health and Substance Use Services Mental illness is estimated to occur in 25 per cent of seniors, many of whom may be cognitively impaired or have concurrent disorders or developmental disabilities, language barriers or weak social networks. The misuse of prescription and over-the-counter medications and alcohol is also a significant problem among older adults, particularly when alcohol is used in combination with medications. Older adults are especially vulnerable to alcohol use disorders as a result of loneliness, loss, decline in physical capabilities and many other psychosocial factors. At the same time, older adults are often reluctant to seek help because of historical contexts and social stigma and therefore at-risk individuals rarely enrol directly in mental health and substance use treatment. It is imperative that older adults be supported by a community-based system of health care. Providing them with safe and effective care in the community helps them maintain their independence and avoids or delays the need for acute and residential care, with all the associated upheaval. There is strong evidence that older adults have fundamentally different needs from those of younger adults, Fraser Health has the fastest growing population of seniors of all health authorities in BC. This population segment is expected to increase by 35.9 per cent between now and 2020. The communities that will experience the most significant growth of seniors are Coquitlam (50.6 per cent), Surrey (47.0 per cent), Maple Ridge (41.1 per cent) and Langley (38.5 per cent). a Given this projected increase, MHSU is facing significant service pressures, and must be prepared for an older adult client population with a diverse range of mental health and substance use needs that will impact care and service delivery. and that these needs must be supported by services designed specifically for those needs. MHSU currently has very few older adult substance use outreach counsellors, and despite recent initiatives to improve staffing mix and capacity, existing acute and community resources continue to fall short of the recommended national benchmarks for specialized older adult mental health services. 10 Given the significant growth projected for the senior population over the next several years, it is essential to find innovative ways to partner with other service providers, agencies and caregivers to meet the unique needs of this population in Fraser Health. Clearly defined care pathways must be established to ensure that specialized and a BC Stats, Population Projections. BCStats. [Online] May 28, 2014. www.bcstats.gov.bc.ca/statisticsbysubject/ Demography/ PopulationProjections.aspx 10 The Mental Health Commission of Canada recommends the following service benchmarks per 10,000 population: Seniors Mental Health Outreach and Community Teams: 5.5 FTE (full-time equivalent) health professionals Intensive Community Treatment and Support: 5.25 FTE health professionals Acute, Short-Term Inpatient Psychiatric beds: three beds usually located on a general acute care psychiatric inpatient service, ideally with older adult psychiatrist consultation/support and average length of stay of approximately one month. MHSU Strategic and Operational Priorities 2015 2020 19
Community Services efficient mental health and substance use services are in place and prioritize recovery, early intervention, well-being and choice for older adults and their caregivers. 11 Priority Action Increase timely access to services for older adults with mental health and substance use issues across the continuum. We will achieve this by: improving care transitions across the continuum of care; standardizing and streamlining processes for older adult mental health services in the community; expanding housing services to increase capacity, through collaborations with community partners; strengthening linkages and developing transition protocols between each level of service within the older adult MHSU continuum; simplifying referrals and improving access to services by developing a single point of entry (i.e., a regional centralized intake system) and a system navigator role; developing housing, respite and short-stay stabilization capacity; actively participating at seniors advocacy and planning tables; strengthening the relationships between MHSU, home health and end-of-life services through joint training initiatives and partnership opportunities; collaborating with primary care and various divisions of family practice to introduce a model of early screening and engagement of older adults and to create corresponding care pathways; and engaging front-line staff and programs by increasing existing knowledge and skill development. Signs of success: With standardized protocols and processes in place, older adult MHSU services are linked and transitions are seamless. Access to community older adult mental health services is through a regional centralized intake system. New service delivery models are developed in collaboration with internal and external partners. Older adult admissions to acute care are prevented or reduced. 11 Mental Health Commission of Canada (2011) 20 MHSU Strategic and Operational Priorities 2015 2020
Community Services Older clients experience improved personal and global outcomes such as physical, social and emotional well-being. Older adults with problematic substance use have strengthened linkages with family, significant others and caregivers. More housing resources are available for older adults who have challenging behaviours and complex issues related to cognitive decline. Substance Use Services Outreach and Outpatient Substance Use Services Outpatient or community-based substance use services take many forms: outreach; counselling and therapy; psycho-educational groups; group and family therapy; screening; assessments; consultations; and referrals. These services share some aspects of intensive residential treatment services, but provide clients with more freedom of movement and a greater degree of privacy and anonymity. Outreach and outpatient services allow clients to maintain regular commitments to family, work and educational responsibilities, and provide unique supports to families and significant others impacted by the substance use behaviours of their family members or partners. Current MHSU outpatient and outreach services require significant change in order to become a more robust, sustainable system of evidence-informed and collaborative services. The Fraser Health Addiction Outpatient-Outreach Services: An Environmental Scan (2009) found that not all practices were rooted in evidence, and that the competencies and practices within MHSU s outpatient and outreach services varied widely. 12 That environmental scan resulted in the document List of Twenty-Three Principles for the Delivery of Ethical, Efficient and Effective Services in Addiction Outpatient-Outreach Services. The principles recognize that: no one person, team or organization has the capacity to meet all the needs of clients, and instead a strong multi-partner approach is required; increased outreach and liaison services are needed; and client feedback is critical and powerful evidence when used to shape service delivery. These 23 principles support the need to redesign services and create program benchmarks. 12 Goheen, M. (2009a). Addiction Outpatient-Outreach Services: An Environmental Scan. Surrey: Fraser Health Authority MHSU. [unpublished document] MHSU Strategic and Operational Priorities 2015 2020 21
Community Services Priority Action Improve the quality of community-based substance use services for MHSU clients. We will achieve this by: implementing the standardized substance use best practices identified in the Fraser Health Addiction Outpatient-Outreach Services: An Environmental Scan (2009); introducing and reinforcing the use of core practice tools as a requirement of clinical practice; evaluating the use of the 23 best practices and principles identified in the environmental scan through the use of a self-monitoring tool for outpatient and outreach services; and developing, implementing and evaluating models that will allow for an integrated mental health and substance use approach, where requested, in a variety of health care settings. Signs of success: An increased percentage of the substance use workforce have completed Core Addiction Practice (CAP) 13 and use core tools such as feedback-informed treatment, trauma-informed practice and motivational interviewing. Increased partnerships exist within Fraser Health between mental health and substance use services, and with other community services. More community service providers are knowledgeable about effective, evidenceinformed practices that increase client retention and improve outcomes. Withdrawal Management Services The need for withdrawal management services in Fraser Health is expected to increase, requiring each community within the region to make these services available. Withdrawal management services, including sobering centres, are a vital part of the continuum of substance use services, and provide a gateway to other supports and services within a community-based health care system. These services can support even the most complex, marginalized clients with multiple challenges. 13 The Core Addiction Practice (CAP) course is a practical and skill-based course endorsed by the BC Ministry of Health. It is designed to give service providers information, theories and concepts about psychoactive substance use as well as strategies and skills for providing effective supports and services to those with substance use problems. 22 MHSU Strategic and Operational Priorities 2015 2020
Community Services Fraser Health s Mental Health and Addiction Services 2007 2012 strategic plan called for an expansion of withdrawal management services. It highlights the need for a range of withdrawal management programs including short-term assessment and stabilization beds, and medical, social, home and day-tox services. Barriers to timely access to withdrawal management and detox services are evident from the long waitlists and a lack of available alternative withdrawal management programming. Unique populations requiring withdrawal management services have not been adequately identified, and the absence of dedicated sobering support services may contribute to hospital congestion and be an unnecessary burden on policing resources. Clients using withdrawal management services often express an interest in continuing their recovery journey by directly entering a support recovery or intensive treatment program post-detox, but the transition from withdrawal completion to residential program admission frequently leads to relapse. Such clients need enhanced stabilization support post-detox/pre-treatment to help them maintain sobriety through this process. An integrated and accessible continuum of care is vital to ensuring that clients are supported, particularly at vulnerable transition points. MHSU will strategically align and integrate withdrawal management supports and services with existing services to ensure that clients can access a seamless continuum of care and the program continues to increase capacity for withdrawal management and sobering centres. The exploration of alternative medications to support clients experiencing problematic alcohol use and the availability of stabilization beds to support client s post-detox/ pre-treatment is key to closing service gaps and preventing client relapses. Timely access to suitable withdrawal management services is essential for engaging clients in the substance use system of care and preparing them for subsequent steps along the recovery continuum. Priority Action Increase timely access to effective withdrawal management services for all clients. We will achieve this by: developing post-detox/pre-treatment, short-term stabilization beds to meet the projected need for increased capacity as resources allow; exploring alternative medications that will improve clients success with problematic withdrawal; collaborating with clients and community partners in researching, developing and implementing alternative withdrawal management models and identifying unmet withdrawal management needs within Fraser Health; MHSU Strategic and Operational Priorities 2015 2020 23
Community Services building stronger relationships with hospital emergency departments, local police detachments and other community partners to develop a sustainable, competent and capable response that meets the needs of intoxicated clients; and collaborating with support recovery, treatment facilities and other community partners in building capacity for client stabilization beds post-detox and pretreatment. Signs of success: Clients accessing the Fraser Health withdrawal management system have timely access to services and supports through access to alternative withdrawal management models and post-detox, short-term stabilization beds. Clients continuing to relapse with alcohol while attending outpatient day-tox programs are offered alternative medication-assisted supports and services to aid their sobriety. Residential Substance Use Programs Fraser Health offers two models of residential substance use service: intensive residential treatment (IRTs); and stabilization and transitional living residences (STLRs) (previously called support recovery). On average, IRT stays range from 35 to 70 days and STLR stays range from 60 to 90 days. Most models are based on a 12-step approach, and include peer counsellors, step work, psycho-educational presentations and discussions, and lifeskills training. These services work especially well for clients who are homeless or at risk of being homeless and those with unstable or unsafe housing who require substance use supports and services. All residential substance use services funded by Fraser Health include the use of medication-assisted supports and services (MASS), particularly for clients who use opiates such as heroin. MASS may include the use of methadone or suboxone and other evidence-informed practices to assist clients with addictions. Delays in access to residential services often lead to relapses, which result in clients cycling unsuccessfully through MHSU services. Once in a residential service, clients recovery success can be hampered by premature discharges or their leaving a facility too soon on their own. Improving the integration of services is a critical step in improving the efficiency of client access and maximizing occupancy for all direct service and contracted residential substance use programs, which in turn will help to build capacity within existing services. It will be important to evaluate and adapt IRT and STLR programming in response to changing client needs and emerging at-risk populations. Particular attention needs to be paid to the provision of appropriate, specialized services for severely addicted and mentally ill (SAMI) clients. 24 MHSU Strategic and Operational Priorities 2015 2020
Community Services Priority Action Increase timely access to a robust, flexible and seamless continuum of care for the stabilization, support and retention of all clients, particularly the population of severely addicted and mentally ill (SAMI) who require specialized services. We will achieve this by: expanding the Assertive Community Treatment (ACT) team infrastructure; strengthening system linkages so clients experience seamless service delivery by improving feedback and communication mechanisms between clients and community referral agents; and monitoring and evaluating client and system needs to address service quality issues and capacity needs, as opportunities arise. Signs of success: A minimum of two ACT teams are established to serve MHSU clients. Clients have timely access to program beds and experience improved treatment outcomes, increased completion rates and better linkages to appropriate aftercare services. Improved residential service delivery models are available to clients with complex needs, such as the SAMI population. MHSU and community partners, stakeholders and families participate in improved communication that focuses on client needs, capacity issues and the quality and safety of services provided. Primary Care Substance Use Services The interface between primary care and the wider MHSU continuum is integral to the development of MHSU services that are integrated, accessible and effective. Primary care is often the first point of entry for clients seeking support. Primary Care Substance Use Services will focus on two priorities: the provision of public opiate substitution therapy clinics operating out of the Primary Care Substance Use Services site; and the introduction of the pathway model to screen for substance use issues that require further interventions and referrals. Public opiate substitution therapy service Methadone maintenance treatment (MMT) and use of suboxone are two forms of opioid substitution treatment. They are among the most effective means to address opioid dependence, preventing and reducing the MHSU Strategic and Operational Priorities 2015 2020 25
Community Services transmission of blood-borne pathogens. Since 1996, the MMT program has gained acceptance worldwide and British Columbia has become a leader in providing this treatment. An effective MMT program has three components: prescribing methadone; dispensing methadone; and providing psychosocial services and supports or counselling. 14 In the Fraser Health region, MMT is delivered in private settings, often without the services of professional substance use counsellors and often at an extra cost to the client. A disconnect exists between current MMT services available through GPs (general practitioners) and the wider substance use system of care. A review of the province s MMT program in 2010 made recommendations to improve the delivery, effectiveness and continuity of MMT services within Fraser Health. According to the review 15 : MMT services must be coordinated within the province and current gaps in responsibility and accountability must be addressed. Government should work together with health authorities, the College of Physicians and Surgeons of British Columbia, the College of Pharmacists of British Columbia, and professional training institutions to develop and implement workforce development strategies to support a coordinated multidisciplinary approach to MMT. Primary care/gp pathway model Traditionally, screening for substance use disorders has not been done in a consistent and systematic way in primary care settings. This has resulted in many missed opportunities to help clients recognize emerging substance use issues or to engage with those who have problematic substance use behaviours. Lack of adequate screening also means that opportunities are being missed to assist clients at low or moderate risk through the use of brief interventions such as motivational interviewing, dialogue, change talk and cognitive behavioural therapy. The Saskatchewan Ministry of Health developed and piloted a care pathway model that typically begins with a GP and moves clients through a process of screening and then specific assigned interventions. Evaluations of the model have pronounced it a great success and Saskatchewan is expanding it to multiple sites throughout the province. Manitoba and Prince Edward Island are now engaging with its developer, Dr. David Brown, to initiate implementation of the pathway model in those provinces. The model could be promising for Fraser Health MHSU as well, providing opportunities for interprofessional partnerships that could improve health outcomes for those living with substance use issues. 14 15 Centre for Addictions Research BC (2010) Reist and Parkes (2010) 26 MHSU Strategic and Operational Priorities 2015 2020
Community Services Priority Action Increase timely access to evidence-informed primary care substance use services for all clients. We will achieve this by: developing and implementing a model of publicly operated, inter-professional opiate substitution therapy services, including Methadone Maintenance Treatment (MMT), that involves clearly defined roles; exploring the adoption of the Saskatchewan patient care pathway prototype; and developing an evaluation framework for potential pilot sites, in partnership with MHSU s Knowledge Exchange Leader and participating family physicians. Signs of success: Clients using opiates receive quality, safe and ethical services delivered by an integrated team of physicians, nurses, nurse practitioners and substance use counsellors. Clients on prescribed methadone have a decreased financial burden in paying for the service. Identification of individuals with problematic substance use is increased within primary care settings, and therefore so are interventions and referrals to a range of more intensive services. MHSU Strategic and Operational Priorities 2015 2020 27
Acute Services ACUTE SERVICES Acute Mental Health Services Fraser Health MHSU works across the community and acute continuum to ensure optimal coordination of resources and care that maximizes existing capacity. Actions currently underway include: problem-solving for system-wide access, flow and resource utilization; monitoring the ALOS/ELOS ratios and readmission rates; enhancing inpatient programming; and enhancing capacity with the Royal Columbian Hospital redevelopment. Access, flow and resource utilization MHSU will continue to problem-solve systemwide access, flow and resource utilization issues through a number of processes, including weekday portfolio-wide congestion calls with representation from all acute sites, tertiary, withdrawal management and community housing programs and weekly meetings of the Regional Tertiary, Housing and Acute, Access and Flow Steering Committee to address systems barriers and challenges and improve coordination of resources and care. ALOS/ELOS and readmission rate In order to build capacity for care across all sectors, improve efficiencies and reinvest savings in community and long-term care, MHSU carefully monitors ALOS/ELOS and readmission rate. Managers, clinical directors and medical directors are all committed to carefully monitoring ALOS/ ELOS. ALOS/ELOS is the ratio of the average length of stay (ALOS) in an acute setting divided by the expected length of stay (ELOS). ELOS is provided by the Canadian Institute for Health Information (CIHI) and reflects the Canadian average time to treat similar conditions in a single site. A ratio of 1 implies treating these conditions in Canadian average time. Readmission rate is defined as any unplanned inpatient hospitalization occurring within 28 days of discharge from a previous hospitalization for a related primary diagnosis of mental health and/or substance use issues. Since MHSU s inception, its Quality Performance Monitoring System (QPMS) is the body that monitors and evaluates key performance indicators (KPIs) with the goal of improving quality, safety and efficiency in care. Looking ahead, the MHSU QPMS will continue to strengthen its role in order to achieve this shared vision of a quality, community-based system of care. Inpatient programming In 2010 2011, the BC Ministry of Health conducted a Patient Experience of Care survey across all of the province s Inpatient Psychiatric Unit (IPU) sites. Within Fraser Health, patients voiced dissatisfaction with programming and activity services, citing boredom as a main concern. This prompted the first extensive survey of MHSU IPU sites, which revealed considerable inconsistencies between facilities in staffing, programming, evaluation and feedback mechanisms. 28 MHSU Strategic and Operational Priorities 2015 2020
Acute Services The Inpatient Psychiatric Unit (IPU) is an intensive service where acutely and severely ill individuals receive the care they need to recover from acute symptoms and safely return to the community. Fraser Health provides inpatient psychiatric care at eight designated hospitals and emergency department services at 12 hospitals. There are 196 funded adult inpatient beds, including 16 psychiatric high acuity beds at two sites (Abbotsford, 4; Surrey, 12). Trending over the past two years (2011/12 2013/14) shows a 16 per cent increase in presentations to Emergency Departments of persons struggling with mental health and/or substance use issues across Fraser Health. To address clients concerns, ensure provision of the highest quality of care, and develop programming that facilitates flow through acute services, MHSU is developing standardized, evidence-informed best practices that are client directed and informed by client outcomes. A central part of the IPU mandate is to deliver programming that provides patients with opportunities to learn skills that improve wellbeing and aid recovery following discharge. All MHSU IPU sites offer a mix of group and one-on-one activities that include life-skill building, coping mechanisms, mindfulness and relaxation, leisure, and social interaction. Clients meet one-on-one with IPU staff and often with occupational therapists, recreation therapists, mental health workers or social workers to discuss their individual needs for recovery and discharge planning. Inpatient units play a critical role in caring for severely ill clients who are most likely to experience prolonged stays in acute care; be readmitted upon discharge; and be in need of more appropriate services such as community-based care or services through tertiary or housing programs. Acute inpatient services will concentrate on developing effective recovery programming, allowing clients to initiate and sustain recovery, gain independence and develop a plan for discharge. Looking ahead, MHSU recognizes that a full review of inpatient therapeutic programming is necessary. A high level of coordination, planning and collaboration will be required to ensure that changes occur in a way that is manageable, person-centred, outcome-oriented and evidence-informed, and is supported by MHSU staff, patients and the latter s natural supports. MHSU must maintain focus on inpatient access and flow in order to relieve pressures on Emergency Departments and to ensure that those in acute psychiatric crisis receive appropriate, timely and effective care. Royal Columbian Hospital Redevelopment Inpatient capacity will increase by 45 beds by 2020 as part of phase one of the hospital s redevelopment. This will include 15 general adult psychiatry beds, 20 geriatric psychiatry beds and 10 psychiatric high acuity beds. Outpatient MHSU services provided at Royal Columbian will be expanded to support a spectrum of care aimed at reducing readmission, facilitating discharge and providing specialized expertise to complement local and regional community-based services. MHSU Strategic and Operational Priorities 2015 2020 29
Acute Services Priority Action Increase timely access to acute care and ensure that appropriate recovery-based inpatient treatment, programming and discharge planning are in place for all clients requiring inpatient care. We will achieve this by: improving access and flow across the acute, tertiary and community continuum, through improved coordination of care and process efficiencies; maintaining the ALOS/ELOS ratio at 1 or less, and striving for a readmission rate below 11 per cent; developing, implementing and evaluating standardized recovery-oriented core programming across all MHSU Inpatient Psychiatric Units (IPUs) by completing a multi-year plan based on a full review of services, employee complements and physical environments; increasing regional IPU capacity by: adding 45 beds at Royal Columbian Hospital (15 adult, 20 geriatric, 10 psychiatric high acuity); expanding Royal Columbian s MHSU outpatient program to provide specialized services that prevent admission; facilitating discharge; and complementing local and regional community-based services; and providing standardized opportunities for clients and their natural supports to offer feedback on their experience of care on the IPU. Signs of success: MHSU maintains an ALOS/ELOS of 1 or less. MHSU maintains a readmission rate of 11 per cent or less. MHSU has core IPU programming that incorporates evidence-informed practices and recovery-oriented services that are guided by a multi-year implementation plan. Clients are active and informed participants in their treatment through the use of recovery-based group or individual programming available seven days a week. Clients and their support networks have meaningful opportunities for involvement and feedback that inform changes to IPU programming. Employees are fully engaged in the implementation of change, and understand the link between programming and behaviour/recovery on the IPU. 30 MHSU Strategic and Operational Priorities 2015 2020
Acute Services Seclusion Room Practice With 45 seclusion rooms in acute inpatient units, tertiary mental health facilities and Emergency Departments across Fraser Health, seclusion is an intervention frequently used to manage a client s risk of self-injury and physical aggression toward other psychiatric patients and MHSU staff. However, the practice of seclusion poses a high risk of both physical and psychological harm to patients and staff. MHSU has been working toward reducing these risks, though little evidence is currently available in the literature to support the development of an evidence-informed approach. Seclusion is a physical intervention during which a person is contained in a room that is either locked or from which free exit is denied. The Ministry of Health and the MHSU Planning Council have identified seclusion as an area of particular risk for patients and staff, an area that requires clear, evidence-informed and measurable minimum standards. An evidence review was completed and published online in September 2012, 16 clearly outlining the expectation that all health authorities would develop a clear and unwavering trauma-informed, recoveryoriented approach to seclusion. 17 Since 2010, the MHSU team at Fraser Health has been working to reduce the risks associated with seclusion. The MHSU Seclusion Room Working Group has been actively engaged in developing guidelines for seclusion that align with these standards and guidelines. To align current practice with provincial quality, health and safety standards, Fraser Health MHSU will require the development of a consistent approach to the use of seclusion across all designated sites. The aim will be to reduce the number of seclusion events, reduce the risk of harm to patients and staff associated with the practice of seclusion, and ensure that practice is consistent with provincial guidelines. Priority Action Enhance patient and staff safety by standardizing seclusion room practices across MHSU services. We will achieve this by: developing Fraser Health policy to support compliance with the Provincial Quality, Health and Safety Standards and Guidelines for Secure Rooms in Facilities Designated under the BC Mental Health Act ; 16 17 BC Ministry of Heatlh (2013). Provincial Quality, Health and Safety Standards and Guidelines for Secure Rooms in Facilities Designated under the BC Mental Health Act [draft]. Ibid. MHSU Strategic and Operational Priorities 2015 2020 31
Acute Services developing clinical procedure guidelines for front-line staff to use to ensure dayto-day compliance with standards; and establishing performance expectations, measurable outcomes and data collection methodologies that demonstrate compliance with provincial standards and guidelines. Signs of success: An annual audit demonstrates compliance with clinical policy and achievement of Ministry of Health targets. The number of incidents involving threats to the safety of clients, staff and seclusion room patients decreases. All seclusion room incidents involving threats to the safety of clients and staff are reported on the Patient Safety Learning System (PSLS). 32 MHSU Strategic and Operational Priorities 2015 2020
Tertiary Service Stream TERTIARY SERVICE STREAM Tertiary mental health services are specialized programs for individuals with complex mental health disorders that are often resistant to treatment and require a higher level of care than that provided in primary or secondary care. Tertiary clients require specialized assessment, treatment and rehabilitation activities provided by highly trained staff. Tertiary services include both short- and long-term stays in tertiary residential facilities in addition to support that is provided by Assertive Community Treatment (ACT) teams in the community. Over the past 10 years, a number of tertiary facilities in Fraser Health have been developed as part of the Riverview Redevelopment Project. Fraser Health played a major role in this project, developing a total of 267 tertiary beds. The opening of the Timber Creek tertiary facility in September 2012 marked the final phase in Fraser Health s commitment to this project. Tertiary services need to be reviewed and rebalanced in response to capacity pressures, changing program needs, and the evolution of the tertiary program. In addition, MHSU tertiary services need to develop standardized assessment and evaluation tools and implement provincially established tertiary care standards. Redefining tertiary services will be aimed at aligning the tertiary program with provincial initiatives currently underway and supporting recommendations made in the 2013 BC Tertiary Mental Health Services Progress Report. 18 Figure 4. Levels of Care within MHSU Tertiary Services 18 Provinicial Health Services Authority (2013) MHSU Strategic and Operational Priorities 2015 2020 33
Tertiary Service Stream Priority Action Increase timely access to tertiary services and ensure appropriate placement for clients requiring these services. We will achieve this by: standardizing policy and practices to align with provincial standards; implementing assessment tools and evaluation processes; partnering with acute, community and housing service streams; working with key tertiary staff, internal and external stakeholders, and the Provincial Tertiary Steering Committee to realign and redefine tertiary resources based on newly established provincial definitions and standards; clearly defining admission criteria, program goals and referral pathways to ensure that clients are receiving an appropriate level of tertiary care and that capacity is optimized through improved resource utilization; implementing standardized assessment and decision-support tools at admission, during treatment and at pre-discharge; working closely with referring partners to increase the transparency of admission processes and improve knowledge and understanding of MHSU tertiary services; and in conjunction with the Provincial Tertiary Steering Committee: establishing baselines for wait times into tertiary care; monitoring length of stay data, readmission rates and empty-bed days; and establishing key performance indicators to measure progress annually or semi-annually. Signs of success: Care outcomes are improved as clients receive the most appropriate level of care with increased access to tertiary services. Performance baselines are established that include wait times for tertiary services, expected length of stay, readmission rates and number of empty-bed days, allowing ongoing monitoring of key performance indicators. Clients are placed in the right level of care through clearly defined admission criteria, program goals and referral pathways, improving access and flow. Other Fraser Health programs, external partners and referring sources have better knowledge and understanding of MHSU tertiary services. Provincial tertiary care standards are established and implemented. 34 MHSU Strategic and Operational Priorities 2015 2020
Housing and Residential Service Stream HOUSING AND RESIDENTIAL SERVICE STREAM A growing body of research on housing models and service-user preferences suggests that supported housing programs based on the principles of psychosocial rehabilitation are effective in helping clients recover from mental illness. Without adequate housing, many individuals are vulnerable to homelessness and increased hospital visits. Fraser Health MHSU has invested in a range of supported housing over the past seven years, increasing the supported housing stock by 305 beds (19 per cent) between 2007 and 2014. However, the growth in MHSU housing is not The development of noncustodial, rehabilitation-oriented housing programs has clearly demonstrated that mental health consumers can thrive in more independent housing if the right balance of supports is in place. Centre for Addiction and Mental Health (2012) keeping pace with population growth, and analysis of the housing shortfall suggests that Fraser Health must continue to build housing capacity in specific communities. Fraser Health s MHSU Housing and Residential Program Priority Action Plan (2015 2020) focuses on providing a continuum of housing options and supports for adults at various developmental stages and in different contexts, building on individual, family and community strengths. Current MHSU housing capacity cannot meet the changing needs of clients, particularly young adults, older adults and the SAMI population. Many MHSU facilities are aging and no longer meet community standards; and many have features that make them inaccessible for people with mobility challenges. Overall, affordable housing is lacking in Fraser Health, and meeting current and future demands will require strong partnerships to create sustainable housing opportunities for clients. MHSU s vision for the future is for a person-centred residential housing program that offers flexibility and engages the service user in an individualized, collaborative and holistic support program where opportunities for recovery and focused interventions correspond with individual goals and level of motivation. To achieve this vision, the program is focusing on quality improvement and the development of an evaluation framework. The housing program must include support for an aging population, allowing individuals in that group to remain independent whenever possible. Housing redesign will be an important part of the plan, recognizing the need to improve accessibility to and within buildings, and to increase capacity for specific communities, including those in the severely addicted and severely mentally ill (SAMI) population. MHSU s work in this area will necessarily be in collaboration with key partners, including BC Housing, Fraser Health Residential Care and Assisted Living, and health service providers. MHSU Strategic and Operational Priorities 2015 2020 35
Housing and Residential Service Stream Priority Action Increase timely access to appropriate levels of safe housing for young adults, older adults and the severely addicted and mentally ill (SAMI) population, as resources allow. We will achieve this by: developing housing options for young adults, older adults and the SAMI population; ensuring that community and safety standards are met through housing replacement options; collaborating with key partners; optimizing existing capacity and building new capacity to respond to the aging population requiring mental health housing; providing low-barrier support and housing for people with concurrent disorders, including the SAMI population, by developing or modifying existing supported housing and residential resources; addressing the unique needs of young adults, using a young-adult-focused approach; providing improved housing options by collaborating with partners such as BC Housing and health service providers; improving client access and flow to the appropriate level of housing support by creating processes that optimize resource utilization; and monitoring program accountability and supporting safety and quality improvements in, for example, recovery-centred practice, and program involvement and satisfaction for residents/participants. Signs of success: Service capacity is increased through strong partnerships and services that are built around the unique needs of the most vulnerable populations, and results in reductions in the risk of homelessness and repeat hospital readmissions. MHSU housing resources are brought to acceptable and accessible standards that facilitate optimal care and well-being for all clients, including those with mobility challenges, and are consistently monitored for quality. Housing environments reflect a culture of recovery, and residents are in a program that is aligned with their recovery goals. Wait times and waitlist numbers for MHSU housing are reduced. Resident satisfaction surveys are routinely offered and results indicate an increase in quality of life, health status, and increased housing opportunities and choice. 36 MHSU Strategic and Operational Priorities 2015 2020
Service Quality and Safety SERVICE QUALITY AND SAFETY Quality and Performance Monitoring One of the seven strategic enablers identified by the BC Ministry of Health as critical for successful change is quality. 19 The provincial strategy emphasizes the importance of consistency across clinical services as well as of safety and quality assurances aimed at improving patient outcomes. The strategy also highlighted: the creation of a clinical care management system to improve care for patients; the development of a guideline identifying 15 high-priority areas for system improvement; and the linking of clinical quality improvement initiatives with the BC Patient Safety and Quality Council. The MHSU Quality Performance Committee (QPC) is accountable for enhancing patient safety and quality of services across the MHSU continuum of care. Since 2010, the committee has played a key role in managing a consistent patient safety review process and quality improvement initiatives across the continuum. As a governance body, it ensures: senior administrative and physician leadership and sponsorship for quality assurance; promotion of a culture of safety at all levels of the program through collaboration with front-line staff and physicians; and performance monitoring and evaluation of the service environment. The MHSU Quality Performance Committee will strengthen its leadership by setting strategic goals and aligning its efforts with those of the Fraser Health Authority. Key to this effort will be the use of the Quality Performance Monitoring System (QPMS) and the Patient Safety and Learning System (PSLS). The QPC also ensures that resources are available to sustain and implement effective measures that enhance patient safety and quality of care. 19 BC Ministry of Health (2014a) MHSU Strategic and Operational Priorities 2015 2020 37
Service Quality and Safety Priority Action Embed, enhance and sustain a culture of safety and quality across the continuum of MHSU services. We will achieve this by: strengthening the MHSU Quality Performance Committee; developing a three-year, phased work plan for the Quality Performance Committee; strengthening our partnership with the Patient Care Quality Office to address issues that are important to patients, clients, residents and families and to improve the quality of our services; and promoting stakeholder engagement in the Quality Performance Monitoring System by providing opportunities for knowledge exchange, training, action planning, and broader education and dissemination of information. Signs of success: The MHSU Quality Performance Committee is widely recognized as a strong governing body with the primary role of ensuring the quality of care and safety of MHSU patients, clients, residents and employees. A three-year work plan is developed, with community services at the centre, identifying 15 high-priority initiatives for system improvement and the implementation of five a year from 2015 to 2018. The Quality Performance Monitoring System is used at all MHSU leadership levels for monitoring and action planning. Performance monitoring and evaluation planning are included in all MHSU quality initiatives and services. Employees are aware of the Quality Performance Committee s role. Rehabilitation and Recovery (R&R) Services Rehabilitation and Recovery (R&R) Services is responsible for contracted psychosocial rehabilitation (PSR) services within the community, as well as for most internal specialized rehabilitation staff working in community mental health positions. PSR services focus on recovery and include occupational therapy, vocational counselling and recreation therapies. In 2007, MHSU s R&R Services were reconfigured to a regional structure to: align service delivery and staffing resources with a recovery service model; develop consistent programming across Fraser Health; and improve client outcomes. This has resulted in 38 MHSU Strategic and Operational Priorities 2015 2020
Service Quality and Safety a number of positive outcomes, including a marked increase in the number of MHSU clients obtaining employment. While significant gains have resulted, service gaps still exist due to a lack of specialized PSR resources across the region. Some communities still do not have access to the full range of PSR services. The BC Ministry of Health has stressed the importance of comprehensive rehabilitation and recovery-oriented services by calling for the implementation of evidence-informed rehabilitation services. 20 The Ministry s 2013 draft PSR Service Framework 21 calls for all of the province s health authorities to ensure that their entire workforce in mental health and substance use receives ongoing education related to PSR and recovery. The framework also requires specialized rehabilitation staff for assessment, goal setting and intervention planning; and recommends that PSR approaches be available to transitional youth (15 18 years old) as well as to adults across the five life domains (employment, education, leisure, wellness and living). Continued implementation by MHSU of the evidence-informed Recovery-Centred Clinical System (RCCS) model (or recovery journey ; see Figure 5) will meet the Ministry s requirements while helping MHSU provide equitable PSR services and support its employees in working collaboratively with clients. Figure 5. The Recovery Journey Source: www.telecarecorp.com 20 21 BC Ministry of Health (2014a) BC Ministry of Health Working Group (2013). British Columbia Psychosocial Rehabilitation (PSR) Service Framework. Victoria: BC [draft]. MHSU Strategic and Operational Priorities 2015 2020 39