Improving Transitions in Care for Children and Youth With Mental Health Concerns

Improving Transitions in Care for Children and Youth With Mental Health Concerns: Implementation and Evaluation of an Emergency Department Mental Health Clinical Pathway

The overarching goal of this project is to improve timely access to appropriate mental health (MH) care for children and youth. The investigators will conduct and rigorously evaluate implementations of this pathway in four exemplar hospitals and associated CMHA dyads within a local health region. Outcomes-based validation of this pathway is important for effective adoption in other communities. A multiple baseline study design and conduct interrupted time-series analysis will be used to evaluate whether the EDMHCP has resulted in improved health care utilization, medical management, and health sector coordination. To ensure EDMHCP feasibility in various settings, implementation will occur in four exemplar hospital-community dyads with different workflows and patient populations.

Commissioned by the Ontario Ministries of Health and Long Term Care(MOHLTC) and Child and Youth Services(MCYS), an expert-developed clinical pathway(CP) has been created with two main goals: 1) to guide risk assessment and disposition decision-making for children and youth presenting to the emergency department(ED) with MH concerns, and 2) to ensure seamless transition to follow-up services with community MH agencies(CMHAs) and providers. This pathway, referred to as the EDMHCP, is unique in undertaking to provide a seamless transition of care for children/youth and caregivers between hospital EDs and CMHAs.

Working with 4 exemplary hospital EDs and 2 Community Mental Health Agencies across Eastern Ontario, the investigators will conduct a 3-year mixed methods health services research project with three components to i) implement the EDMHCP using a theory driven, evidence-based approach, ii) evaluate EDMHCP effectiveness through measurement of relevant outcomes, and iii) conduct a process evaluation to document and assess the EDMHCP implementation strategy against the outcomes achieved.

This 3 year study will take place in five different phases, which include:

• Preparation: Qualitative interviews with ED team members and strategy development
• Implementation: Working with each ED team to implement the clinical pathway (including standardized assessments) within 8 months
• Post-implementation: Qualitative interviews with ED team members
• Data collection: 9-month pre/post chart audits of patients with mental health and caregiver satisfaction surveys
• Follow up: to discuss findings, database creation, and dissemination strategy.

To ensure the findings directly impact relevant service delivery areas, the investigators have specifically recruited study team members with decision-making authority and/or influence on delivery of care for children and youth with MH concerns. This project will provide an implementation model for the EDMHCP to be used in any ED and CMHA setting, and will demonstrate decreased wait times and increased access with EDMHCP adoption. The findings will guide policy decision-making on access to timely and appropriate MH care and add to current knowledge of implementation science. In addition to knowledge translation via team member dissemination within their areas of influence, the investigators plan to disseminate the findings through presentation at scientific and healthcare conferences, and publication in relevant peer-reviewed journals.

Inclusion Criteria:

• Ages > 5.99 and < 18 years
• Presented to the ED of the four chosen hospitals within a selected 8 month time frame (between January, 2016 to May 2017)
• Mental health issue as their primary complaint (all complaints identified at triage as involving MH [psychosocial, emotional, behavioural])
• Proficient in English.

Exclusion Criteria:

• CTAS of 1 (Resuscitation)
• Patient is not medically stable
• Intubation/PICU care required
• Direct admission to hospital for ongoing medical management and observation
• Patients presenting with head injury or post-concussional syndrome