Psychiatry in Ontario: Current Evidence and Future State AGHPS Leadership Summit 2018 Paul Kurdyak MD PhD Scientist, Institute for Mental Health Policy Research, CAMH Core Senior Scientist and Program Lead, Mental Health and Addictions Program Institute for Clinical Evaluative Sciences Associate Professor, IHPME

Disclosures No conflicts of interest Funding from: CIHR MOHTLC

Objectives To understand the importance of performance measurement to address issues related to health service quality. To learn about recent research describing access to mental health care amongst certain patient populations. To learn about emerging evidence describing different mental health service delivery models.

What do we know about access?

Access: ED vs. Outpatient by income

ED as Point of Access

ED as First Contact by Diagnosis

First Episode Psychosis – Access to Care 20,096 with FEP between 1999 and 2008 Approximately 40 per cent did not receive any physician follow-up within 30 days Nearly 60 per cent did not receive follow-up by a psychiatrist Males had lower odds of receiving any physician follow-up. The odds of psychiatrist follow-up decreased with increasing age and were lower for those living in rural areas.

Early Intervention and Mortality Anderson et al. , Am J Psychiatry Early Intervention and Mortality Anderson et al., Am J Psychiatry. 2018 May 1;175(5):443-452

Substance Use and ED use 1 out of 15 frequent ED users is for Mental Health/Addictions 64% of frequenty MHA ED users have substance-related issues

Types of Substances at Index ED Visit

Transitions from ED to Outpatient

Hospitalization Transitions

How does this compare to non-psychiatric Dx?

30-day readmission by diagnosis

7-Day Post-Discharge Physician Follow-Up

How do we compare – CHF and COPD?

Post-Discharge Follow-up by Diagnosis

SCZ – Highest Readmission Rate; Lowest F/U Rate

Shifting Gears Overview of previous slides: Indirect evidence that access to outpatient services is inadequate and transitions of care from the ED and hospitalizations to outpatients is poor What do we know about psychiatrist supply and practice patterns?

Ontario Regional Psychiatrist Supply

Avg total and new patients/year

<100 and <40 Patients/Yr by Years Since Graduation

Supply, Psychiatrist Age and Region

What about incentives? In September, 2011, MOHLTC introduced bonus payments for: Rapid access to patients within 30 days of psychiatric hospitalization discharge Ongoing care for 6 months following a suicide attempt Stated objective – to increase access at a critical period of time that would reduce deterioration, early readmission and possibly suicide attempts We can identify individuals post-discharge AND post-suicide attempt (ED only)

Reminder – Post-discharge follow-up

Access to Psychiatrists Post-Discharge

Psychiatrist Visit 180 Days Post-Suicide Attempt

A long list of issues Access to care is problematic There is evidence that the people with the greatest need are least likely to get the care they need There are concerning trends in regional psychiatrist supply that will make access worse

What evidence exists to move forward? Measurement-based care Integrated Care VERY little evidence on how to achieve good outcomes (medical and psychiatric) for individuals with serious mental illnesses

Psychiatric Services, Feb. 2017; 68(2):179-188 18% of US psychiatrists and 11% of US psychologists routinely incorporate symptom rating scales into their practice BUT MH providers MISS clinical deterioration in 80% of their patients Systematic review conclusions – ALL RCTs showed frequent and timely feedback of patient-reported symptoms during pharmaco- or psychotherapy improved patient outcomes Here we shift from measuring system-level performance to program/clinic/clinician-level performance.

JAMA. 2016;316(8):826-834

Conclusions Emerging evidence that access and transitions in care are problematic Existing psychiatrist supply and practice patterns will not address access and transition evidence without change Evidence exists, but is not being implemented in Ontario

Thank you! Questions?