Systems Improvement through Service Collaboratives (SISC) Brian Rush, PhD (on behalf of the Performance Measurement & Implementation Research Team) Centre for Addiction & Mental Health Ontario, Canada

Outline Background and Context Ontario CAMH Systems Improvement through Service Collaboratives (SISC) Initiative Implementation Framework Background Adaptation of the National Implementation Research Network (NIRN) Active Implementation Framework to SISC Balancing between Science & Pragmatism Implementation research dilemmas 2

Ontario, you say? Source: http://www.fmcsa.dot.gov/intl-programs/canada/index.htm

Ontario, you say? What Ontario is… What Ontario isn’t… Image references: CN Tower: http://start-a-business-canada.ca/start-a-business-ontario/ Map of Northern/Southern Ontario: http://www.rom.on.ca/ontario/fieldguides.php Scenic picture: http://coucoucanada.blogspot.ca/2011/04/le-temps-dun-week-end.html

Ontario: Population density

What is CAMH? The Centre for Addiction and Mental Health (CAMH) is Canada's largest mental health and addiction teaching hospital, as well as one of the world's leading research centres in the area of addiction and mental health. CAMH combines clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues. CAMH has been recognized internationally as a Pan American Health Organization and World Health Organization Collaborating. 6

Open Minds, Healthy Minds Background: Open Minds, Healthy Minds CAMH has been asked by the province of Ontario to lead several key provincial activities which are now underway as part of Open Minds, Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strategy. The Strategy begins with a three-year-plan that focuses on children and youth. 7

Ontario’s Comprehensive Mental Health and Addictions Strategy OVERVIEW OF THE THREE YEAR PLAN Starting with Child and Youth Mental Health Our Vision: An Ontario in which children and youth mental health is recognized as a key determinant of overall health and well-being, and where children and youth reach their full potential. Provide fast access to high quality service Kids and families will know where to go to get what they need and services will be available to respond in a timely way. Identify and intervene in kids’ mental health needs early Professionals in community-based child and youth mental health agencies and teachers will learn how to identify and respond to the mental health needs of kids. Close critical service gaps for vulnerable kids, kids in key transitions, and those in remote communities Kids will receive the type of specialized service they need and it will be culturally appropriate THEMES INDICATORS Reduced child and youth suicides/suicide attempts Educational progress (EQAO) Fewer school suspensions and/or expulsions Decrease in severity of mental health issues through treatment Decrease in inpatient admission rates for child and youth mental health Higher graduation rates More professionals trained to identify kids’ mental health needs Higher parent satisfaction in services received Fewer hospital (ER) admissions and readmissions for child and youth mental health Reduced Wait Times Pilot Family Support Navigator model Y1 pilot Implement Working Together for Kids’ Mental Health Implement standardized tools for outcomes and needs assessment Enhance and expand Telepsychiatry model and services Provide support at key transition points Improve public access to service information Develop K-12 resource guide for educators Improve service coordination for high needs kids, youth and families Funding to increase supply of child and youth mental health professionals Increase Youth Mental Health Court Workers Amend education curriculum to cover mental health promotion and address stigma Hire new Aboriginal workers Implement Aboriginal Mental Health Worker Training Program INITIATIVES Outcomes, indicators and development of scorecard Expand inpatient/outpatient services for child and youth eating disorders Provide designated mental health workers in schools Hire Nurse Practitioners for eating disorders program Reduce wait times for service, revise service contracting, standards, and reporting Implement school mental health ASSIST program and mental health literacy provincially Strategy Evaluation Implement Mental Health Leaders in selected School Boards Provide nurses in schools to support mental health services Create 18 service collaboratives

“Create 18 Service Collaboratives” Systems Improvement through Service Collaboratives (SISC) is one initiative encompassed within the Comprehensive Strategy. 18 Service Collaboratives established across Ontario will focus on addressing system gaps related to mental health and addictions services. SISC’s Goal To support local systems to improve coordination of and enhance access to mental health and addiction services. 9

Which Ministries are involved? The Centre for Addiction and Mental Health (CAMH) is working with six provincial ministries to ensure the Service Collaboratives’ success. They are: Ministry of Health and Long-Term Care; Ministry of Children and Youth Services; Ministry of Education; Ministry of Training, College and Universities; Ministry of the Attorney General, and; Ministry of Community Safety and Correctional Services. 10

Advisory and Accountability Structures Systems Improvement through Service Collaboratives (SISC) Project Sponsor: CAMH Provincial Government Oversight Committee Advice, Communication and Approvals Accountability Communication Ministry of Health and Long-Term Care Provincial Collaborative Advisory Group Service User Expert Panel Advice and Communication Scientific Expert Panel Other Expert Panels Communication Related Services and Stakeholders

Minimum Specifications Focus on improving transitions Multi-sector partnerships Use of Implementation Science & Quality Improvement tools Focus on Equity Evaluation

What is a Service Collaborative? A group of local service providers who work together to improve access to and coordination of mental health and/or addiction services. Membership in Collaboratives reflects the cross section of sectors that provide service to children and youth with complex needs. 14 Service Collaboratives are geographically based, and 4 focus on transitions between the health and justice systems. Statement of Purpose Service Collaboratives will bring together service providers and other stakeholders from various sectors that interact with people who have mental health and/or addictions problems, in particular children and youth agencies, justice programs, health providers, and education organizations. By working together to identify and implement system level changes, the Collaboratives will improve individuals’ ability to access services, their service experience, and their health outcomes. (Government of Ontario, 2011) Open Minds, Healthy Minds, available at http://www.health.gov.on.ca/en/public/publications/ministry_reports/mental_health2011/mentalhealth_rep2011.pdf

Key Transition Points Hospital Community Services E.g. Clients transitioning from inpatient to community based services. Child Services Adult Services E.g. Youth transitioning to adult services. E.g. An individual with mental health and/or addiction issues moving between health and justice services. Health Justice System

Who is participating? Community-led Service Collaborative Service Users Children & youth services Mental health and addictions Justice Programs Community Hospital Culture- specific care centres Family health Educational institutions

Service Collaborative Rollout The Strategy’s First 3 Years – Children & Youth 2012-2013 2011-2012 2013-2014 4 demonstration sites have been established (Cluster 1). 8 Service Collaboratives (6 geographic and 2 justice + health) (Cluster 2). 6 Service Collaboratives (4 geographic and 2 justice + health) (Cluster 3).

Service Collaborative Locations (to date) Thunder Bay London Simcoe/Muskoka Ottawa Cluster 1 2011/2012 Champlain (J) Cluster 2 2012/2013 Hamilton Kingston, Frontenac, Lennox & Addington Waterloo/Wellington Peel Durham Toronto (J) 17

Implementation Framework A specified set of purposeful activities at the practice, program, and system level designed to put into place a program or intervention of known dimensions with fidelity. A “make it happen” process, as opposed to diffusion or dissemination, which can be more passive in nature (Greenhalgh, Robert, Macfarlane, Bate, and Kyriakidou, 2004). Implementation Science The study of the methods to implement research findings (i.e. evidence-based research) into routine practice to ultimately improve client outcomes; Reference: National Collaborating Centre for Methods and Tools. A model for evidence-informed decision-making in public health. Retrieved August 7, 2012, from http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf

Adaptation of the National Implementation Research Network (NIRN) Active Implementation Framework to SISC Implementation Stages – SC sites phased in by 3 clusters Exploration Installation Initial Implementation Full Implementation Implementation Teams - Central and regional resources Implementation Cycles - QI tools (i.e. PDSA and practice-policy communication loop) Implementation Drivers – a) Leadership; b) Competency; c) Organization (e.g. program evaluation / decision support data systems).

Implementation Science in a Community Development Context Pragmatism Where we land depends on the issue, stakeholder perspective and perceived costs and benefits

Balancing between Science & Pragmatism Developmental evaluation (Patton, 2011) has been applied from the beginning of the SISC initiative and aligned with the implementation stages. Seeks to balance the gold standards of evaluation practice, policymaking and implementation science with the realities of community development

SISC Evaluation Plan Performance Measures Provincial Level Health equity Key transitions Partnership/collaboration Implementation progress Intervention outcomes Performance Measures Provincial Level Strengths, Weaknesses, Opportunities, Threats (SWOT) Semi-annual Internal Interim Assessments In-depth analysis to understand the factors associated with the implementation of the Service Collaboratives and their impact. 4 sites Case Studies of Selected Service Collaboratives Performance Measures – Local level

Local Evaluation Logic model / Evaluation Framework / Contribution Analysis Linking activities, processes and outcomes Evaluation Plans with Key Principles Distinction between process and outcome objectives Stakeholder-based Consistent with developmental evaluation Local indicators developed after decision on interventions 23

Evaluation Challenges I Meeting provincial expectations while supporting community development process Intervention + context = outcome NOT a linear process Developmental Evaluation Evaluation is part of the development of SISC, not above or outside of it Time constraints Timeline for SISC program development, including for PMIR (e.g. hiring Regional Evaluation Coordinators) Timeline for intervention and short to medium term outcomes – what is measurable and when? 24

Evaluation Challenges II Holding space for Implementation Science Tremendous opportunity but needs time and resources ‘Levels of evidence’ – Implementation Science for EBPs compared to reality of lack of evidence Moving timelines Challenges with fidelity to stages with moving timelines (community reality) Data sharing Sharing of client info, confidentiality, legal issues…etc 25

Balancing between Science & Pragmatism Not an easy balancing act but it’s exciting and we don’t think we’re alone!

ServiceCollaboratives.ca About SISC - The Strategy - FAQ - Who we are - Implementation Framework News & Resources - Project Updates - Upcoming Events - Resources - Newsletters Service Collaborative Communities - Map of active Service Collaboratives - A page for each Collaborative

For more information about the Systems Improvement through Service Collaboratives (SISC) initiative, contact: Brian Rush Director, Performance Measurement and Implementation Research Team Provincial System Support Program (PSSP) CAMH brian.rush@camh.ca Fiona Thomas Research Coordinator, Performance Measurement and Implementation Research Team Provincial System Support Program (PSSP) CAMH fiona.thomas@camh.ca

Appendix: Cluster 1 Gaps & Interventions System Gap Intervention London Continuity of care for children and youth with complex needs during transitions between services and/or sectors. The intervention is informed by: The Transitional Discharge Model The Emergency Department Clinical Pathways for Children and Youth Thunder Bay Community linkages that increase access to care and supports for Dennis Franklin Cromarty (DFC) High School students, and a service delivery plan that coordinates access of services for youth at DFC. The Fostering School, Family, and Community Involvement: Effective Strategies for Creating Safer Schools and Communities model (Adelman and Taylor, 2002) to bring together the family, community, and school to improve the student’s chance of success. Adelman & Taylor (2002.) Fostering School, Family and Community Involvement: Effective Strategies for Creating Safer Schools and Communities model. Accessed February 20th from https://www.ncjrs.gov/pdffiles1/ojjdp/book7.pdf 29 29

Appendix: Cluster 1 Gaps & Interventions System Gap Intervention Ottawa Access to services for transition aged youth (14-24) that are coordinated, youth-centred, timely, consistent, effective and evidence-based, least intrusive, innovative and community driven. The implementation of a formalized care plan including critical components: Formalized Care Plan Interagency and Cross‐sectoral Collaboration Meaningful Priority Population Involvement Meaningful Child and Youth Involvement Meaningful Family and Supporter Involvement Simcoe/ Muskoka Youth with mental health and/or addiction concerns transitioning between youth services (e.g., community services, justice and education) and Emergency Department and Hospital mental health services. The Transition to Independence Process (TIP) model to: Engage youth in their own future planning process; Provide youth with services and supports that are developmentally appropriate, non‐stigmatizing, culturally competent, and appealing; Involve youth, their families, and other informal key players. 30