1. 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

2. Disclosures
No conflicts of interest
Funding from:
CIHR
MOHTLC

3. 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.

4. What do we know about access?

5. Access: ED vs. Outpatient by income

6. ED as Point of Access

7. ED as First Contact by Diagnosis

8. 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.

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

10. 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

11. Types of Substances at Index ED Visit

12. Transitions from ED to Outpatient

13. Hospitalization Transitions

14. How does this compare to non-psychiatric Dx?

15. 30-day readmission by diagnosis

16. 7-Day Post-Discharge Physician Follow-Up

17. How do we compare – CHF and COPD?

18. Post-Discharge Follow-up by Diagnosis

19. SCZ – Highest Readmission Rate; Lowest F/U Rate

20. 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?

21. Ontario Regional Psychiatrist Supply

22. Avg total and new patients/year

23. <100 and <40 Patients/Yr by Years Since Graduation

24. Supply, Psychiatrist Age and Region

25. 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)

26. Reminder – Post-discharge follow-up

27. Access to Psychiatrists Post-Discharge

28. Psychiatrist Visit 180 Days Post-Suicide Attempt

29. 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

30. 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

31. 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.

32. JAMA. 2016;316(8):

33. 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

34. Thank you!
Questions?