1. Increasing Access to Mental Health & Addictions (MH&A) Services in Rural Areas BC Patient Safety & Quality Council Quality Forum, Vancouver, Feb 2015 Presenters: Kathleen Collins, Selina Tsang

2. 2 Rural Setting: Pemberton Pemberton is located 25 min north of Whistler 2 hours from Vancouver Health Services Served by 4 to 5 GP’s No local hospital Only emergency in local health centre

3. 3 Stakeholders Family doctors MCFD / CYMH – community mental health services Emergency (community and acute) BC Ambulance Transport Secondary level of acute care Tertiary level of acute care A fractured youth mental health system in B.C. that is confusing and frustrating for youth and their families to navigate Communication lapses between service providers Long waits to see mental health professionals or to receive treatment

4. 4 Mental Health Services in Pemberton CYMH services not well understood -- often confused with Child Protection Services and Adult MH Services Variation in who delivers community MH services. Note: Vancouver Coastal Health (VCH) Child Youth Mental Health (CYMH)

5. 5 Barriers to Access CYMH services available only during weekday office hours Inadequate child psychiatrist coverage –only available in Squamish –up to 2 months wait

6. 6 Lack of coordination between systems  Unsupported vulnerable youth GP not following protocol to certify kids under the MH Act Nearest hospital (LGH) not staffed with child psychiatrist GP confused why they can’t refer directly to BCCH (CAPE unit) Child & Adolescent Psychiatric Emergency

7. 7 Project Goals Establish standardized process for Pemberton children, youth and families to access psychiatric assessment Emergent need Urgent need

8. 8 Lean Approach Assembled design team GP, psychiatrists, nurses, leadership from Regional Mental Health, Lion’s Gate Hospital, CYMH Established clarity and shared understanding Clarified roles and responsibilities

9. 9 Current State Map

10. 10 An emergent patient may be… Refused transport to secondary hospital if ER Doc refuses to accept patient Typically only accepted for medical issues

11. 11

12. 12 An urgent patient Ideally accesses local help But when local resources are unavailable / inadequate Cannot escalate to Emergency (do not fit Emergent criteria) Take their chances to get seen by BCCH Urgent Assessment Clinic

13. 13 Future State Map

14. 14 Emergent Cases LLTO Policy Revisions Policy specifically references MH&A patients Receiving sites must accept the transfer of a patient in a LLTO situation when the services needed for the patient do not exist at the sending site Resulting Changes Certified children and youth receive psychiatric assessment at LGH (by adult psychiatrist in the interim) Addition of child psychiatrist at LGH

15. 15 What does it take to … Create a New Urgent Assessment Clinic? In a rural setting (aka lack of resources)?

16. 16 Unleash the Power & Passion of a Committed Team

17. 17 PEOPLE Combination of adult & child psychiatrists CYMH + VCH staff Psychiatrist bills MSP for seeing patient COST CYMH covers transcription costs VCH covers cost of psychiatrist time for no- shows Same space used by adult MH - VCH PLACE CYMH office space (child psych) Private office space in Whistler (child psych) CONSULT NOTES Charts held by CYMH TIME Clinic available every 1– 2 weeks Hold time or book lunch time slots

18. 18 Referral Process Accept referrals from Self / Family Schools General Practitioner Emergency Clinic CYMH Intake coverage 7 days a week Referral triaged by CYMH leader Standard process documented in Pemberton Child and Youth Urgent Assessment memorandum of understanding

19. 19 LGH liaison notifies Community of impending discharge Community Mental Health Pemberton emergency medical centre Urgent Ax Clinic LGH GP / Referring MD Partners … for the Benefit of the Kids * If patient gets transferred to BCCH, CAPE doctors invite CYMH in discharge planning Psychiatrist consult notes sent to GP / referring physician CYMH shares specific strategies for high risk youth in anticipation of future patient visits.

20. 20 Measures of Success Urgent Psychiatric Assessment Clinic Established urgent assessment clinic in Dec 2013 Guaranteed appointment within 2 weeks, often seen as soon as next day 8 urgent cases seen to date 8 urgent cases receiving psychiatric assessment within target of 1 week

21. 21 Voice of Providers We know we can call CYMH when we need help with a patient Knowing there are local psychiatric services we can access makes it much easier to make decisions about urgent patients. We now have much more confidence that patients will receive the urgent care they need in their own community within a quick time frame.

22. 22 Voice of Patient They were going to send me to the city...to Lion's Gate... They phoned someone from the Ministry and found out I could see a psychiatrist in Pemberton. Then someone came to the clinic to help my parents understand how to help me. My parents let me come home with them... I am doing much better now. I am glad I didn't have to go to the city."

23. 23 Design Team Project Sponsors: –Yasmin Jetha, Regional Director, MH&A Program –Dr. Steve Mathias, Regional Youth Medical Lead –Olga O’Toole, Regional Manager, CYMH Vancouver Coastal Region –Rena van der Wal, Executive Director, Lean Transformation Services Process Champion: Elizabeth Stanger, Director MH&A Coastal Project Owner: Kathleen Collins, CYMH Team Leader Physicians: Dr. Lance Patrick, Dr. Apu Chakraborty, Dr. Rebecca Lindley, Dr. Helen Rosenauer, Dr. Bobbie Rathbun Health Centre : Tracey Kavanagh, Janet Hamer Lean Advisor: Selina Tsang