1. 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

2. 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

3. Ontario, you say?
Source:

4. Ontario, you say? What Ontario is… What Ontario isn’t…
Image references:
CN Tower:
Map of Northern/Southern Ontario:
Scenic picture:

5. Ontario: Population density

6. 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

7. 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

8. 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

9. “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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. Service Collaborative Rollout
The Strategy’s First 3 Years – Children & Youth
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).

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

18. 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

19. 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).

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

21. 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

22. 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

23. 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

24. 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

25. 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

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

27. 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

28. 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
Fiona Thomas Research Coordinator, Performance Measurement and Implementation Research Team
Provincial System Support Program (PSSP)
CAMH

29. 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 29 29

30. 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