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Editorial: How youth mental healthcare is being transformed in diverse settings across Canada: Reflections on the experience of the ACCESS Open Minds network

2019; Wiley; Volume: 13; Issue: S1 Linguagem: Inglês

10.1111/eip.12811

1751-7893

Srividya N. Iyer, Patricia Boksa, Ridha Joober,

Child and Adolescent Health

Having been part of the ACCESS Open Minds (ACCESS OM) project since before its inception, we take pleasure in reflecting on the conception and implementation of the project in its diverse contextual realities. In 2013, partnering with the Graham Boeckh Foundation, the Canadian Institutes of Health Research, launched a call for grant applications under their new Strategy for Patient-Oriented Research. The 18-month application process brought together various stakeholders from across Canada—youth, families, community organisations, clinicians, researchers, and decision-/policy-makers—around the common recognition that extant systems were not meeting the mental health needs of youth. The resultant ACCESS OM network faced a task that represented both an immense opportunity and a substantial challenge. We were to create a model for youth mental health services transformation that had to be evidence-informed yet anchored in all pertinent stakeholders' perspectives. Our model's core strategies had to have inbuilt flexibility to leverage the strengths and accommodate the realities of diverse sites. Some of the flexibility was necessitated by the nature of Canada's public healthcare system, which is federally mandated but provincially administered (with varying combinations of federal, provincial, and local governance in Indigenous jurisdictions). This has proven to be a strength that makes our model likelier to enjoy local buy-in and ownership and broad applicability in and beyond Canada. ACCESS OM is being implemented in 14 diverse settings across Canada (Malla et al., 2018). The articles in this supplement describe how the project's core service objectives are being addressed at seven sites that represent distinct contexts. The transformation of youth mental healthcare on such a large scale has been coordinated by a central office in Montreal through common structures and processes that standardise, support, and accelerate implementation. Working with the project's various governance bodies (Malla et al., 2018), the central office has created a conducive environment for various stakeholders to co-create and influence the project. Consulting actively and regularly with network members and sites, the central office arrived at and has been executing various mechanisms to initiate, support, and monitor the implementation of the ACCESS OM model. In this regard, the central office elaborated the definitions of and built consensus around five core service objectives and associated benchmarks/indicators (Malla et al., 2018). These objectives are: (a) early identification of youth in need; (b) rapid, engaging access to services; (c) provision of appropriate care; (d) removal of the transition between adolescent and adult services; and (e) youth and family involvement in service planning and care. The central office also listed the activities required to achieve these objectives at all sites, including the creation of a site team comprising, at least, clinicians, youth, and families; the hiring and training of a non-physician clinician (known as the ACCESS Clinician) to serve as a first point of contact and to respond to help-seeking requests within 72 hours; the deployment of a youth-friendly space, designed with inputs from youth, that offers walk-in access and youth-oriented activities; and the implementation of a standardised research/evaluation protocol at all sites. A menu of activities aligned around the five objectives was created to inspire sites in developing their site-specific transformation plans. Sites and the central office have been collaboratively developing annual work plans that detail activities to be conducted by each site in pursuit of the project's objectives. The human, financial, and material resources required for these activities at any site are identified and supplemented by the central office with additional funds. Thus, transformation at sites has entailed optimising existing resources and transferring additional funds from the project. All work plans include a combination of staff positions and activities common to all sites and some activities that are site-specific (e.g., a gaming night as an outreach exercise in Eskasoni First Nation to promote early identification). The central office has helped build site-level capacity through training and knowledge translation and by making common resources available (e.g., a website containing site descriptions, a YouTube video promoting ACCESS OM services, etc.). The central office designed and coordinates a regulation-compliant online data collection and management system that enables measurement-based care and research. An important element of capacity-building was a training program that familiarised core staff at all sites with the project's philosophy and model, including its intake assessment, the integration of evaluations into care, and youth and family engagement. The training included core components that were tailored to each site and was delivered at sites by central office staff. Additionally, site staff were offered specialised training (e.g., on Single-Session Therapy [Campbell, 2012]), expert presentations (e.g., on substance misuse), and booster training. The central office also offers in-person and phone- or Web-based support and training. Ongoing knowledge translation strategies have included knowledge exchange seminars; guides and tools that have been made freely available, including on the project's website (e.g., on peer support); and interactive webinars (e.g., on informed consent). Sites are supported by the central office with communications (e.g., creating site narratives and impact statements); with showcasing their work and advocacy (e.g., by informing them about relevant conferences); with data analysis to inform ongoing quality improvement; etc. Ad hoc, task-specific multi-stakeholder working groups have also been formed. One such group developed a consensus on core values to guide service delivery. These core values are prominently displayed at all sites. There has also been exchange, cross-fertilisation of ideas, and mutual learning across sites, often facilitated by the central office especially through network meetings, and sometimes undertaken by sites on their own initiative. For example, the Ulukhaktok site team visited the Eskasoni First Nation site, where service transformation had begun a year earlier, to learn from their experience. Inter-site exchanges have resulted in more enthusiastic uptake across sites of strategies seen as valuable. For example, the Edmonton site decided to offer skills training to families after learning about it from the Chatham-Kent site. The network's Indigenous Council has brought Indigenous communities together to develop culturally appropriate approaches and solutions. The network's youth and family/carer councils have supported sites' efforts to involve youth and families in site teams. The youth council passed a motion that mandated involving youth and families in the hiring of staff at all sites, which was accepted by all sites. As is evident in this supplement, youth mental health service transformation is an ongoing, dynamic, and non-linear process. The degree to which sites have been able to attain ACCESS OM objectives has been determined by their ability to implement the project's core components, which in turn has been influenced by certain common facilitators and barriers. The core components that have enjoyed a high degree of implementation across sites are multi-stakeholder site teams; mapping and reorganisation of diverse extant youth-focused services for co-location or streamlining of connections; the engagement of youth at sites and in the National Youth Council; outreach/publicity; the deployment of an ACCESS Clinician to offer an initial evaluation in a timely fashion (or, in the case of Ulukhaktok, a non-professional community worker); walk-in or direct access; a youth-friendly space; and the hiring/deputation of additional staff to meet project objectives. At most sites, youth can now access help via technology-enabled portals (e.g., Facebook, text messaging, etc.). Nonetheless, technology-enabled solutions (e.g., telepsychiatry, online interventions) need to be further harnessed by the network to enhance capacity for offering rapid access and appropriate mental healthcare. Key components that have been more challenging to effectively implement across sites include the involvement of families in site teams; peer support; the integration of or seamless linkages between all youth-oriented and youth mental health services; flexibility in terms of location and hours at which services can be accessed; affordable and rapid access to psychotherapy (brief, longer-term, individual, group, etc.); and connection and rapid access to specialised services for those needing them, particularly at more remote sites. All services at all ACCESS OM sites are provided free of cost, mostly through Canada's public healthcare system and in some instances, by non-profit organisations that receive government and philanthropic funds. The strength of our model has been its commitment to creating transformational change within existing systems. This has also sometimes proven to be a hurdle as it has necessitated managing change of significant magnitude within existing bureaucratic organisations, some of which were in the midst of their own reorganisation. Our experience reiterates the importance of committed local leadership, an often-noted critical factor in implementing systems-level changes. Such leadership can facilitate buy-in at a larger organisational level (e.g., regional health boards, local clinical administrations, Indigenous band councils, etc.). Our experience also highlights that members of different stakeholder groups—youth, families, clinicians, community leaders, etc.—can become effective local champions and ambassadors. Some unique factors have facilitated and hindered efforts at specific sites at various junctures. For instance, the Chatham-Kent site stands to benefit from being selected for the province of Ontario's youth mental health services initiative for having been an ACCESS OM site for three years. At our Centre de Bénévolat de la Péninsule Acadienne site, the implementation of the service transformation was delayed as it could begin only after the site was selected for ACCESS OM by a competition managed by the province of New Brunswick. However, this competition process may bring longer term provincial policy commitment. Nearly all sites, especially remote ones, have sometimes struggled with recruiting and retaining qualified staff. Many sites face the ongoing challenge of reducing stigma around accessing mental healthcare. In small communities, youth are often reluctant to seek services as they have concerns about their confidentiality being maintained. While most sites were able to engage youth in service design, their retention has sometimes proven difficult because young people tend to have other interests and pursuits to which they move on. A constant pre-occupation for all sites is the sustenance of buy-in from key decision-makers, policy commitment, and funding. These limitations notwithstanding, the network and individual sites have a collective sense of having engaged in a much-needed endeavour of gargantuan magnitude. The project's service transformation objectives and each site's service transformation plans have been co-developed by multiple stakeholders. This multistakeholder involvement has emerged as a key ingredient for success. Because many ongoing and planned youth mental health reorganisation efforts involve a similar structure of a central coordinating entity managing transformation at multiple sites, it is useful to examine the experience of the ACCESS OM central office. In understanding and addressing diverse stakeholders and sites, the central office had to learn to cope with vast differences in geography, culture, priorities, modes of communication, and types of expertise. Organisational change was also complicated by administrative, structural, and political realities that vary across sites and sometimes change within sites over time. These included differing financial management regimes; labour unions resisting the inclusion of youth and families in hiring panels and varied working hours for ACCESS OM staff; widely varying ethics and institutional/community approval procedures; leaders being replaced; etc. Exceptionally salient in the Canadian context has been the project's fostering of collaboration between Indigenous and non-Indigenous communities and network members. In this regard, the central office adopted a stance of cultural humility, acknowledging Canada's colonial past. The central office also committed itself to appropriate Indigenous governance precepts and practices such as the OCAP (ownership, control, access, and possession) principles. Service transformation in Indigenous communities often served as inspiration for the network as it was predicated on many of the same values that ACCESS OM was seeking to instil, such as building on community strengths and connections and holistic perspectives on health and wellness. In collaborating with, supporting, and coordinating 14 diverse communities, the central office has found that building strong relationships and trust has been essential. These same factors have also been important for multiple stakeholders to work effectively together. The commitment to collaboration created a degree of tension because while building trust takes time, the project, being funded for a fixed timeframe, had substantial time constraints of its own. A striking achievement of the project has been the basing of its transformative efforts in core principles, objectives, and protocols that have been sensitively contextualised to the realities of diverse sites. Because the project's insights regarding the processes underpinning youth mental health services transformation and the factors fostering and hindering such transformation come from its implementation across diverse real-world settings, they can serve as inspiration for other jurisdictions worldwide and generate meaningful directions for continuing research, policy, and service efforts to improve youth mental health outcomes. ACCESS Open Minds is a Strategy for Patient-Oriented Research (SPOR) network funded by the Canadian Institutes of Health Research and the Graham Boeckh Foundation. S.N.I. and R.J., have received salary support from the Fonds de recherche du Québec-Santé. S.N.I. is supported by the Canadian Institute of Health Research's salary award program. Dr. Joober reports having received honoraria for conference presentations and advisory board participation from Janssen, Lundbeck, Myelin, Otsuka, Perdue, Pfizer, Shire, and Sunovian; he also received grants from Astra Zeneca, BMS, HLS, Janssen, Lundbeck, and Otsuka; and has royalties from Henry Stewart talks. None of these have any relation to manuscripts in this supplement. Other authors report no conflicts of interest.