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Innovative models of mental health care around the world – and at SickKids, SickKids CCMH

Today, we share our final instalment of our five-part series for Children’s Mental Health Week. Dr. Peter Szatmari, Chief, Child & Youth Mental Health Collaborative, SickKids, CAMH and University of Toronto; Chief of the Department of Psychiatry, SickKids; and Trustee, SickKids Centre for Community Mental Health (SickKids CCMH) Board of Trustees, outlines models of care that are breaking down some of the barriers in providing timely and effective mental health services to our children and youth.

There are many problems with our mental health system. For example, most kids with mental disorders are not recognized as having a mental health challenge. If they are recognized they are not often referred to a mental health provider. Among those who do access mental health services, often those services are not evidence-based, and if they do access evidence-based services, most youth do not complete a full phase of treatment. 
To address these barriers, models of care must: involve systems and not just individual clinics; include client engagement; and ensure commitment to evidence-based treatments. Some of the models described below (and implemented in different jurisdictions around the world, with some examples at SickKids and SickKids CCMH) attempt to address many of these issues. 

Stepped-based care. In this model of care the intensity and type of treatment is determined by need, by complexity and previous response to treatment. As need or complexity increases, or if the child has not responded to a generic approach, more resource-intensive and personalized interventions are employed. For example, many children with emotional and behavioural problems can respond to a brief positive parenting program. Some kids will not respond and may require a more intensive in-home service. An important component of this model is measurement-based care; where outcome data are regularly fed back to the clinician and to the family to monitor progress and response to treatment. Only in this way, can one systematically and reliably assess response to an intervention. 

The YouthCan IMPACT trial in Ontario is a project that was co-designed with youth and involves a stepped-care model that integrates community mental health, hospitals (including SickKids), and youth to maximize access and provide evidence-based treatments. Check out frayme.ca​ to learn more about stepped-care models as they are practiced around the world.      
Value-based care. Value-based care builds on the measurement of outcome data in a stepped-care model but also involves assigning a cost to achieving a particular health outcome (e.g. how much does it cost to achieve a 50 per cent response rate for the treatment of depression among adolescents presenting to a general mental health clinic?) Process outcomes (e.g. how many clients with depression did we treat last month?) are often used as measures of clinical efficiency but do not reflect health outcomes and are of secondary importance. Value-based care is becoming a common way of comparing and contrasting services in health care in general (especially in the U.S.) but has not been widely applied to mental health. Sometimes more resource intensive services cost more but provide a proportionately greater improvement in outcome. For example, a treatment may result in a 50 per cent response rate and cost $5,000 per client. Such a service is of more “value” than a service that costs $3,000 per client but only results in a 10 per cent response rate. The former treatment has, in such circumstances, greater value and is definitely worth supporting even if it costs more. 

Teams work across SickKids – and the community – to provide quality ​mental health care​, including through innovations such as Telepsychiatry and a single session model implemented at SickKids CCMH. 

Choice and Partnership Agreement (CAPA) model. From the United Kingdom and New Zealand, the CAPA triage system offers a single assessment session (two to three hours) where the focus is on understanding the goals of the client and then triaging them to appropriate evidence-based services that can meet their goals. The focus of the assessment is not a diagnostic formulation as is usual among child and adolescent mental health clinics but on understanding patient goals. Adoption of CAPA is becoming more common in Canada (SickKids, SickKids CCMH, CAMH, CHEO, IWK) and around the world and has been shown to increase clinical volumes and patient satisfaction. SickKids CCMH has implemented a single session model with subsequent referral to appropriate treatment services, an excellent example of the CAPA model in practice. 

Community-based collaborations. Providing all services within the walls of the hospital is no longer seen as the only answer to providing universal access to mental health care. Some of those services can be provided in the community and in collaboration with other community-based services. This is analogous to a “one-stop shop” model of care based in a store front which provides a range of mental health services. There are no restrictions on referral and anyone can walk in and access services. Ontario’s Youth Wellness Hubs and Toronto’s what's up walk-ins are based on these models which were originally developed in Australia under the headspace brand. 

Of course all of these models can be supplemented by vigorous use of technology to facilitate access, to deliver treatment programs and to monitor outcomes. Technology is becoming more and more common in the provision of mental health services around the world and serves as a key platform for all of these models. The Telepsychiatry program at SickKids is an international leader in the provision of mental health services to rural communities in Ontario. At SickKids CCMH, online support will be available to intensive services clients with the goal of extending therapy beyond the physical walls of the clinic. 

The traditional way of providing services based on treatment programs isolated from the community will no longer meet the needs of today’s children and youth. It is important that as we address the changing landscape of mental health care for children and youth in Ontario that we are aware of these innovative models and see if they fit into our evolving provincial landscape. It is gratifying to see both SickKids and SickKids CCMH leading the way for many of these new and exciting initiatives.