Transitional Aged Youth Mental Health and Addictions (TAYMHA) Advisory Committee Final Report

Submitted: April 30, 2015

Table of Contents LIST OF ACRONYMS USED IN THIS REPORT.................................................................................................. 3 EXECUTIVE SUMMARY .......................................................................................................................... 4 DETAILED REPORT ............................................................................................................................. 11 PART 1: Background and Mandate of the TAYMHA Advisory Committee ....................................... 12 PART 2: Environmental Scan ......................................................................................................... 13 PART 3: Areas of Focus and Recommendations ............................................................................. 30 APPENDICES..................................................................................................................................... 40 Appendix A - TAYMHA Membership and other Participants .......................................................... 41 Appendix B – TAYMHA Terms of Reference................................................................................... 42 Appendix C –Emergency Department Clinical Pathway.................................................................. 45 Appendix D – Review of Other “Quick Wins” ................................................................................ 47 Appendix F – Youth Engagement Organizations ............................................................................ 49 Appendix G – Transitional Aged Youth Focus Group Guide ............................................................ 50 Appendix H – Environmental Scan Approach................................................................................. 55 Appendix I – Transitional Aged Youth Engagement Findings .......................................................... 58 Appendix J – Proposed Training Content for Developing Youth Friendly Spaces ............................. 62 Appendix K – Key Informant Interview Guide ............................................................................... 64 Footnotes ..................................................................................................................................... 65

LIST OF ACRONYMS USED IN THIS REPORT The following is a list of acronyms used in this report. AMHAS

Adult Mental Health and Additions Services

CARS

Centralized Access to Residential Services

CAS

Children's Aid Society

CMHA

Canadian Mental Health Association

CYAT

Children and Youth Advisory Table (of the Toronto Central LHIN)

CAMH

Centre for Addiction and Mental Health

CYMHAS

Child and youth mental health and additions services

EA

Emerging Adults

ECFAA

Excellent Care for All Act

ED

Emergency Department

ED Clinical Pathway Child and Youth Mental Health Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions LGBTTQ

Lesbian, gay, bisexual, trans, two spirited, queer and questioning

LHIN

Local Health Integration Network

MAG

Ontario Ministry of the Attorney General

MCSS

Ontario Ministry of Community and Social Services

MCYS

Ontario Ministry of Children and Youth Services

MHA

Mental Health and Addictions

MHCC

Mental Health Commission of Canada

MOE

Ontario Ministry of Education

MOHLTC

Ontario Ministry of Health and Long-term Care

MPA

Medical Psychiatry Alliance

PCMCH

Provincial Council for Maternal and Child Health

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EXECUTIVE SUMMARY Child and youth mental health and addictions (CYMHA) continues to be a growing area of concern and an important focus for health system transformation at the national, provincial and local levels. Transitional aged youth (TAY), which for the purposes of this report were defined as those between the ages of 16 and 25, represent a large and complex subpopulation of young people characterized by differences in age, culture, race, gender, ability, socioeconomic status, sexual orientation, education, and religion, etc. Mental health and/or addictions (MHA) challenges that occur in this population are often compounded by the intersection of many important physical, sexual, psychosocial, familial, educational and vocational developmental issues that already arise during this developmental period. TAY with MHA issues tend to be an underacknowledged and underserved group within healthcarei. A recently published report by the Mental Health Commission of Canada argues that current approaches to address the needs of this population are substantially limitedii and that up to 60% of TAY with continuing MHA concerns disengage from services during this transitional periodiii. This is of particular significance given that 70% of MHA problems appear in childhood/adolescenceiv. If left untreated, MHA issues that occur during this age can result in an early exit from school, involvement with youth justice, unemployment, and traumatic release from care; and can ultimately become more severe and long lasting later in adulthood. This has important implications for increasing the human and economic burden of MHA morbidity and mortality.

TRANSITIONAL AGED YOUTH MENTAL HEALTH AND ADDICTIONS (TAYMHA) ADVISORY TABLE Within this context, and as part of the TC LHIN’s ongoing commitment to support health system planning, the Transitional Aged Youth Mental Health and Addictions (TAYMHA) Advisory Table (or “the Committee”) was convened with the following three objectives:

1.

Lead the development of recommendations to address challenges faced by TAY experiencing MHA issues in the TC LHIN

2.

Provide strategic oversight of the implementation of the Child and Youth Mental Health Emergency Department Clinical Pathway

3.

Review and provide advice to the TC LHIN on other TAY MHA “quick wins”

The TAYMHA committee brings together a cross-sectoral membership that reflects a diversity of perspectives, skills and expertise from across the child, youth and adult MHA health system and is co-chaired by Dr. Tony Pignatiello, Associate Psychiatrist-InChief, The Hospital for Sick Children; and Karen O’Connor, Director, Community Support and Engagement, Canadian Mental Health Association (CMHA).

ENVIRONMENTAL SCAN – WHAT WE LEARNED An Environmental Scan was conducted to better understand: the current national, provincial and local strategic environment related to child and youth MHA issues to ensure strategic alignment; the issues and challenges facing TAY with MHA issues in the TC LHIN; and work currently underway to avoid duplication of effort and identify synergistic opportunities. The Environmental Scan included: structured key informant interviews with 35 national, provincial, and local stakeholders with knowledge and experience related to TAY with MHA issues; youth engagement sessions with approximately 85 TAY representing a variety of TAY subpopulations (e.g. LGBTTQ youth, Aboriginal youth, newcomer youth, youth living in poverty, etc.); and a review of the key national, provincial and local publications related to TAY with MHA issues.

Strategic Landscape and Alignment A scan of national, provincial, and local strategies related to health and/or MHA was conducted to ensure that the recommendations developed by the TAYMHA Advisory Committee are aligned with the overall strategic landscape. These key strategies include: the Mental Health Commission of Canada’s (MHCC) Mental Health Strategy for Canada and Taking the Next Step Forward, the Ontario Ministry of Health and Long Term Care’s (MOHTLC) Action Plan for Health; the Ontario Ministry of

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Children and Youth Services’ (MCYS) Open Minds, Health Minds - Ontario’s Comprehensive Mental Health and Addictions Strategy and Moving on Mental Health, Ontario’s Special Needs Strategy; and the City of Toronto Youth Equity Strategy. Key themes emerged, including: •

A focus on providing timely and equitable access to services; improving linkages, coordination and integration across sectors (health, education and community); and a focus on performance, transparency and accountability.

•

A continued focus on improving the quality and value of the patient/client and family experience through the application of evidence-based care and quality improvement approaches.

•

Transformation of the child and youth mental health system continues to be a strategic focus at the provincial and local levels, including: strategies to ensure faster access to high quality care, identifying and intervening early by equipping providers with the tools and knowledge they need, and identifying and closing critical gaps in services.

•

Addressing the needs of TAY with MHA issues, specifically, is emerging as an important area of focus at the national, provincial and local levels. Involvement of TAY and their families in this process is critical.

•

A continuum of services that is integrated, accessible and responsive to the needs of TAY is needed, supported by developmentally competent service providers delivering evidence-based assessments and interventions.

•

Key system transformation strategies, such as MCYS’s Moving on Mental Health system change initiative, provide important opportunities for alignment. Moving on Mental Health includes the implementation of lead child/youth mental health agencies in the community, the definition of core services, and the strengthening of clear care pathways and partnerships.

•

Fostering collaboration across ministries and organizations is occurring and is critical to enhancing system integration (e.g. Ontario Special Needs Strategy, Open Minds, Health Minds - Ontario’s Comprehensive Mental Health and Addictions Strategy) particularly for children and youth.

Key Challenges and Gaps Facing TAY with MHA Issues Through stakeholder engagement and a review of the literature, the TAYMHA Committee identified 5 broad categories of challenges facing TAY with MHA issues: 1) unique characteristics of the TAY population; 2) challenges accessing and navigating between services, 3) the way existing services are delivered to TAY; 4) the need for unique services that address the needs of TAY; and 5) broader system issues outside the purview of a of a single agency or ministry.

Delivery of Services

Access and Navigating Services

Characteristics of the Population

Service Offerings

Transitional Age Youth

System Issues

Key challenges include: 

The issues related to MHA comprise a large and growing struggle for TAY - approximately 70% of mental health problems appear in childhood/adolescence but up to 60% of TAY with continuing MHA concerns disengage from service during the transitional period.



The needs of TAY with MHA issues are complex and compounded by the intersection of many important physical, sexual, psychosocial, familial, educational, and vocational developmental issues that arise between the ages of 16 and 25. There is also considerable diversity among the TAY population that further complicates their MHA challenges (e.g. differences in age, culture, race, gender, sex, ability, socioeconomic status, sexual orientation, gender identity, education, and religion).



TAY with MHA issues often experience considerable difficulty in accessing appropriate services, citing concerns related to stigma and confidentiality, knowledge of service availability, financial constraints, family perceptions, eligibility criteria, and challenges connecting to services because they are “unattached” (i.e. do not have a family

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doctor or other attachments to the system). 

Differences between the child and adult systems can pose major challenges for TAY, including differences in the amount and forms of support available from service providers, the processes used in decision-making and obtaining consent, and the level of family involvement.



In addition to transitioning from child and youth mental health and addictions services (CYMHAS) to adult mental health services (AMHAS), many TAY must also undergo other potentially stressful transitions, which may include moving from secondary education to post-secondary education or employment, leaving provincial care (i.e. Children’s Aid Society), and transitioning out of the youth justice system.



The current provision of MHA services for TAY is often not “youth friendly”. Service providers in both the child/adolescent and adult sectors often lack the skills and knowledge to effectively engage with and address the distinct needs of TAY with MHA challenges (i.e. this includes a lack of training related to developmentallyappropriate care, cultural competence, oppression, confidentiality, and the impact of the social determinants of health).



TAY report feeling a lack of trust and confidence in MHA service providers, primarily due to their perceived lack of understanding of the unique struggles of TAY with MHA issues.



Both youth informants and expert stakeholders identified a gap in services specifically targeted towards TAY, advocating for a unique programmatic approach to the transitional aged period, and expressing a desire for more services that look beyond crisis situations and instead offer “life skills” and long-term supports.



Addressing many of these challenges extends beyond the purview of a single organization or ministry and requires an inter-ministerial approach. A lack of system-wide coordination, under acknowledgement and representation of TAY in policy making and planning, and widespread stigma surrounding MHA issues was also highlighted.

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RECOMMENDATIONS: Based on a review of the strategic landscape, input from TAY and other stakeholders, identification of gaps and challenges, and a review of the literature, the Committee developed recommendations with the ultimate goal of improving the experience, quality of care, and outcomes for TAY with MHA challenges.

Training & Capacity Building

Connection & Navigation among existing services

Evaluation & Quality Improvement

Services for Transitional Aged Youth

Influence Broader System Change and Policy

The Committee began by identifying Areas of Focus in which to develop its recommendations. The goals and recommendations within each Area of Focus are described below. For more detail on each please refer to the recommendation section of the “Detailed Report”: Goal: Address gaps in knowledge, skills and tools (for service providers delivering care to TAY) in order to create youth friendly, non-judgmental environments that address the unique needs of TAY with MHA challenges. Recommendation: Establish a Working Group to lead the implementation of the following recommendation: 1.

Design and implement training for service providers to build capacity for culturally and developmentally-informed service provision (e.g. development of youth friendly, non-judgmental environments, etc.) that addresses the unique needs of all TAY with MHA challenges.

Goal: Improve the way TAY and their families access and move between existing MHA services (including moving from child-focused to adult services). The Committee identified the differing connection and navigation needs of different TAY populations (e.g. complex/life-long utilization of services, one-time/episodic service utilization, unattached TAY, etc.) Recommendations: Establish a Working Group to lead the detailed design and implementation of initiatives within this Area of Focus. As a first step, the Working Group will prioritize the following initiatives identified by the Committee to improve connection and navigation for TAY and their families: 1.

Monitor the results of the Service Collaboratives and adopt their emerging best practices in the TC LHIN targeted towards TAY with MHA issues.

2.

Disseminate transition best practices across the system to prepare TAY and families’ early to transition to the adult system.

3.

Implement models to improve connection and navigation for TAY (and families) moving from hospital to community services (e.g. potential expansion of the ED Clinical Pathway to TAY) and vice versa.

4.

Build connections between existing access points to ensure seamless system navigation (e.g. 211, Family Navigation at Sunnybrook Hospital, The Access Point, Centralized Access to Residential Services (CARS), and Access CAMH, etc.).

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5.

Improve connections to services for TAY leaving the Child Welfare and Justice Systems.

Goal: Address gaps in MHA services specifically targeted towards the unique needs of TAY - from prevention and health promotion to the more intensive level of services for TAY with the most complex needs. Recommendations: Establish a Working Group to lead the detailed design and implementation of the following recommendations: 1.

Confirm the most pressing gaps in services for TAY with MHA challenges in the TC LHIN. TAYMHA recommends the following as the most pressing gaps: o

Transitional aged youth friendly spaces

o

Flow of TAY between acute beds (hospital) and the community (working closely with the Acute Care Alliance )

o

Medically-fragile TAY with MHA issues (Medical Psychiatry Alliance – described in more detail later in this report)

o

Improve connections to services for TAY leaving the Child Welfare and Justice Systems

o

Housing and respite needs for TAY

2.

Design and implement a structure to enable ongoing identification of specific service gaps for TAY with MHA challenges in the TC LHIN.

3.

Utilize a set of design principles to guide the design and implementation of services to address identified gaps in services for TAY.

Goal: Embed a consistent evaluation and quality improvement approach for new initiatives aimed at addressing the needs of TAY with MHA challenges. Recommendations: A separate Working Group is not required to lead the detailed design and implementation of recommendations within this Area of Focus. Rather, evaluation and quality improvement will be underlying principles embedded within the work of the three aforementioned Working Groups. 1.

All newly funded initiatives for TAY (through the TC LHIN) will utilize a consistent evaluation and quality improvement approach.

2.

A health equity impact assessment will be conducted for all new system enhancements with TAY as a key stakeholder group. This should include recently implemented MHA services and access points (i.e. recently funded Health Links teams, The Access Point)

Goal: Given that many of the challenges facing TAY are outside the purview of a single organization, agency, or ministry, this Area of Focus aims to make recommendations as to how the TAYMHA committee can continue to play a role in influencing greater interorganizational, cross-sectoral and inter-ministerial collaboration to address the unique needs of TAY.

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Recommendations: A separate Working Group is not required to lead the implementation of recommendations within this Area of Focus. Rather, advocating for broader system change is an ongoing principle that needs to be embedded within the work of the three Working Groups and the TAYMHA Advisory Committee. 1.

TAY continue to be identified by the TC LHIN as a distinct population from a policy, planning, funding and service delivery perspective.

2.

The TAYMHA Advisory Committee will have an ongoing mandate with the TC LHIN to oversee implementation of these recommendations and to continue to provide ongoing strategic advice to the TC LHIN.

3.

TC LHIN to be a lead influencer for improved collaboration between the other GTA LHINs, child welfare services and justice related to TAY with MHA challenges

4.

TC LHIN influence and leverage the MCYS transformation to support selected lead MCYS agencies in working with TC LHIN funded organizations “to outreach and collaborate with mental health and addictions to improve transitions for youth to adult and young adult community mental health and addiction services” (i.e. local pathways and protocols).

5.

An inter-ministerial strategy is needed to provide a common lens and leadership for sectors providing services to TAY with MHA challenges. Leadership must be taken by one group to lead changes and pull together different ministries (MOHTLC, MCYS, MoE, MCU, MAG, etc.).

IMPLEMENTATION AND NEXT STEPS To support the next phase of work, the TAYMHA Advisory Committee recommends the following oversight and implementation structure to move its recommendations forward: 

The TAYMHA Advisory Committee will have an ongoing mandate with the TC LHIN to: 1.

Oversee the work of the three aforementioned Working Groups; and

2.

Continue to provide ongoing strategic advice to the TC LHIN related to TAY with MHA challenges.



A member of the TAYMHA Committee will be selected to lead each of the three Working Groups.



All Working Groups will engage TAY and families in the detailed design, implementation, and evaluation of recommendations contained within this report.



Working Groups will be given a two-year mandate to lead the detailed design and implementation of recommendations (with oversight from the TAYMHA Advisory Committee).



TAYMHA will continue to report to the TC LHIN’s Children and Youth Advisory Table and the Strategic Advisory Table (on the progress of design and implementation).



As a critical enabler of this work, funding will be required to enable Project Management support for each Working Group.

The strategic framework and recommendations put forward by the TAYMHA Advisory Committee in this report establishes a strong foundation for coordinated health system planning for this important population in the TC LHIN. This strategic planning process brings together input from almost 50 child/youth and adult MHA stakeholders from across heath care, community and

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social supports, education, and government; and 85 TAY from across the TC LHIN representing a variety of subpopulations (i.e. LQBTTQ, aboriginal, francophone, newcomer, youth living in poverty, etc). As we begin implementation of our recommendations, the TAYMHA Committee looks forward to continuing its important role in advising the TC LHIN.

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DETAILED REPORT

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PART 1: Background and Mandate of the TAYMHA Advisory Committee Background In October 2013, the TC LHIN’s Children and Youth Advisory Table (CYAT) began its second year of strategic planning by refining its original mandate – to provide ongoing strategic advice and recommendations to the TC LHIN related to the child and youth health system. Through this process, CYAT confirmed three new priority areas: mental health and addictions, palliative care, and primary care/Health Links. Since the TC LHIN already had other planning tables focused on the latter two areas, the CYAT elected to focus its efforts primarily on strategic planning in child and youth mental health and addictions, while playing a more advisory role in the other two areas. Concurrently, the TC LHIN’s Strategic Advisory Council (SAC), a group of senior leaders from across different sectors was brought together to advise the LHIN on matters of strategic importance that advance transformative strategies and improve the health and the healthcare experience of the population (seniors, adults, children and youth). The SAC identified the following three areas of focus for the TC LHIN: 1) creating a healthier and more equitable city; 2) development of a senior’s strategy; and 3) child and youth mental health and addictions. With a clear alignment between the child/youth mental health priority identified by both CYAT and SAC, the TC LHIN requested that CYAT take a leadership role overseeing strategic planning and implementation in this priority area. To this end, CYAT convened the Transitional Aged Youth Mental Health and Addictions (TAYMHA) Advisory Committee (or “the Committee”), a group with expertise in child/youth and adult mental health and addictions, to lead three areas of activity within this priority area (described below).

Transitional Aged Youth Mental Health and Addictions (TAYMHA) Advisory Committee The TAYMHA Advisory Committee was given a mandate to lead the following three areas of activity: 1.

Develop recommendations to address challenges faced by TAY experiencing MHA issues.

2.

Provide strategic oversight of the implementation of the Child and Youth Mental Health Emergency Department Clinical Pathway.

3.

Review and provide advice to the TC LHIN on other TAY MHA “quick wins”.

Co-chaired by Dr. Tony Pignatiello, Associate Psychiatrist-In-Chief, The Hospital for Sick Children; and Karen O’Connor, Director, Community Support and Engagement, Canadian Mental Health Association (CMHA) - the TAYMHA Advisory Committee brought together a cross-sectoral membership that reflected a diversity of perspectives, skills and expertise from across the child, youth and adult MHA health system. A list of the full TAYMHA membership can be found in Appendix A and the Committee’s Terms of Reference in Appendix B. This report focuses primarily on summarizing the environmental scan, recommendations, and implementation plan developed by the TAYMHA Committee to address challenges faced by TAY experiencing MHA issues. For additional information on the activities related to oversight of ED Clinical Pathway and advice to the TC LHIN on other TAY MHA “quick wins” please refer to Appendix C and Appendix D. The Committee’s primary mandate, to develop strategic recommendations to address challenges faced by TAY with MHA issues in the TC LHIN, was further subdivided into the following three tasks:

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1.

Understand the issues and gaps for TAY with MHA issues within the TC LHIN (by engaging subject matter experts, adolescents, young adults, families, and other stakeholders);

2.

Understand who the players are and define what work is underway so that recommendations align with existing work/groups in an effort to avoid duplication; and

3.

Recommend value-add strategies/initiatives that can be implemented within the health system scope (with strong support from partners) to improve quality of care and outcomes for TAY.

PART 2: Environmental Scan The TAYMHA Committee began its work by conducting an environmental scan in order to: better understand the issues and challenges facing TAY with MHA issues in the TC LHIN; understand the current national, provincial and local strategic environment related to child and youth mental health to ensure strategic alignment; and scan work currently underway to avoid duplication of effort and identify synergistic opportunities.

Definition of Transitional Aged Youth The Committee began by confirming its definition for TAY through a review of definitions used by mental health organizations as well as other Canadian and internal sources. Based on this review, the Committee established a definition for transitional aged youth as those between the ages of 16 and 25 to guide its work.

Geography of the TC LHIN For the purposes of planning, the TAYMHA Advisory Committee focused on the TC LHIN geography. The TC LHIN is one of five LHINs within the City of Toronto and is the most geographically compact LHIN in the province, sharing borders with the Mississauga Halton, Central West, Central, and Central East LHINs. Figure: LHINs that make up the City of Toronto

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Strategic Environment A scan of national, provincial and local strategies related to health and/or mental health and addictions was conducted to ensure the recommendations of the TAYMHA Advisory Committee were developed in alignment with the overall strategic landscape. The following provides a brief overview of the scan and concludes with a summary of “key learnings” that were relevant to the work of the TAYMHA Advisory Committee. Mental Health Commission of Canada (MHCC) As part of its Changing Directions, Changing Lives Mental Health Strategy for Canada, the MHCC identified “youth transitions” as a significant area of concern for mental health policymakers and is calling for the removal of barriers to successful transitions between child, youth and adult mental health services. Building on this identified priority, Taking the Next Step Forward “consider[s] the current state of Canadian and international policies and programs that support youth with mental health problems and mental illnesses transitioning into adulthood, argue[s] that our current approaches are substantially limited, and offer[s] a framework for bettering these practices in Canada” (MHCC, 2015). In anticipation of the May 2015 release of the comprehensive report, the MHCC released an Executive Summary that provides a preliminary outline of the full report’s national, provincial and regional recommendations for enhancing services for TAY with MHA challenges, and includes a proposed framework for the TAY MHA system in Canada, as follows:

“In order to effectively address the needs of emerging adults transitioning to adult mental health and addiction services, an integrated, accessible, and responsive service system needs to be in place. We require a full continuum of services – from universal prevention and health promotion to the most intensive level of services for a small proportion of emerging adults with the most complex needs. Developmentally competent service providers must deliver evidence-based assessment and intervention services and supports across this continuum… Coordinated approaches will need support and leadership from all levels of government and, most importantly, require the input and guidance of EA (emerging adults) and their families and communities” (MHCC, 2015, p. 4) An important aspect of the proposed continuum is the fluid movement across tiers in accordance with the intermittent and shifting nature of many MHA issues. The continuum requires a “TAY-responsive” MHA service sector as well as the implementation of peer support approaches and consistent EA engagement across all tiers. In addition to this continuum framework, the report offers recommendations for change at the national, provincial and regional levels. National recommendations include: identifying EA as a priority population, establishing a national EA mental health initiative and young adult advisory group, implementing a report card for EA MHA outcome indicators, and establishing a Canada Research Chair focused on EA with MHA issues.

Provincial recommendations include establishing EA as a priority population, the creation of transition protocols and supports for those transitioning out of child and youth services, confirming the proposed service continuum, and creating a provincial/territorial EA Advisory Council. Finally, at the regional level, recommendations include identifying EA as a priority population, creating an accountability plan to monitor EA engagement levels and outcomes, identifying the most urgent gaps among service 14

offerings for EA, ensuring the existence of prevention and health promotion strategies across all tiers, and the development of regional transition protocols and resources. The Ontario Ministry of Health and Long Term Care (MOHTLC) The MOHLTC’s strategic landscape includes various initiatives with particular relevance to the work of TAYMHA, for example: The Excellent Care for All Act (ECFAA) puts patients first by focusing on improving the quality and value of the patient experience through the application of evidence-based care. More specifically, the legislation requires organizations to implement quality improvement plans and surveys to assess patient/client, caregiver, and staff satisfaction as well as a process to address patient experience issues. Foundational to this strategy is a focus on the quality of care and optimal use of resources. Unveiled in 2012, Ontario’s Action Plan for Health (Part 1) outlines the Ontario government’s continued focus on “provid[ing] Ontarians with better health care by getting better value for our health-care dollars”. Funding is being prioritized to ensure it is shifted to areas of best value, supported by new measures to encourage prevention and health promotion, and improved access to primary care to keep people out of hospital. Ontario’s Action Plan for Health Part 2: Patients First again continues the province’s commitment to putting people/patients at the centre of the system and outlines four core objectives: 1. Improving access to appropriate care; 2. Enhancing coordination and integration of care; 3. Providing the education and information necessary to allow Ontarians to make informed decisions about their care; and 4. Protecting our universal public healthcare system by making evidence-based decisions on value and quality.

Open Minds, Healthy Minds - Ontario’s Comprehensive Mental Health and Addictions Strategy In 2011, the Ontario government unveiled its multi-year mental health and addiction strategy. The goals of the strategy are to: improve mental health and well-being for all Ontarians by creating healthy, resilient inclusive communities; identify mental health and addictions problems early and intervene; and provide timely, high quality, integrated, person-directed health and other human services. Implementation of the strategy takes a long-term view of transformation and has started with children and youth over the first three years - in 2011, the Ontario government committed an investment of $257 million over three years for child and youth mental health. Highlights from the Child and Youth Mental Strategy include the following priority areas: 1. Providing fast access to high quality service by monitoring wait times and building capacity so that community agencies are equipped to meet local demands, and creating links between and across education, health care and the community, and finding ways to link families with services. 2. Identifying and intervening in children and youth mental health issues early by equipping service providers with the tools and knowledge they need, encouraging communities to work together and build a shared understanding of mental health issues, and developing strong regional and local leadership, particularly in community-based mental health agencies and schools. 15

3. Closing critical gaps for vulnerable children and youth in rural areas by improving access to care, increasing the availability of culturally appropriate services, and addressing the needs of those who have complex mental health needs requiring specialized care, and/or who must navigate across key transition points.

Ontario Ministry of Children and Youth Services (MCYS) Transformation - Moving on Mental Health Building on Ontario’s Mental Health and Addictions Strategy, as well as other important policy documents, MCYS launched Moving on Mental Health as the next step in building a system that makes sense for children and youth with mental health problems and their families. The core objective of this initiative is to transform the experience of children and youth in Ontario with mental health problems such that individuals anywhere in the province are able to determine what mental health services are available in their communities and how to access them. More specifically, the framework outlines: the identification of lead agencies for community-based child and youth mental health; the definition of core services that must be available across Ontario; minimum expectations associated with the delivery of the core child and youth mental health (CYMH) services funded by MCYS; core services and care pathways; and clear pathways to care across sectors. MCYS/MCSS Ontario’s Special Needs Strategy Families of children and youth with special needs, including physical, developmental and/or communications needs, can have difficulties receiving services in a timely and coordinated way. Several ministries are working to improve how families access the services they need, as close to home as possible and are committed to improving this service experience. This represents a joint strategy of the Ministry of Children and Youth Services, Ministry of Health and Long Term Care, Ministry of Education and Ministry of Community and Social Services. The strategy builds on recent investments and initiatives to help children and youth with special needs get the timely and effective services they need at home, at school, in the community, and as they prepare to reach their goals for adulthood. Ontario is taking steps to connect children and youth with special needs to the services they need as early as possible and to improve the service experience of families in three key areas: identifying children earlier and getting them the right help sooner, coordinating service planning, and making the delivery of children’s rehabilitation services more seamless.

City of Toronto Youth Equity Strategy This strategy aims to support Toronto youth (aged 13-29) who are most vulnerable to involvement in serious violence and crime by setting out 28 recommendations for youth service delivery enhancements and actions for achieving those recommendations. A service plan approach sets out six principles to guide future decisions regarding funding priorities and service improvements. These principles include: equitable access and outcomes; complexity of vulnerability; commitment to positive youth development; an age-friendly city; collaborative action; and accountability.

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KEY LEARNINGS FROM THE STRATEGIC ENVIRONMENT The review of the national, provincial and local health/MHA strategic landscape highlighted several recurring themes that the TAYMHA Advisory Committee utilized in the development of its recommendations, including: •

A focus on providing timely and equitable access to services; improving linkages, coordination and integration across sectors (health, education and community); and a focus on performance, transparency and accountability.

•

A continued focus on improving the quality and value of the patient/client and family experience through the application of evidence-based care and quality improvement approaches.

•

Transformation of the child and youth mental health system continues to be a strategic focus at the provincial and local levels, which includes: strategies to ensure faster access to high quality care, identifying and intervening early by giving providers the tools and knowledge they need, and identifying and closing critical gaps in services.

•

Addressing the needs of TAY with MHA issues, specifically, is emerging as an important area of focus at the national, provincial and local levels.

•

A continuum of services, integrated, accessible and responsive to the needs of TAY is needed, supported by culturally and developmentally competent service providers delivering evidencebased assessments and interventions.

•

Key system transformation strategies, including the Moving on Mental Health Service Framework provide important opportunities (implementation of lead child/youth mental health agencies in the community, core services, care pathways, and key processes to support the child/youth and family throughout their involvement with CYMHAS).

•

Fostering collaboration across ministries and organizations is occurring and is critical to enhancing system integration (e.g. Ontario Special Needs Strategy) particularly for children and youth.

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Key Service Delivery Initiatives As part of its initial planning, the TAYMHA Advisory identified a need to understand what services are available for TAY in the TC LHIN; at present, no centralized inventory exists. As such, the TC LHIN provided funding for the completion of an inventory of TC LHIN funded MHA services for TAY, including case management, counselling, family support and supportive housing for MHA. This project also included providing recommendations for how the inventory should be maintained over time, taking into account The Access Point and other coordinated access projects TAY may use. In anticipation of the completion of this comprehensive inventory, the TAYMHA Committee conducted a high-level review of initiatives that have important implications for TAY with MHA issues. This was not meant to be a comprehensive inventory of services, but rather, to help the Committee identify extant innovative practices/pilot projects that might be leveraged in the development of recommendations. System Improvements through Service Collaboratives In alignment with the initial child and youth focus that emerged from Ontario’s Comprehensive Mental Health and Addictions Strategy, 18 Service Collaboratives were created in communities across Ontario. These Collaboratives were established with the ultimate goal of improving services for children and youth in transition: between community and hospital settings; between health and justice systems; and from child-focused to adult services. Six of the Service Collaboratives are focused on improving transitions. In Simcoe-Muskoka, Hamilton, and Waterloo Wellington for example, the Transition to Independence Process (TIP) is being implemented. This process involves working with TAY to engage them in their own future planning process and providing them with developmentallyappropriate, non-stigmatizing, and culturally-competent services and supports. Additionally, the Kingston, Frontenac, Lennox and Addington, Four Counties, and Sudbury Manitoulin Service Collaboratives are using the guidelines from The Track Study as a basis to form a protocol outlining the process for child to adult transitions.

MOHLTC - Health Links Health Links are evidence-based integrated health service provider communities that work together to improve client care through enhanced accountability. They bring together networks of providers, including primary care, CCAC, hospital, teaching/education, social support services, etc., and enable primary care providers’ improved access to multidisciplinary providers, specialist care, chronic disease management programs and other community supports offered in their local communities. With improved coordination and information sharing, patients will ideally receive faster care, spend less time waiting for services and receive support from a team of health care providers at all levels of the health care system. Health Links are accountable to the LHINs for improving the health outcomes and experiences of the patients served in their areas. There are currently 67 Health Links across Ontario, with nine of these located in the TC LHIN. Of these, three are focused in some way on children and youth: • • •

The North West Toronto Health Link, which is focused on addressing the needs of TAY generally; Central West Toronto Health Link, which is focused on improving sexual health and mental health services for children and youth; and West Toronto Health Link, which is focused on addressing the needs of children with medical complexity. 18

In 2013, the TC LHIN established 4 Working Groups to design Blueprints outlining how Complex and At-Risk populations will be supported through Health Links, including a Community Mental Health and Addictions Blueprint to enhance community MHA capacity to connect clients to services by increasing access, improve coordination, and enhance care management. MCYS - Lead Agency A key element of the MCYS Moving on Mental Health initiative is the identification of lead agencies in defined communities across Ontario that will be responsible for planning and delivery of CYMH services. For Toronto, the identified lead agency is East Metro Youth Services (EMYS). Within each defined community, and reporting to a community-based Board of Directors, a lead agency will be responsible for five primary functions: 

Establish a plan for the delivery of CYMH services to be submitted to MCYS for review and approval (in collaboration with the local service system and the MCYS Regional Office);

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Create clear and simple to use access pathways for parents, youth as well as justice, education, and health professionals who wish to refer;

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Deliver or contract for the range of defined core MCYS-funded CYMH services, and hold sub-contracted agencies accountable;

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Make those services effective and accountable to parents, youth, and children; and

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Lead the development of a community mental health plan which will identify service priorities and strengthen inter-agency and inter-sectoral partnerships, protocols and transparent pathways to care.

Medical Psychiatry Alliance The Medical Psychiatry Alliance (MPA), the first-of-its-kind in Canada, is a collaborative partnership whose goal is to transform mental health care. Supported by The Centre for Addiction and Mental Health (CAMH), The Hospital for Sick Children, Trillium Health Partners (THP) and the University of Toronto (UofT) in conjunction with the Ministry of Health and Long-Term Care (MOHLTC) and a generous donor, this Alliance is dedicated to transforming the delivery of mental health services for patients who suffer with physical and psychiatric illness and medically unexplained symptoms. MPA goals are: 

To improve the quality of life and increase life expectancy for those with serious, simultaneous mental and physical illnesses while reducing the burden of illness on their families, the healthcare system and society.

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To create a new model of clinical care that will support patients with medical and psychiatric issues.

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To teach current and future health professionals how to prevent, diagnose, and treat mental and physical illness within a novel integrated care model.

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To develop a better understanding of the interaction between the body and the brain regarding co-morbid medical and psychiatric illness.

The New Model of Clinical Care will be built using validated and practice-based evidence and focus initially on: 1. Creation of Integrated Advanced Screening and Diagnostic Tools 2. Development of New Models of Integrated Care - it is clear that multi-disciplinary teams are crucial to the successful treatment of these patients and should include Psychiatrists, Psychologists, Registered Nurses, 19

Nurse Practitioners, Social Workers, Child and Youth Workers and other professionals depending on patient and family needs. 3. Build “Best Practice” Treatment Plans – expand upon existing programs that have shown early results, including Virtual Wards and Tele-psychiatry.

Mental Health and Addictions Acute Care Alliance The Mental Health and Addictions Acute Care Alliance (the Alliance) is a partnership of seven adult-serving Toronto Central Local Health Integration Network (LHIN) hospitals (Centre for Addiction and Mental Health, Mount Sinai Hospital, St. Joseph’s Health Centre, St. Michael’s Hospital, Sunnybrook Health Science Centre, Toronto East General Hospital, University Health Network) and the Department of Psychiatry at the University of Toronto. In 2004, the Alliance was formed to develop a coordinated system response to the anticipated transformation of the Centre for Addiction and Mental Health’s Emergency Department into an Urgent Care Centre. While this transformation did not come to pass, through their collaboration, Alliance members realized the benefits of working together to plan and further develop the mental health and addictions acute care system in the Toronto Central LHIN. Over time, the Alliance has grown in size and scope, expanding beyond its initial focus on hospital Emergency Departments to include hospital inpatient units and related mental health and addictions acute care services. The true innovation of the Alliance has been in establishing an ongoing collaborative process aimed at optimizing the utilization of the Toronto Central LHIN's existing acute mental health and addictions service capacity to the benefit of Toronto Central LHIN residents and beyond. In accordance with its three-year strategic plan, Alliance members are currently working together to: 

Accelerate development of the culture of collaboration within the MHA acute care system and beyond

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Continuously improve the quality of MHA acute care in the Toronto Central LHIN

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Promote recovery-oriented, evidence-based MHA care across the system

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Ensure value for resources entrusted to the Alliance

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Create and share knowledge to influence MHA care within the Toronto Central LHIN and beyond

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Strengthen the Alliance organization to enable delivery against the strategic plan

Access Points Various services exist to aid Toronto residents in identifying and connecting with appropriate MHA services. Following are some examples of these points of access:   

211 Toronto is a help line and website that provides comprehensive and up-to-date information on services provided by nonprofit, community-based organizations or the public sector, including MHA services. The Family Navigation Project is a call-in and email service housed at Sunnybrook Hospital that is designed to provide expert navigation of the mental health and addictions service system for youth aged 13-26 with serious mental health and/or addictions problems and their families (also described in more detail below). The Access Point provides information and referral to 51 different community-based mental health and supportive housing services across Toronto. 20





Centralized Access to Residential Services (CARS) provides a variety of services to 400-500 children and youth in Toronto each year, including managing referrals to mental health and residential beds, tracking clients in placement, monitoring available resources, and providing system-based information for residential services. Access CAMH is the centralized intake system at CAMH which processes all outpatient referrals and schedules them with the right outpatient service. Access CAMH also provides live access to the general public and community care providers during business hours.

Family Navigation Project The Family Navigation Project housed at Sunnybrook is a non-profit program designed to provide expert navigation of the MHA service system for youth aged 13-26 with serious MHA problems. Specifically, the project offers a call-in and email navigational service to guide and support families who have youth struggling with MHA concerns. The ultimate goal of this service is to engage with families to help them navigate the health care and related services system, connect to appropriate and credible assessment and treatment resources, and receive timely assistance and support. Furthermore, the program aims to enhance the healthcare system by building relationships with treatment providers, centres, and programs that will facilitate connections for families and youth. Toronto Mental Health and Addictions Acute Care Alliance Hosted by the University of Toronto’s Department of Psychiatry, the Alliance is an organization that works to improve clinical coordination and management of behavioural and psychiatric emergencies in Toronto. The Alliance works in partnership with seven hospitals across the TC LHIN: CAMH, Mount Sinai Hospital, St. Joseph’s Health Centre, St. Michael’s Hospital, Sunnybrook Health Sciences Centre, Toronto East General Hospital, and the University Health Network. The clinical objective of the Alliance is to ensure the availability of timely and appropriate acute mental health and addictions services in a respectful and client-centered environment. This is accomplished by optimizing existing capacity through connections with appropriate inpatient, outpatient, and/or community-based services. The Alliance is currently working to develop innovative programs that will enhance the care provided to patients who rely on the Emergency Department and related acute care services as an important source of their MHA care. School Social Worker Supports As part of a multidisciplinary educational team, the Toronto District School Board’s Social Work and Attendance Services are available in every school to provide mental health and addiction support to students and their families, maximizing the educational and personal potential of each student. Social workers and attendance counsellors assist students in defining their own strengths and needs, helping build capacity and self-advocacy skills through individual, family and group counselling services. The school social worker is available for consultation and assessment services to the school community for early intervention and prevention initiatives, including referral to, and case coordination with, other community services including health care providers. Additionally, school social workers provide crisis response and in-service training sessions to school board staff about mental health and wellness, how to have mentally healthy school environments, and how to support students with mental health and addiction issues. Attendance counsellors provide outreach services to vulnerable youth who have disengaged from the education system due to mental health struggles/difficulties/obstacles/barriers. The attendance counsellor can conduct home visits, liaise with school, home, and community services and devise action plans to ensure that students’ mental health and educational needs are met. The Toronto District School board provides at-risk students with the option of attending alternative schools to provide educational experiences suited to individual learning styles and /or needs, including the Triangle Program, for LGBTQ students.

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Mental Health and Addictions Nurses in District School Boards Funded by MOHLTC, through the new Mental Health and Addictions Nurses in District School Boards Program, 144 Registered Nurses and/or Registered Practical Nurses with mental health and addictions were hired by Community Care Access Centres (CCAC). LHINs work with CCAC’s, district school boards, and other local providers to develop appropriate implementation strategies to reflect local capacity and needs. Nurses hired for this program are working in inter-disciplinary teams with mental health leaders, mental health workers, and existing district school board staff to support the development of school board strategies in recognizing and responding to student mental health and addictions issues. Nurses are providing services and supports for students including referrals to community mental health and addictions agencies and primary care.

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Issues and Gaps for TAY with MHA Issues The TAYMHA Advisory Committee also implemented a stakeholder engagement process and a review of the literature to understand the key issues and gaps facing TAY with MHA issues within the TC LHIN. This included: 

Structured key informant interviews with 35 national, provincial and local stakeholders with knowledge and experience related to TAY with MHA issues; (for a full list of stakeholder engaged refer to Appendix E)

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Youth engagement sessions with approximately 85 TAY representing a variety of TAY subpopulations (e.g. LGBTTQ youth, Aboriginal youth, newcomer youth, youth living in poverty, etc.); (for a list of the organizations engaged to support TAY engagement and the approach used, please refer to Appendix F and Appendix G)



A review of the key national, provincial and local publications related to TAY with MHA issues.

For a more detailed overview of the Environmental Scan approach refer to Appendix H. Overview The Ontario health system is widely acknowledged as fragmented and difficult to navigate. The TAY population experiences a particularly elevated risk of “falling through the cracks” as they move between CYMHA and AMHA services. This is a result of several factors, including: a lack of awareness of where to access services, limited access to resources and supports, complex needs that may not be adequately met by adult care, and a general sense of marginalization. As a result, TAY often struggle to find stability during a stage of life that already tends to be challenging, given the need to balance social, academic, employment, and other demands commonly experienced by individuals in this age range. This struggle can lead to deficiencies in knowledge about one’s condition, limited selfcare skills, poor social outcomes, and anxiety caused by having to adapt to a new care team, and ultimately a lack of adherence to proposed treatment plans. Other potential barriers to effective transitions between the child and adult systems are created by differences in service delivery practices, for example: different care/treatment philosophies (i.e. family- to patient-centered care), a lack of training in how to work with youth in transition, poor communication between professionals, and inadequate coordination between agencies/services. As mentioned, one of the most significant implications of poor transitions is that TAY tend to prematurely disengage from service. Research demonstrates that TAY often experience a decrease in follow-up visits and may even drop out of the health system completely. Eventual re-engagement tends to be crisis driven, when preventative action may have enabled the individual to avoid crisis entirely. It is important to note that these and other costs associated with unsuccessful transitions may easily exceed the costs of establishing and implementing proper transition processes. More specifically, the TAYMHA Advisory Committee identified five broad categories of challenges facing TAY with MHA issues: 1.

Unique Characteristics of the TAY Population: includes a description of the unique needs and characteristics of the TAY population that have important implications for MHA services.

23

2.

Access to and Navigation Between Services: describes some of the key challenges that TAY and their families face when accessing and moving between MHA services - with a focus on the difficulties that accompany the transition between CYMHAS and AMHAS.

3.

Delivery of Services: provides an overview of several challenges related to MHA service delivery, including providers’ inability to meet the age-specific needs of TAY or tailor their services to various TAY subpopulations.

4.

5.

Service Offerings: outlines some of the critical gaps present among existing service offerings for TAY with MHA issues.

Delivery of Services

Access and Navigating Services

Characteristics of the Population

Service Offerings

Transitional Age Youth

System Issues

Broader System Issues: provides a high-level description of some of the key systemic issues that create challenges for TAY with MHA issues and their families.

Each of these five areas is described in more detail below, combining information gathered from a review of relevant literature as well as engagement sessions with TAY and expert stakeholders. Although most of the information gathered through the engagement session with TAY is included in the section below, a complete list of findings can be found in Appendix I. Unique Characteristics of the Population TAY experiencing MHA issues represent a large and complex subpopulation that tends to be “underacknowledged and underserved” within healthcarev. Both research literature and stakeholder engagement findings suggest that issues related to MHA comprise a large and growing struggle for this group. According to the Government of Canada, approximately 70% of mental health problems appear in childhood/adolescencevi. In the Canadian Community Health Survey, published in 2003, adolescents and young adults between 15 and 24 were more likely than any other age group to report having experienced MHA issues, with a self-reported prevalence of 18%vii. Other research suggests that 8% of Canadians between 15 and 24 years of age experience substance dependenciesviii and 3% have cooccurring mental health and substance use disordersix. The complexity of MHA service need among TAY is further compounded by the intersection of many important physical, sexual, psychosocial, familial, educational and vocational developmental issues that arise between the ages of 16 and 25x. These issues may include establishing independence from the family, developing an adult identity, gaining employment and forming important extra-familial relationshipsxi. In addition to transitioning between CYMHAS and AMHAS, many TAY must also undergo other potentially stressful transitions, which may include moving from secondary education to post-secondary education or employment, leaving provincial care (i.e. CAS) and transitioning out of the youth justice system. Despite the many issues that are common to TAY, there is also great diversity within this population, further complicating their MHA challenges. Differences in age, culture, race, gender, sex, ability, socioeconomic status, 24

sexual orientation, education, and religion bear important implications for MHA servicesxii. For example, youth in all of the groups engaged by this Committee revealed that service providers’ perceptions about different “cultural groups” have important implications for the way they provide MHA services. Youth engagement also highlighted two additional challenges for TAY with MHA issues. Youth expressed that they often find themselves in a constant state of “burnout”, which has widespread negative consequences related to school attendance and performance, employment, treatment, familial relations, etc. Second, although families can often be a critical source of support for TAY with MHA issues, some youth revealed that families may also act as a barrier to accessing MHA services. Some youth reported a fear of disclosing their MHA issues to family members. Research supports this observation as familial stigma surrounding mental illness and a lack of family resources can contributor to this nondisclosurexiii,xiv. Services provided through the existing bifurcated child and adult mental health systems often fail to address the complex and unique needs that characterize TAY. One of the many problems arising from this deficiency is that up to 60% of TAY with continuing MHA concerns disengage from service during the transitional periodxv. This disengagement elevates their risk of developing more serious, long-term mental health issuesxvi,xvii. In order to address this and other problems and still effectively serve this population, age-specific MHA services that acknowledge their distinct characteristics are necessary. According to stakeholder engagement with youth, service providers must also recognize that youth “know themselves best” and incorporate this notion into their approach to service design and delivery.

Accessing and Navigating Between Services Access to and navigation among MHA services is a significant challenge for TAY and their families as these processes tend to be fragmented and inconsistent - undermining seamless and effective service deliveryxviii. TAY with MHA issues and their families often experience considerable difficulty in accessing appropriate servicesxix,xx. Youth and experts engaged by this Committee repeatedly underscored this issue, citing concerns about stigma and confidentiality, financial constraints, and family perceptions as key barriers to accessing MHA services. Additionally, both youth and service providers expressed their lack of a good understanding about what services are currently available for TAY with MHA issues. Furthermore, the focus on chronological age rather than developmental age in determining eligibility criteria for services was commonly identified as problematic. Support for this notion comes from a 2013 CAMH report, in which many service providers surveyed agreed that developmental characteristics can differ widely among TAY of the same chronological agexxi. Finally, youth who were not connected to a family doctor or educational institution reported experiencing considerable difficulty in locating an access point to MHA services. The latter component of this issue pertains to challenges navigating among services, in particular, the transition between CYMHAS and AMHAS. According to a report by the Joint Commissioning Panel for Mental Health, the current structure of mental health services “creates gaps through which young people may fall” as they transition between CYMHAS and AMHASxxii. Differences between the child and adult systems can pose major challenges for TAY and their family members. These differences may include the amount and forms of support available from service providers, the processes used in decision-making and obtaining consent, and the level of family involvementxxiii. Within the paediatric system, families tend to play an active role in patient care as parents/caregivers and are considered to be responsible for ensuring patient adherence to treatment plans and advocating on their behalf. However, as TAY move into the adult system they face a sudden expectation to play a much more active role in their own care, which can lead to feelings of distress and intimidationxxiv. 25

Children’s Mental Health Ontario identified further potentially disruptive inconsistencies between CYMHAS and AMHAS, including differing eligibility criteria, care philosophies, language, access points, and assessment and treatment modalitiesxxv. Youth informants spoke to the need for more comprehensive transition programs that begin earlier in order to improve the quality of transitions between these two systems.

Delivery of Services The way in which existing MHA services are delivered to TAY is another challenge that is prominent within the existing literature and was repeatedly emphasized by TAY and stakeholders. A common finding emerged that current provision of MHA services for TAY is not “youth friendly”. Although there is no clear definition for this term, it relates to the sensitivity and training of service providers, physical and qualitative characteristics of care settings, and other important aspects of service provision. Given the unique nature of TAY and their MHA needs, it is important that services being delivered to members of this population are tailored accordingly. Otherwise, service providers risk encountering a variety of problems when working with TAY including: failure to accurately detect existing MHA issues and/or the tendency to erroneously pathologize normal TAY behaviorxxvi. Unfortunately however, research indicates that consideration of important agespecific factors is rarely practiced in MHA service delivery. According to Haber et al., most MHA services for TAY fail to adequately acknowledge their unique developmental needsxxvii. Experts engaged by the TAYMHA Advisory Committee echoed these concerns, stressing that service providers in both the paediatric and adult sectors often lack the skills and abilities to effectively engage with and address the distinct needs of TAY with MHA challenges. Furthermore, they lack the capacity to tailor services to unique subgroups within the TAY population (e.g. different racial, cultural, and gender groups). These key informants cited a lack of training related to cultural competence, oppression, confidentiality, and the social determinants of health as specific factors contributing to this problem. Youth engaged by the Committee verified and expanded upon these issues. They reported feeling a lack of trust and confidence in MHA service providers, primarily due to their perceived lack of understanding of the unique struggles of TAY with MHA issues and general apathy and insensitivity towards TAY clients. Moreover, several youth informants spoke of hospital Emergency Departments (ED) as negative and intimidating environments. According to these individuals, ED service providers tend to view TAY through a singular lens of medical pathology thereby neglecting their complex holistic needs. Youth informants reported feeling merely “like a number” when accessing MHA services and voiced a strong desire for service providers to address these and other prominent deficiencies. Expert stakeholders outlined two additional problems associated with current delivery of MHA services for TAY. First, the lack of engagement between MHA services and the education and youth justice systems undermines providers’ ability to address the holistic needs of TAY. Finally, there are currently not enough “youth friendly” services or spaces available in the TC LHIN for TAY with MHA issues. Part of this problem is the tendency for TAY MHA services to be delivered in what Haber et al. describe as a “stigmatizing, deficient-oriented manner”, which according to youth, makes them feel alienated from and misunderstood by providersxxviii. Youth emphasized the importance of addressing this gap by actively engaging youth in future efforts to design MHA services and care settings. Finally, services should be delivered in such a manner that acknowledges and addresses the needs of TAY’s family members, including their caregivers and siblings. Research suggests that families tend to receive little assistance in the management of their affected relative’s mental illness from service providers, except in times of crisisxxix. Additionally, in a U.S. study of siblings of individuals with schizophrenia, the majority of individuals surveyed reported 26

a desire for increased communication with the providers caring for their affected sibling. Specifically, respondents wanted providers to educate them about their sibling’s mental illness and to be available to provide answers about the affected sibling as neededxxx. Service Offerings Another key issue relates to the lack of services specifically designed to address the unique needs of TAY with MHA issues. Specific gaps in service were identified in the research literature as well as by the youth and experts engaged by this Committee. The first of these gaps is the lack of services that are specifically designed to serve the TAY populations with MHA issues. According to a review of youth services in Ontario by CAMH, there is a need for more “youth-oriented” services that will engage youth, rather than alienate them as services geared towards older adults tend toxxxi. Support for this proposed change comes from a 2012 U.S. study in which clients in youth-specific versus traditional adult outpatient mental health services displayed a significant increase in their engagement with servicesxxxii. A critical component of this issue is the relative lack of services offered through AMHAS versus CYMHAS. Research suggests that while CYMHAS generally support the needs of individuals with a wide array of MHA issues of varying severity, AMHAS typically concentrate on a small number of serious and lasting conditions, such as major depression or psychosisxxxiii. As a result, TAY with less severe ongoing MHA needs who move into the adult system may be unable to access services that provide an appropriate level of care and/or support. Both youth informants and expert stakeholders spoke about this gap, advocating for a unique programmatic approach to the transitional aged period. A related issue is the shortage of services that look beyond acute needs and crisis management and attend to recovery and long-term wellbeing. There is a clear need for services that take a more holistic and long-term approach, by supporting TAY in maintaining treatment gains and addressing age-specific issues related to employment, education, housing, and independent livingxxxiv. Youth focus groups validated this finding, as several participants expressed a desire for more MHA services that look beyond crisis situations and instead offer “life skills” and long-term supports. These individuals reported experiencing great difficulty in trying to locate such services within the TC LHIN. Stakeholders expanded upon this finding, indicating that TAY often have to wait until they are experiencing a crisis to access services, with little available for those who wish to maintain treatment gains or prevent crisis situations from occurring through early intervention. Expert stakeholders identified further gaps, including a lack of existing services to address issues that are prevalent among the TAY population such as concurrent disorders and traumatic past experiences. Insufficient service offerings and the resulting long waitlists often require individuals struggling with these issues to resort to services that do not address all of their needs. In addition to scarce services and long waitlists, several youth informants cited a lack of free or low-cost services as a major barrier to receiving treatment. Finally, focus group participants voiced the need for MHA programs to offer greater support for families and caregivers through the provision of resources, education, and other forms of assistance. Ideally, these services would enable the families of TAY to develop a greater understanding and acceptance of MHA issues and to better support the individual receiving care. Broader System Issues Systemic issues that extend beyond the purview of a single organization, agency or ministry also create important challenges for TAY with MHA issues. Among these are: a lack of system-wide coordination, under acknowledgement and representation of TAY in policy making and planning, and widespread stigma surrounding MHA issues. 27

Ministries that play an important role in the provision and funding of MHA services for TAY (i.e. MOHLTC, MCYS, MOE, MCU, MAG, etc.) currently operate in silos, further reinforcing a fragmented system of care. This presents a considerable problem for TAY with MHA challenges that persist into adulthood, including those with concurrent mental health and substance use disorders. The result is a lack of coordination and continuity in their carexxxv. It is generally agreed that an inter-ministerial strategy is necessary to address these problems and enable greater coordination in the planning and funding of MHA services. Further coordination issues exist between CYMHAS and AMHAS, where there are differences in frameworks, structures, mandates, funding sources, service offerings and other factorsxxxvi. As previously mentioned, these disparities, in addition to a lack of bridge planning between CYMHAS and AMHAS, can result in poor transition experiences and high rates of disengagement among TAY. A closely related systemic issue is the lack of attention that TAY with MHA issues receive in policy making and program planning. In a report entitled “The Gap: Moving Toward Youth Centered Mental Health Care for Transitional Aged Youth,” the authors highlight that the TAY population is generally overlooked when it comes to decision-making in this domainxxxvii. Recent research from the Mental Health Commission of Canada (MHCC) identifies several specific manifestations of this issue, including the lack of national government leadership, strategy or policy guidance to support those working to enhance TAY transitions. Additional problems identified by the MHCC include the fact that no province or territory is currently tracking youth MHA service transitions or has implemented comprehensive transitional protocols for this population. Furthermore, there is no existing provincial or territorial policy requiring health authorities and/or providers to follow protocols for the TAY populationxxxviii. To address this problem, TAY advocates must encourage governments, ministries and health authorities to assume a more youth oriented approach and to address some of the key challenges that this population faces as prioritiesxxxix. Finally, the need to tackle the persistent and pervasive stigma surrounding MHA issues was repeatedly emphasized by youth focus group participants as well as within the research literature. Research suggests that this stigma can have an especially profound negative impact on TAY compared to other age groups. The impact associated with receiving a formal MHA diagnosis may cause TAY to experience other negative impacts including premature withdrawal from school and the loss of other opportunities, family, and peers. These secondary effects may cause permanent disabilities, thereby reinforcing the stigma associated with the initial diagnosisxl. Youth informants verified this concern, expressing that stigma regarding MHA issues creates challenges not only when accessing mental health services, but also when trying to obtain employment, change schools, and make other important transitions. This stigma can also be detrimental to family members of TAY, including siblings and caregivers, who experience stigma by association – stigma that occurs by virtue of association with another stigmatized individualxli. In a 2002 study of relatives of individuals with mental illness, 83% of family members reported experiencing some form of psychological distress as a result of this harmful phenomenonxlii.

KEY LEARNINGS FROM STAKEHOLDER ENGAGEMENT AND LITERATURE REVIEW Through stakeholder engagement and a review of the literature, the TAYMHA Advisory Committee identified 5 broad categories of challenges facing TAY with MHA: 1) unique characteristics of the TAY population; 2) challenges accessing and navigating between services, 3) the way existing services are delivered to TAY; 4) the need for unique services that address the needs of TAY; and 5) broader system issues outside the purview of a of a single agency or ministry. 

The issues related to MHA comprise a large and growing struggle for TAY - approximately 70% 28

of mental health problems appear in childhood/adolescence but up to 60% of TAY with continuing MHA concerns disengage from service during the transitional period. 

TAY emphasized the importance of actively engaging them in any future efforts to design MHA services target towards their needs.



The needs of TAY with MHA issues are complex - compounded by the intersection of many important physical, sexual, psychosocial, familial, educational and vocational developmental issues that arise between the ages of 16 and 25.



There is considerable diversity among the TAY population that further complicates their MHA challenges (e.g. differences in age, culture, race, gender, sex, ability, socioeconomic status, sexual orientation, education, and religion).



TAY with MHA issues often experience considerable difficulty in accessing appropriate services, citing concerns related to stigma and confidentiality, knowledge of service availability, financial constraints, family perceptions, eligibility criteria, and challenges connecting to service because they are “unattached” (i.e. not having a family doctor or being unattached to services).



Differences between the child and adult systems can pose major challenges for TAY, including differences in the amount and forms of support available from service providers, the processes used in decision-making and obtaining consent and the level of family involvement.



In addition to transitioning between CYMHAS and AMHAS, many TAY must also undergo other potentially stressful transitions, which may include moving from secondary education to postsecondary education or employment, leaving provincial care (i.e. CAS) and transitioning out of the youth justice system.



The current provision of MHA services for TAY is often not “youth friendly”. Service providers in both the child/adolescent and adult sectors often lack the skills and knowledge to effectively engage with and address the distinct needs of TAY with MHA challenges (i.e. this includes a lack of training related to developmentally-informed care, cultural competence, oppression, confidentiality and the impact of the social determinants of health).



TAY reported feeling a lack of trust and confidence in MHA service providers, primarily due to their perceived lack of understanding of the unique struggles of TAY with MHA issue.



Both youth informants and expert stakeholders identified a gap in services specifically targeted towards TAY, advocating for a unique programmatic approach to the transitional aged period, and expressing a desire for more services that look beyond crisis situations and instead offer “life skills” and long-term supports.



Addressing many of these challenges extends beyond the purview of a single organization or ministry and requires an inter-ministerial approach. A lack of system-wide coordination, under acknowledgement of TAY in policy making and planning, and widespread stigma surrounding MHA issues was also highlighted.

29

PART 3: Areas of Focus and Recommendations OVERVIEW Based on a review of the strategic landscape, input from TAY and stakeholders, identification of gaps and challenges, and a review of the literature, the Committee developed recommendations with the ultimate goal of improving the experience, quality of care, and outcomes for TAY with MHA challenges. The Committee began by identifying Areas of Focus to in which to develop its recommendations. The following five foci were confirmed by the Committee:

1. Training & Capacity Building: This Area of Focus aims to address gaps in knowledge, skills and tools (for service providers delivering care to TAY) in order to create youth friendly, non-judgmental environments that address the unique needs of TAY with MHA challenges. 2. Improving Connection & Navigation Among Existing Services: Given that access and navigation among MHA services is often fragmented and inconsistent, this Area of Focus aims to improve the way TAY (and families) access and move between existing MHA services (including moving from child-focused to adult services) . 3. Services for Transitional Aged Youth: This Area of Focus aims to address gaps in MHA services specifically targeted towards the unique needs of TAY - from prevention and health promotion to the more intensive level of services for TAY with the most complex needs. 4. Evaluation and Quality Improvement: The aim of this Area of Focus is to ensure that a consistent evaluation/quality improvement framework is embedded in all new initiatives aimed at addressing the needs of this population. 5. Influence Broader System Change and Policy: Given that many of the challenges facing TAY are outside the purview of a single organization, agency or ministry, this Area of Focus aims to make recommendations as to how the TAYMHA Committee and the TC LHIN can continue to play a role in influencing greater interorganizational, cross-sectoral inter-ministerial collaboration to address the unique needs of TAY.

30

DETAILED RECOMMENDATIONS IN EACH AREA OF FOCUS

FOCUS AREA 1: TRAINING & CAPACITY BUILDING Goal: Address gaps in knowledge, skills and tools (for service providers delivering care to TAY) in order to create youth friendly, non-judgmental environments that address the unique needs of TAY with MHA challenges. Recommendation: Establish a Working Group to lead implementation of the following recommendation: 1. Design and implement training for service providers to build capacity for culturally and developmentallyinformed service provision (e.g. development of youth friendly, non-judgmental environments, etc) that addresses the unique needs of all TAY with MHA challenges. The following elements were identified by the TAYMHA Advisory Committee to inform the design and implementation of the training: Targets for Training 

Training will be targeted towards CYMHAS and AMHAS providers who deliver services to TAY with MHA issues.

Content & Design of Training 

Identify a lead organization to design and implement the training through an RFP process. Many organizations are currently leading initiatives in this area, including: University of Toronto (Dr. John Teshima); Planned Parenthood, Hamilton – Youth Wellness Centre; and CAMH.



Based on engagement with TAY and other stakeholders, a proposed training content is attached in Appendix J. However, to further inform content development, it is recommended that a more detailed analysis be conducted to understand the unique knowledge and skill requirements of service providers in dealing with TAY with MHA issues in the TC LHIN (and to validate if some or all of the content proposed will meet these needs). Consideration should be given to tailoring content to address gaps relevant to different stakeholder groups where appropriate.



A review of existing training materials should also be conducted and leveraged where possible.



TAY and families should be involved in the both the design and implementation of the training.



Training methods should be developed that are innovative and interactive and that focus on building both individual and organizational capacity (i.e. this includes consideration for utilizing technology, instructor-led, self-taught, mentor-based learning approaches).



Tools, checklists and other supports should be developed to support implementation of practice changes and reinforce training.

31

Implementation of Training 

A phased implementation approach is recommended, initially targeting selected existing and new programs and initiatives that serve TAY with MHA issues (e.g. Health Links teams focused on providing MHA services to TAY, and other system change initiatives that are taking place in the TC LHIN by ensuring that new services receive training).



Broader implementation of training will take place in a second phase. This could include linking with the professional training organizations (i.e. Social Work, Medical Schools etc.).

Enablers of Implementation and Sustainability 

Identify mentors/coaching teams to support ongoing sustainability of training.



Organizations, teams or individuals that take part in the training could be ‘certified’ to be “youth friendly” with an understanding of the issues affecting TAY. A sticker for a window, poster for an office, statement for a website, etc., would identify to youth and/or referring service providers that the service provider they are seeing has participated in and is demonstrating a commitment to providing youth positive, inclusive, transitional aged sensitive services.



Organizations that have completed the training could also be added to a list of agencies that are certified so that when a referral is made there can be some assurance that the services will be youth positive and understanding of the specific needs of TAY.



Develop a strategy to ensure ongoing monitoring/auditing of training to ensure the content remains relevant and uptake is as expected. There should be a feedback loop so that the training and capacity building continuously evolves to prepare providers to address/ respond to the gaps.



Utilize learnings from other initiatives, such as those promoted as “Baby friendly” and “Senior Friendly.”



There should be system level expectation that organizations serving TAY provide training to staff in the system (i.e. TC LHIN mandated training).

32

FOCUS AREA 2: IMPROVING CONNECTION AND NAVIGATION Goal: to improve the way TAY and their families access and move between existing MHA services (including moving from child-focused to adult services). The committee identified that there are differing connection and navigation needs for different TAY populations (e.g. complex/life-long utilization of services, one-time/episodic service utilization, unattached TAY, etc.) and these must be considered in the implementation of these recommendations. Recommendations: Establish a Working Group to lead the detailed design and implementation of initiatives within this Area of Focus. As a first step, the Working Group will prioritize the following initiatives identified by the Committee to improve connection and navigation for TAY and their families: 1. Monitor the results of the Service Collaboratives and adopt their emerging best practices in the TC LHIN targeted towards TAY with MHA issues 

Systems Improvement through Service Collaboratives (SISC) is an initiative under Ontario’s Comprehensive Mental Health and Addictions Strategy (2011). The ultimate goal of these Service Collaboratives is to improve access and transitions to MHA supports for children, youth and families across services and sectors.



These Collaboratives are focused on improving services for children and youth in transition: between community and hospital settings; between health and justice systems; and from child-focused to adult services.



As previous mentioned in the Environmental Scan, some of the Service Collaboratives (e.g. SimcoeMuskoka and Kingston, Frontenac, Lennox and Addington (KFL&A)) are focusing specifically on improving transitions from child-focused to adult services.

2. Disseminate transition best practices across the system to prepare TAY and families early to transition to the adult system. 

Design and implement a “mentor/navigator” role to support the transition process for TAY and families.



Develop and implement consistent practices to support transitions to the adult system (i.e. standards for connection and navigation between services).

3. Implement models to improve connection and navigation of TAY (and families) moving from hospital to community services. 

TAY accounted for approximately 12% of all MHA Emergency Department visits in FY 2013-14. This share varied significantly across sites, with CAMH having the highest share of TAY ED visits at 23%, and UHN and TEGH having the lowest share of TAY ED visits at 3%.



TAY accounted for approximately 13% of all MHA admissions in FY 2013-14. Again, this share varied significantly across sites, with Sunnybrook having the highest share of TAY admissions at 30% (a function of their having a dedicated youth inpatient service), and TEGH having the lowest share of TAY admissions at 5%.



Consider expansion of the ED Clinical Pathway to TAY. The goal of the ED Pathway project is to provide timely linkages to community services for ongoing care for children and youth up to the age of 17 with 33

mental health issues. There may be opportunities to expand elements of the ED Pathways project to TAY with MHA issues. 

Improving flow from acute beds (hospital) to and from the community for TAY working closely with the Acute Care Alliance.

4. Build Connections between existing access points to ensure seamless system navigation. 

As access points such as 211, Family Navigation at Sunnybrook Hospital, The Access Point, CARS, and Access CAMH are built across the system; they need to have the capacity to speak to each other at point of service to ensure service coordination and seamless navigation.

5. Improve Connections to Services for TAY leaving the Child Welfare and Justice Systems. 

TAY leaving the Child Welfare and/or Justice System often do not have family support to help them access and navigate the MHA system. Specific supports for these TAY need to be developed. Identifying key informants from both of these systems is a first important step in improving sector connections.



Build on the learnings from the Central West Health Link Care Coordination Pilot for TAY transitioning to the adult system from the child welfare system.

FOCUS AREA 3: SERVICES FOR TRANSITIONAL AGED YOUTH Goal: to address gaps in MHA services specifically targeted towards the unique needs of TAY - from prevention and health promotion to the more intensive level of services for TAY with the most complex needs. Recommendations: Establish a Working Group to lead the detailed design and implementation of the following recommendations: 1. Confirm the most pressing gaps in services for TAY with MHA challenges in the TC LHIN. 



The TAYMHA Advisory Committee recommends prioritizing the following identified gaps in service for TAY: o

TAY friendly spaces

o

Flow of TAY between acute beds (hospital) and the community (working closely with the Acute Care Alliance)

o

Medically-fragile TAY with MHA issues (Medical Psychiatry Alliance)

o

Improve connections to services for TAY leaving the Child Welfare and Justice Systems

o

Housing and respite needs for TAY

The Working Group will conduct a Needs Assessment to confirm the prioritization of the above mentioned services by comparing existing TAY MHA services available in the TC LHIN to the MHCC’s “Proposed Continuum of Mental Health and Addictions Services for Emerging Adults: A Tier-Based Approach.” 34



The Working Group will also utilize the Environmental Scan conducted by the TAYMHA Committee (including engagement with TAY and other stakeholders), and the “Inventory of TAY MHA case management, counseling and housing services funded by the TC LHIN” referenced previously to help inform this Needs Assessment.

2. Design and implement a structure to enable ongoing identification and monitoring of specific service gaps for TAY with MHA challenges in the TC LHIN. 3. Utilize a set of design principles to guide the design and implementation of services to address identified gaps in services for TAY. The following are recommended by the TAYMHA Committee as a starting point: PRINCIPLES FOR THE DESIGN AND IMPLEMENTATION OF TRANSITIONAL AGED YOUTH MENTAL HEALTH AND ADDICTIONS SERVICES 1. Improve accessibility by ensuring that services offered for TAY are:  Offered during the times TAY need and use them (including after hours and on weekends);  Easily accessible in person or via technology; and  Delivered at or in partnership with agencies/organizations frequented by TAY (i.e. community centres, schools). 2. Develop Youth Positive Services by ensuring that they are:  Developed with youth input and opinion;  Include peer involvement and are peer led whenever possible;  Developmentally appropriate; and  Non-judgmental, sex positive and drug neutral. 3. Ensure that services are responsive and reflect the complexity of TAY needs:  Early identification of needs and intervention;  Endorse and support partnerships between sectors to enable a smooth transition between services;  Incorporate access to non-medical treatment such as psychological therapies; and  Give equal focus to both substance use and mental health supports.

35

FOCUS AREA 4: EVALUATION AND QUALITY IMPROVEMENT Goal: to embed a consistent evaluation and quality improvement approach for new initiatives aimed at addressing the needs of TAY with MHA challenges. Recommendations: A separate Working Group is not required to lead the detailed design and implementation of recommendations within this Area of Focus. Rather, evaluation and quality improvement will be an underlying principle embedded within the work of the three aforementioned Working Groups. 1. All newly funded initiatives for TAY (through the TC LHIN) will utilize a consistent evaluation and quality improvement approach. 

A group with an affiliation to an Academic Health Sciences Centre would lead the development of the evaluation/QI strategy/toolkit (e.g. Slaight Centre/McCain Centre at CAMH, CHSRG at Sickkids, etc.)



This framework would inform the implementation work of the three Working Groups (proposed by the TAYMHA Committee).

2. A healthy equity impact assessment will be conducted for all new system enhancements with TAY as a key stakeholder group. This should include recently implemented MHA services and access points (i.e. recently funded Health Links teams, The Access Point).

FOCUS AREA 5: INFLUENCE BROADER SYSTEM CHANGE AND POLICY Goal: Given that many of the challenges facing TAY are outside the purview of a single organization, agency or ministry, this Area of Focus aims to make recommendations as to how the TAYMHA Committee can continue to play a role in influencing greater inter-organizational, cross-sectoral and inter-ministerial collaboration to address the unique needs of TAY. Recommendations: A separate Working Group is not required to lead the implementation of recommendations within this Area of Focus. Rather, advocating for broader system change is an ongoing principle that needs to be embedded within the work of the three Working Groups and the TAYMHA Advisory Committee. 1. TAY continue to be identified by the TC LHIN as a distinct population from a policy, planning, funding and service delivery perspective. 2. The TAYMHA Advisory Committee will have an ongoing mandate with the TC LHIN to oversee implementation of these recommendations and to continue to provide ongoing strategic advice to the TC LHIN in alignment with regional, provincial and national strategies. 3. TC LHIN to be a lead influencer for improved collaboration between the following related to TAY with MHA challenges:  

Other GTA LHINs; and TC LHIN MHA services and Child Welfare services and Justice to support effective access to MHA services for TAY leaving the Child Welfare or Justice Systems.

36

4. TC LHIN influence and leverage the MCYS transformation to support selected lead MCYS agencies in working with TC LHIN funded organizations “to outreach and collaborate with mental health and addictions providers to improve transitions for youth to adult and young adult community mental health and addiction services” (i.e. local pathways and protocols). 5. An inter-ministerial strategy is needed to provide a common lens and leadership for sectors providing services to TAY with MHA challenges. Leadership must be taken by one group to lead changes and pull together different Ministries (i.e. MOHTLC, MCYS, MoE, MCU, MAG, etc).

37

PART 4: Implementation and Next Steps To support the next phase of work, the TAYMHA Advisory Committee recommends the following oversight and implementation structure to move its recommendations forward: 

The TAYMHA Advisory Committee will have an ongoing mandate with the TC LHIN to: 1. Oversee the work of the three aforementioned Working Groups; and 2. Continue to provide ongoing strategic advice to the TC LHIN related to TAY with MHA challenges.



Three Working Groups will be established to continue to design and implement the recommendations outlined in this report. The recommendations contained in this report will form the Terms of Reference for each Working Group.



Membership of the TAYMHA Advisory Table will be reviewed and adjusted based on selected Areas of Focus, in order to support effective implementation oversight of the Working Groups.



A member of the TAYMHA Committee will be selected to lead each of the three Working Groups



All Working Groups will engage TAY and their family members in the detailed design, implementation, and evaluation of recommendations contained within this report.



Working Groups will be given a two-year mandate to lead the detailed design and implementation of recommendations (with oversight from the TAYMHA Advisory Committee).



TAYMHA will continue to report to the TC LHIN’s Children and Youth Advisory Table and the Strategic Advisory Table (on the progress of design and implementation).



As a critical enabler of this work, funding will be required to support Project Management assistance for each Working Group.

Implementation Structure:

Children and Youth Advisory Table (CYAT) & Strategic Advisory Table (SAC)

TAYMHA Advisory Committee

Training and Capacity Building Working Group

Connection and Navigation Working Group

Services for TAY Working Group

High-Level Implementation Timeline The following outlines a high-level implementation timeline for the next phase of work: 38

Apr-15 - Jul-15 Finalize Report & Convene Working Groups

Jul-15 - Oct-15 Each Working Group Develops a Work Plan

Jul-15

Sep-15 - Mar-16

Mar-16 - Mar-17

Year 1 Detailed Design & Implementation

Year 2 Implementation

Oct-15

Jan-16

Apr-16

Jul-16

Oct-16

Jan-17

Apr.-30-15

Mar.-31-17

th

th

Finalize Report and Convene Working Groups - April 30 to June 30 , 2015 

Final draft report submitted to TC LHIN on April 30th



Additional stakeholder engagement with subject matter experts and thought leaders to review recommendations (final report)



Refresh mandate and membership of TAYMHA Committee and identify leads for Working Groups



Secure Project Management support for each Working Group



Convene Working Groups



Confirm Terms of Reference for each Working Group

Work Plan Development - July 1st to October 2015 

Each Working Group will develop a Work Plan outlining the plan to execute on the recommendations contained within this report (including detailed design and implementation)



TAYMHA Committee to review and approve Work Plans

Year 1 Implementation - November 2015 to March 30th 2016 

Each Working Group will execute on this detailed Implementation Work Plan (Year 1)



Quarterly oversight by TAYMHA

Year 2 Implementation - April 2016 to March 30th, 2017 

Recalibration of Implementation Work Plan based on Year 1 achievements



Each Working Group executes on this detailed Implementation Work Plan (Year 2)



Quarterly oversight by TAYMHA

39

APPENDICES

40

Appendix A - TAYMHA Membership and other Participants Co-chairs •

Dr. Tony Pignatiello, Associate Psychiatrist-in-Chief, SickKids

•

Karen O’Connor, Lead for Child and Youth Mental Health, Canadian Mental Health Association, Toronto

Members •

Carmine Stumpo, Vice-President, Programs, Toronto East General Hospital

•

Dr. Nagi Ghabbour, St. Joseph’s Hospital

•

Amy Cheung, Adolescent Medicine Program, Sunnybrook Health Sciences Centre

•

Gloria Chaim, Deputy Clinical Director, Child Youth and Family Program, Centre for Addiction and Mental Health

•

Katherine Dominic, Vice-President, Client Services and Interprofessional Practice, Hincks-Dellcrest

•

Heather McDonald, Director, Adult and Youth Services, LOFT

•

Paul Allen, Clinical Director, Youthdale Treatment Centres

•

Barney Savage, Senior Advisor, System Transition Team, Ministry of Children and Youth Services

•

Brenda McNeill, Executive Director, Anne Johnston Health Station

•

Wendy Shaw, Chief of Social Work and Attendance Services, Toronto District School Board

•

Dr. Su-Ting Teo, Director, Student Health and Wellness, Ryerson University

•

Jabari Lindsay, Manager, Youth Development, Social Development, Finance and Administration Division, City of Toronto

•

Elizabeth Ferguson, Clinical Director, Centre for Brain and Mental Health, SickKids

•

Kendyl Dobbin, Senior Consultant, Toronto Central LHIN

Project Lead •

Paul Davis, Director Health System Integration, The Hospital for Sick Children

Administrative Support •

Jonathon Dionisi, The Hospital for Sick Children

Focus Group Facilitators •

Tyson Herzog, Peer Facilitator, Youth System Innovation Group, Centre for Addiction and Mental Health

•

Olivia Heffernan, Peer Facilitator, Youth System Innovation Group, Centre for Addiction and Mental Health

•

Alicia Raimundo, Mental Health Superhero

Advanced Health System Leadership Program – Rotman School of Management – University of Toronto •

Kim Fraser

•

Robin Griller

•

Sarah Hobbs

•

Vesna Milinkovic

•

Karen O’Connor

•

Rishika Williams

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Appendix B – TAYMHA Terms of Reference Transitional Aged Youth Mental Health and Addictions (TAYMHA) Advisory Committee Terms of Reference January 2013 1.0 Background The Children and Youth Advisory Table (CYAT) was convened in 2012 to provide ongoing strategic advice and recommendations to the Toronto Central Local Health Integration Network (TC LHIN) regarding priorities for the local child and youth health system. CYAT has three overarching goals: to improve the health and wellbeing of children and youth; to improve the quality of the child and youth health system in the TC LHIN; and, to ensure the sustainability of the child and youth health system in the TC LHIN. Following an environmental scan and stakeholder engagement, CYAT identified three areas of strategic priority in 2012 and, and with endorsement and funding from the TC HIN a number of recommendations related to each are being implemented by cross-sector implementation working groups. These three priority areas are: 1. Access to healthcare information for children, youth and families facing socio-economic and ethnocultural linguistic barriers; 2. Care coordination and system navigation for children with medical complexity; and 3. Transitions between the paediatric and adult health systems (initially focusing on children with Spina Bifida). CYAT reconvened in October 2013 to begin its second year of strategic planning. The Table refined its original mandate with the TC LHIN – to provide ongoing strategic advice and recommendations with respect to the child and youth health system, with a focus on the “sick care” system – and confirmed three new priority areas: mental health, palliative care, and primary care/health links. CYAT, however, will primarily focus on strategic planning in child and youth mental health, while playing a more advisory role in the other two priority areas. Simultaneously, the TC LHIN’s Strategic Advisory Council (SAC) identified three areas of focus for the TC LHIN: 1) creating a healthier and more equitable city; 2) senior’s strategy; and 3) child and youth mental health and addictions. With this clear alignment between the child/youth mental health priority identified by both CYAT and SAC, the TC LHIN requested that CYAT take a leadership role overseeing strategic planning and implementation in this priority area. In order to ensure CYAT is able to fulfill its ongoing mandate to provide strategic advice to the TC LHIN in a variety of areas, it was decided that the CYAT would maintain a broad cross-sectoral membership with expertise in a variety of areas of child/youth health. The CYAT has, therefore, elected to convene a Child and Youth Mental Health and Addictions Advisory Committee (“Advisory Committee”), with expertise in child/youth mental health and addictions, to lead two areas of activity within this priority area. 

Lead the development of recommendations to address challenges faced by transitional aged youth experiencing mental health and addictions issues



Provide strategic oversight of the implementation of child and youth mental health “quick wins” in the TC LHIN.

2.0 Purpose Transitional Aged Youth Mental Health and Addictions Strategy 42

At the request of the TC LHIN, this committee will oversee the development of strategic recommendations and implementation planning to address challenges faced by transitional aged youth experiencing mental health and addictions issues. It is important to note, this strategic planning exercise is designed to complement and not duplicate other local, regional, and provincial mental health and addictions initiatives. At the outset we will be conducting a comprehensive environmental scan to map these existing initiatives, to understand gaps and opportunities so that this planning table can address specific challenges of transitional aged youth with mental health and addictions issues. Child and Youth Mental Health Quick Wins Through a consultative process with thought-leaders and the TC LHIN Strategic Advisory Council, three child and youth mental health quick-wins were put forward to the TC LHIN for endorsement and funding: 1. Community-based, integrated collaborative care model for youth with mental health challenges; 2. Transition-aged youth collaborative based on the Transition to Independence (TIP) Model; and 3. Child and Youth Mental Health Emergency Department Clinical Pathway. The TC LHIN has elected to move forward with implementation of the Child and Youth Mental Health Emergency Department Clinical Pathways as this initiative aligns with the LHIN’s current Health Links work and System Transformation agenda. Additional planning will be conducted to further understand alignment/synergies between the two other quick-wins and ongoing mental health initiatives within the TC LHIN through the work of this Advisory Committee, and a final decision is expected in 2014/15. 3.0 Membership Dr. Tony Pignatiello, Associate Psychiatrist -In-Chief, Sickkids will chair the committee, with a vice-chair from the community sector being identified at our first meeting. The Advisory Committee membership will reflect the cross-sector collaboration that will be required to fulfil the mandate as outlined above including: diversity in terms of sector (community mental health services, CCAC, primary care, acute, education, MCYS, services for young adults, youth, etc) and role (senior administrative roles, clinicians etc.) will be important in order to ensure varied input into the decision making process. Advisory Committee members will bring the following skills and experiences: 

Strong understanding of child and youth mental health and addictions resources, challenges and issues – particularly with respect to transitional aged youth;  Strategic system thinkers with the ability to translate strategic thinking into actionable recommendations  An awareness of relevant policies and potential policy barriers;  Serving in a decision-making role within their respective organizations; and,  An ability to influence change Note: At the inaugural meeting of the Advisory Committee, we will discuss various approached to engaging youth, young adults, and families in the strategic planning process (i.e. representation on the advisory committee and/or broader stakeholder engagement. 4.0 Roles and Responsibilities Advisory Committee members will be required to:  Attend all meetings (by teleconference or in person, delegates will not be permitted) – see Transitional Aged Youth MHA Strategy Work Plan attached)  Inform and obtain input from members of their respective organizations as required to inform the work of the advisory committee;  Thoroughly review pre-meeting packages in advance of meetings; 43

  

Make timely decisions as required; Review and provide feedback on the final report; and Maintain confidentiality of documents and meeting discussions, as required.

It is expected that Advisory Committee members will come to all meetings well prepared, having read all pre-reading materials, and considered their position on key discussion points (as outlined in the pre-reading packages). The preparatory work is expected to take no more than 2 hours for each meeting. 5.0 Term Initially the term will be one year with an opportunity to review and extend the term. 6.0 Meeting Schedule and Time Commitment The Advisory Committee will meet no more than monthly with meetings scheduled for 2.0 hours. It is expected that meeting preparation will take no longer than 2 hours per meeting. See the Transitional Aged Youth MHA Strategy Work Plan appended to the Terms of Reference for approximate meeting dates. 7.0 Decision Making Recommendations made by the Advisory Committee will be based on open and direct communication, honesty, respect, and transparency, to ensure that all perspectives are heard. Recommendations will be made based on a thorough review of available information, evidence-based and leading practice, and the collective expertise of Advisory Committee members. Recommendations will be made by consensus whenever possible. If voting is required, all members will have one vote. Recommendations will be based on a 50%+1 vote. 8.0 Conflict of Interest Advisory Committee members shall, without delay, disclose to the co-chairs any actual or potential situation that may be reasonably interpreted as either a conflict of interest or a potential conflict of interest. 9.0 Confidentiality Material presented to the Advisory Committee should be kept confidential, except for the requirements to communicate project progress, and obtain input from members’ respective home organizations, or until recommendations are finalized. Date: ____________________________________ I [print name] __________________________________________, agree to the above terms of reference, and do not have a conflict of interest preventing me from serving on the Children and Youth Mental Health and Addictions Steering Committee.

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Appendix C –Emergency Department Clinical Pathway Prior to convening the TAYMHA Advisory Committee, through a consultative process with thoughtleaders and the TC LHIN’s SAC, three child and youth mental health “quick-wins” were put forward to the TC LHIN for endorsement and funding. These quick wins were: 1.

Community-based, integrated collaborative care model for youth with mental health challenges;

2.

Transition-aged youth collaborative based on the Transition to Independence (TIP) Model; and

3.

Child and Youth Mental Health Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions (ED Clinical Pathway).

The TC LHIN elected to move forward with implementation of the ED Clinical Pathway as it aligns with the LHIN’s current Health Links initiatives and System Transformation agenda. The ED is not only a common entry point for children and youth into the MHA system but also a point of transition when children and youth are waiting for long-term treatment. Still, numerous EDs do not have adequate clinical resources, standardized screening tools and training, integration with other MHA providers, or a streamlined referral process to provide appropriate support to children and youth entering the mental health system. Developed by Provincial Council for Maternal and Child Health (PCMCH), the ED Clinical Pathway is used to guide and support the care of children with MHA problems by utilizing clinical pathway decision support tools and seamless follow-up services with relevant community agencies. Designed for children and youth aged 17 and younger, the ED Clinical Pathway could be implemented with young adults with MHA concerns up to age 24. Informed by a literature review, an environmental scan and expert consultation, the ED Pathway includes the following components: 1. An algorithm that describes key aspects of the flow, activities, and community integration of the ED Clinical Pathway; 2. Mental Health and Addictions Screening Tools to assist ED Clinicians in decision making; and 3. A tool-kit to support implementation of the pathways. The ED Clinical Pathway tool combines best practice recommendations and clinical practice guidelines in a widely accessible format to aid multidisciplinary health teams in the management of MHA care for children and youth. Key to the successful implementation of the ED Clinical Pathway model is partnership between EDs and community MHA service providers. The TAYMHA Advisory Committee was tasked with providing strategic oversight for the pilot implementation of the ED Clinical Pathway Pilot Project. The ED Clinical Pathway Pilot project began by engaging stakeholders and preparing for implementation in March 2014. All project and evaluation activities will be completed by April 2015.

45

For the project, the TC LHIN identified three acute care sites based on data from PCMCH’s 2013 Benchmarking Report that indicates approximately 85% of children and youth who present with a mental health issue in an ED come to one of the three hospitals in the TC LHIN. SickKids’ ED sees 48.3%, St. Joseph’s Healthcare Centre sees 21.9% and Toronto East General Hospital sees 21.9%. Based on discussions at each acute care site between administration, mental health and emergency department staff, the following child and youth community mental health providers were identified and engaged to participate in a partnership with the hospitals for the pilot. The following table illustrates the three groups involved in the pilot:

Group 1

Acute Care Site St. Joseph’s Health Care Centre

Group 2

The Hospital for Sick Children

Group 3

Toronto East General Hospital

       

Community Agencies George Hull Centre for Children and Families Yorktown Child and Family Services Oolagen Youthdale Hincks-Dellcrest Griffin Centre Hincks-Dellcrest East Metro Youth Services

46

Appendix D – Review of Other “Quick Wins” The TC LHIN also requested that the TAYMHA Advisory Committee put forward proposals for funding in 2014/15. These proposals were meant to address challenges faced by TAY with MHA issues. One-time funding (November to March 2015) was available with the potential for ongoing funding in 2015/16. The TAYMHA Committee identified three potential “quick wins” for consideration: 

Youthcan: Integrated Collaborative Care Coordinating Team for Transition Aged Youth (TAY);



Care Co-ordination and Intensive Case Management (ICM) for Transitional Age Youth (TAY) with Complex Mental Health (MH) and Addiction issues; and the development of an inventory of TAYMHA services; and



North West Toronto Health Link (NWTHL) - Primary care attachment for TAY with MHA challenges.

The TAYMHA Committee utilized the following criteria to assess each proposal: 1.

Alignment with the Committee’s five Areas of Focus (outlined previously);

2.

Alignment with other local and/or provincial MHA/transformation initiatives;

3.

Readiness to implement;

4.

Potential impact and in what timeframe;

5.

Ability to leverage existing resources and partnerships; and

6.

Ongoing sustainability plan.

The TC LHIN elected to move forward with implementation of “Care Co-ordination and Intensive Case Management (ICM) for Transitional Age Youth (TAY) with Complex Mental Health (MH) and Addiction issues; and the development of an inventory of TAYMHA services”

47

Appendix E – Stakeholder Engagement The table below contains a list of all expert stakeholders engaged by the TAYMHA Committee to inform the environmental scan, organized by scope of expertise. National & Provincial

Local & Front Line

• Board Member, Mental Health Commission of Canada

• ED, Delisle Youth Services

• Director of Advocacy, Office of the Provincial Advocate for

• ED, Stella’s Place

Children and Youth • Provincial Advocate for Children and Youth • Executive Director, Ontario Centre of Excellence for Child and Youth Mental Health

• ED, Operation Springboard • Deputy Clinical Director, Child, Youth and Family Program, Centre for Addiction and Mental Health • Director, Adult and Youth Services, LOFT

• Director, Provincial Service Collaboratives

• Clinical Director, Across Boundaries

• Manager, Knowledge Exchange, Centre for Addiction and

• ED and Clinical Manager, Native Child and Family Services

Mental Health • Head of Research with Child, Youth & Family Program, Centre for Addiction and Mental Health

of Toronto • ED, Eva’s Initiatives • Medical Director of Underserved Populations; Access and Transitions at the Centre for Addiction and Mental Health • Program Director, Mind to Mind • Therapist, Planned Parenthood Toronto • Case Coordinator, Planned Parenthood Toronto • Transitional Aged Youth Substance Use Program, North York Hospital • Manager, Toronto Drop-In Network

48

Appendix F – Youth Engagement Organizations The following table contains a list of all youth and family groups engaged by the TAYMHA Committee, as well as the corresponding organizations that supported the recruiting and delivery of each engagement session. Youth/Family Group

Organizations

LGBTTQ Youth

Sherbourne Health Centre Egale Youth Outreach 519 Community Centre

Aboriginal Youth

Native Child

Francophone Youth

Centre Francophone de Toronto

Newcomer Youth

Access Alliance

Youth Living in Poverty

Covenant House LOFT

Youth with Disabilities

The Griffin Centre

Post Secondary Youth

The University of Toronto Ryerson University George Brown College

Families

CMHA (National Alliance on Mental Illness) Family Group CMHO Youth Services Parent Group

49

Appendix G – Transitional Aged Youth Focus Group Guide Focus Group Detailed Agenda

INTRODUCTION – 10 MINUTES Introduce facilitators, dietary needs, group norms, comfort agreement Who are we inviting to participate in the focus group? The TAYMHA committee is inviting you to participate in a 1.5 hour focus group discussion to learn more about the experience of young people (ages 16 to 24) who have mental health and/or addictions challenges. We also want to get your ideas on how things can be improved. What is TAYMHA? We know that young people ages 16 to 24 with mental health issues and/or addictions face unique challenges as they become young adults. The Transitional Aged Youth Mental Health and Addictions (TAYMHA) Committee was created by the Toronto Central Local Health Integration Network (TC LHIN) to: • Understand the challenges faced by youth ages 16 to 24 with mental health and/or addictions issues in Toronto • •

Understand what work is being done to support this group – what is working, what’s not, what’s missing To come up with recommendations to make improvements for this group

TAYMHA is made up of people with experience working with transitional aged youth with mental health and addictions challenges. What is the Toronto Central (TC) LHIN? The TC LHIN is responsible for planning and funding healthcare services in Toronto. What will be discussed at the focus group? There has already been a lot of discussions with transitional aged youth to understand their concerns and the barriers to getting the services that they want and need. During the focus groups we want to build off of the work that has already been done and be sure that it is accurate so that TAYMHA can develop recommendations that address your concerns and challenges. The potential solutions that we discuss during the focus group will also help inform the recommendations made by TAYMHA. Learning from your experiences and hearing your thoughts will help to inform how services are delivered to transitional aged youth with mental health and/or addictions issues in Toronto. The ultimate goal is to improve care and the health of young people. 50

What will the information discussed during the focus groups be used for? After the focus groups, TAYMHA will use the information that is discussed to make a list of recommendations. These recommendations will be brought back to the people who participated in these focus groups to get their feedback/opinions. This will happen early in 2015. Next, TAYMHA will make a finalized list of recommendations that they will give to the TC LHIN. The TC LHIN will then decide which of the recommendations will be implemented. Remind youth that if they have something that they would like to say, can submit online to Survey Monkey (ensures anonymity) - https://www.surveymonkey.com/s/WPYWKQR

ICE BREAKER – 5 MINUTES TBD

GENERAL DISCUSSION – 10 MINUTES (MAXIMUM 15) What are transitions? 

Context of specific examples (switching schools, drivers license, transition to independence over health information, sexual consent, cannot be brought into Children’s Aid without a court order, apply for social assistance, apply for a passport)

Different types of transitions within MHA services  

Use the transition examples above to begin discussion about MH&A services i.e. moving to different therapy groups, different housing situations, waitlist, medication

“We just wanted to get you thinking about your own experiences. Now we will be starting to talk about your experiences within the context of MH&A services.”

ISSUES VALIDATION – 15 MINUTES (MAXIMUM 20 – 5 MINUTES FOR WRAP UP) Youth will be asked to discuss some experiences. Note-taker will write down what the youth are saying on the chart paper. Facilitator will mark down which issues from one-pager have been hit on by youth. “We just had an encouraging talk about barriers and issues that we are facing. After the break we want to come up practical solutions, ideas.” 

I.e. Don’t say “change everything”. Give a specific solution or something that you would like to see. 51

PIZZA BREAK! – 15 MINUTES SOLUTIONS – 20 MINUTES (MAXIMUM 25) Provide examples. 

“Johnny says that counselors are stupid – perhaps that means that they need more training. Is more training a solution?”

Break off into groups of 3 If you come up with 3 solutions, you win candy! Instruct all participants to pick one issue/barrier that is most important to them. They can choose from previous discussion or a new issue that they thought of. The group helps to come up with a solution for each barrier of each group member. A volunteer participant from each group will write their solutions on the chart paper. Post areas of focus around the room as visual prompts (see below for youth-friendly wording of focus points) 

Training and Capacity Building – Training and Education for people who provided services to transitional age youth



New services for transitional aged youth – New services and programs



Connection & navigation among existing services – Finding the help that you want (how do you get there, what services do you want to get into, etc.)



Evaluation and Research– Making sure the service works

 

Advocate for broader system change – Advocacy & Stigma Busting Other

CLOSING COMMENTS Thank the youth for attending. Validate what they have said. Do you want more information? Survey Monkey – anonymous comments if you have more to say Transit stuff

52

Facilitation Tips Role of the facilitators at each small group is to engage in a process that leads to insight. We’re there to pull out those gems that answer our objective. Here are some tips: 1. Be transparent about the need to step outside comforts. Engagement is about acculturation to other groups: “If you feel uncomfortable speaking up or drawing your ideas, that’s reasonable and part of the process. Think of how a young person feels when they approach health system and institutions.” 2. Reinforce that this is a brainstorm process; a considered list of improvements changes will be shared in the future. Use “YES! AND …” as a way of moving from one person to others. In this limited amount of time, a single person cannot hold the floor. Setting Up the Environment  

Arrange chairs around a central object (like a table or desk) or in a circle Be sure that you are dressed in a more casual fashion as to not intimidate or cause feelings of

 

shame in youth attending – be audience conscious Arrange snacks/drinks on table Can help to have music playing/radio on in background as youth come in



Welcome the youth as they walk in with a genuine smile – don’t patronize them



Invite them to have a seat and as each group comes in, give a general reminder that you’re just waiting for a few more youth and then will get started. Invite them to help themselves to drinks/snacks.

Ice Breaker Tips  

Be prepared for awkward silences near the beginning of the session; again, the radio can be a nice tool for background noise (and a common ground that many youth share with a love of music) Introduce yourself and be honest/real.



You will start the ice breaker and dictate the rules of who goes next. Don’t leave it up to the youth to volunteer or you may encounter silence.



If there are people with similar interests, make a comment about that – it provides a personal connection between the individuals. Remind the youth that this can be awkward but that they are all here for the same reason, to help out and to get some food and a gift card.



53

Discussion Tips 

After posing the question (writing it down is helpful), begin the discussion by talking about an experience that you have had to open up the floor o o

  

I.e. “What is the worst thing about any service that you have received”? Facilitator: I know that can be a huge question but the first thing that comes to my mind is x. When this happened to me by this agency, I felt x. Has anything like that ever happened to you?

Remember the youth’s names! When you are asking for participation, say their name and ask if they have ever experienced x. If there is silence and no one will speak, talk about your own experiences. Be casual and relatable. If the silence will not break no matter how hard you try, move on to the next topic. Practice active listening. Be sure to truly listen to what the person is saying. Using physical prompts (nodding,

Basic Youth Engagement Tips   

Be open and friendly. Don’t lie, if you don’t know the answer – admit it! Genuinely listen to each participant. Show your appreciation for what they are sharing. Make the environment as comfortable as possible.

54

Appendix H – Environmental Scan Approach The following provides an overview of the approach followed by the TAYMHA Committee to complete its environmental scan and develop recommendations.

Phase 1: Current State Analysis and Future State Inputs to Identify Priority Areas Environmental Scan An initial environmental scan was undertaken to inform the Committee’s work, comprising a literature review, community engagement and a jurisdictional scan. 1. Literature Review In order to identify the issues that TAY with MHA issues currently face in the TC LHIN, the Committee conducted a review of relevant literature. At the request of the Co-Chairs, Committee members made suggestions of potential sources to be included in this scan. A review was then conducted using these and other agency and government reports, peer-reviewed articles and other documents. 2. Community Engagement Community engagement with stakeholders from across the child and youth mental health system was a critical input to the initial work of the TAYMHA Committee. Youth Stakeholder Engagement: Using the Government of Ontario’s Stepping Up Strategic Framework document as a starting point, the Committee identified 11 TAY subgroups, seven of which were selected as priorities to be engaged by the Committee. The Committee subsequently identified specific agencies serving each of these subpopulations through which focus groups could be organized. A focus group facilitation guide was then developed, which outlined the structure and procedures to be followed during each session (See Appendix G). Each youth engagement session consisted of an introduction, followed by a general discussion of transitions, validation of identified issues, and finally, generation of potential solutions. The TAYMHA Committee conducted seven youth engagement sessions with a total of 85 youth representing a variety of TAY subpopulations (e.g. LGBTTQ youth, Aboriginal youth, newcomer youth, youth living in poverty, etc.) Please see Appendix F for a complete record of youth stakeholder groups engaged. Stakeholder Engagement: During the Committee’s initial meeting, members were asked to suggest potential key informants to interview for the purposes of the environmental scan. Through this process, several national, provincial and frontline professionals from across the child and youth health system were identified as key informants. The Committee subsequently developed an interview guide containing eight semistructured questions pertaining to the issues and challenges that TAY with MHA issues face, which was used in one-on-one interviews with each key informant (See Appendix K). In total, the TAYMHA Committee received input from 35 experts, representing a variety of areas of expertise. Please see Appendix E for a complete record of expert stakeholders engaged. 55

3. Jurisdictional Scan The jurisdictional scan involved a review of existing “key players” and initiatives that directly or indirectly address MHA issues among TAY within the TC LHIN. The purpose of this scan was to ensure that this strategic planning exercise would complement, without duplicating, other local, regional and provincial MHA initiatives. Environmental Scan Results The results of the literature review, community engagement sessions, and jurisdictional scan were summarized and presented back to the Committee for consideration over the course of multiple meetings. Additional findings from the stakeholder engagement sessions were communicated to and discussed by the Committee on an ongoing basis. The Committee used all of this information to identify the key gaps and challenges faced by TAY with MHA issues in the TC LHIN. Phase 2: Developing Recommendations within each Area of Focus In phase two, drawing upon the knowledge gained through the environmental scan, five Areas of Focus within which to develop recommendations were identified and confirmed by the Committee. A small Working Group of health leaders with expertise in child and youth MHA issues who were also involved in the environmental scan drafted a set of preliminary recommendations corresponding to each of these Areas of Focus. These recommendations were subsequently refined and expanded upon by the Committee over a series of meetings through processes of active engagement. Phase 3: Translate Recommendations into Action During its final meetings, the Committee’s work was focused on determining how it might move forward with the implementation of its recommendations. Based on this work, the Committee intends to convene several small tactical Working Groups to implement the specific recommendations included in this report. The TAYMHA Committee will continue with a revised mandate to provide oversight for these groups.

56

TAYMHA Advisory Table Work Plan (Revised November 2014) January, 1 2014 Feb 2014 Mar 2014

Apr 2014 May 2014

Jun 2014

Jul 2014

Aug 2014

Sep 2014

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

Project Initiation

Mar 2015

March 31, 2015

Steering Committee Meeting (SC)

Phase 0: Project Initiation

Milestone/Deliverable Environmental Scan

Identify Areas of Focus Stakeholder Engagement

Phase 1: Current State Analysis and Future State Inputs Develop Recommendations within Areas of Focus

Stakeholder Engagement Refine Recommendations

Phase 2: Develop the Strategy Identify Quick Wins

Implementation Planning Final Report

Phase 3: Translate Strategy into Action

Deliverables and Milestones

Jan 2014

Feb 2014 Mar 2014

Finalize Approach Finalize Steering Committee Membership Invite SC Members

Phase 0

Apr 2014 May 2014

SC Kick-Off Meeting

Meeting #2

Approved Project Work Plan and ToR Begin Environmental Scan

Stakeholder Engagement Plan

Phase 1

Jun 2014

Preliminary Environment al Scan Findings:

Jul 2014

Meeting #3 Environment al Scan Summary

Aug 2014

Meeting #4

Sep 2014

Oct 2014

Meeting #5

Finalize Areas of Focus and begin recommendation development

Nov 2014

Ad Hoc Meeting

Dec 2014

Meeting #6

Jan 2015

Meeting #7

Feb 2015

Meeting #8

Mar 2015

Meeting #9 Review Stakeholder Feedback

Develop Recommenda tion(s) within each Area of Focus

Mar 31, 2015

Meeting #10 Finalize Implement ation Plan

Finalize Recommendations

Including Current State Mapping Exercise

Final Report

Phase 2

Phase 3

57

Appendix I – Transitional Aged Youth Engagement Findings The following provides a more detailed summary of TAY youth engagement findings conducted as part of the Environmental Scan. Key Gaps and Challenges: 1. Characteristics of the Population  Youth know themselves best.  TAY are undergoing several important transitions during this period of life (e.g. graduating from secondary or post-secondary education, becoming drivers, entering the workforce, etc.).  Youth with mental health issues are in a constant state of burn-out, and this has important implications in terms of school/job attendance, etc.  Many TAY face significant challenges in addition to their MHA issues, which can make it even more difficult to address them (e.g. lack of money/employment, familial conflict, lack of stable housing, problems with school and/or the law, etc.).

2. How Services are Delivered  Service providers don’t seem to understand the unique struggles of TAY with MHA issues.  Youth feel treated “like a number” and lack trust/confidence in service providers.  Service providers sometimes don’t listen to clients, which results in their under- or overreactions to clients’ presenting needs (e.g. being discharged home when the client feels unsafe or being kept in the hospital when the client feels they are able to go home).  While a harm reduction approach to addictions treatment may be very effective for some TAY, it may actually have detrimental effects among those individuals trying to abstain from substance use entirely. Services must be tailored to meet the distinct needs of these two groups.  Youth are bounced from service provider to service provider, having to switch workers constantly. Being regularly assigned new, unfamiliar workers is a negative experience.  The hospital is a negative and intimidating environment where patients are viewed solely through a medical lens (in contrast to social work, which views the person more holistically).  Youth want to be able to voice their own opinions and contribute to decision-making regarding treatment options, etc.  Service providers lack cultural competence, and their perceptions about different cultural groups can affect the way service is provided.

3. Accessing Services/Navigation  Help is hard to find.  Family can be both a support and barrier to accessing services.  Youth often have to grapple with the question “Am I sick enough to get help?” (E.g. service offered “for alcoholics” may deter people who recognize a problem with their drinking but don’t identify as an “alcoholic”).  Many youth are not connected with a family doctor, which makes it challenging to find an access point to MHA services, as there aren’t enough MH walk-in services.

58

     

Services that TAY want are not available when they’re needed (due to waitlists, lack of MHA staffing in ED at night, etc.). Costs of psychologists/counselors pose a major barrier for many TAY, and create worry in students about to graduate and lose coverage. Access/connection to services is facilitated by many high schools and post-secondary institutions, but what about those individuals not currently enrolled? Before the age of 18, it’s difficult to get services without a parental signature, which may pose a barrier for those who feel they are unable to disclose their MHA concerns to family members. TAY experience difficulty when forced to end relationships with service providers in the paediatric system and then build relationships with new providers in the adult system following transition. Newcomer/ESL youth report language as a major barrier to accessing and navigating services.

4. Service Offerings  Services should not focus solely on “mental health”. They should also provide “life skills.” Some TAY want to learn how to live independently and take care of themselves.  Not enough services that consider the age-specific needs of TAY or the unique needs of individuals struggling with specific MHA issues.  Services need to focus on long-term supports, rather than “Band-Aid solutions.”  Existing services are not “holistic,” treatment does not address the whole person.  Services need to offer supports for families and other caregivers.  For someone in crisis, the only service options are a 72-hour hold or being discharged home. There needs to be a service that falls somewhere in between these extremes.

5. Broader System Issues  There is immense stigma associated with mental health and addictions, and this can be heightened by cultural factors.  Stigma creates challenges for TAY not only when accessing mental health services, but also when trying to get a job, changing schools, etc.  Youths report retelling their stories over and over again to different service providers.  There is a lack of flexibility in age and diagnosis categories.

Key Areas of Focus/Solutions 1. Capacity Building and Training  More training for service providers to enhance their capacity to: o Be culturally sensitive/competent (e.g. understand unique cultures, etc.) o Express empathy, caring, and understanding towards patients (it often seems they don’t care) o Provide a comfortable environment for patients who feel nervous in the MHA setting o Deal with specific subpopulations (e.g. TAY with specific MHA issues, sexual orientations, etc.)  More educational programs for TAY with MHA issues that teach: o Self-care and other “life skills” o How to improve self-confidence and self-worth 59

 

More education for families (parents and caregivers) to enable them to understand, accept, and better manage their youth’s condition. More educational programs for youth (e.g. in schools) to break down stigma and teach them how to support peers struggling with MHA issues.

2. Addressing Gaps in Services  Create more youth-positive spaces (e.g. spaces where youth feel they can say what they want, are free from judgment, etc.) o Display some sort of sticker or other signifier to indicate which services are youth-positive (Modeled after LGBTQ+-positive space stickers.)  Offer more services specific to different cultural groups and in a greater variety of languages.  Provide more services aimed at recovery and prevention – youth shouldn’t have to be in crisis to get help. TAY want services that will prevent them from reaching that point in the first place.  Create more walk-in services  Offer family support programs, especially for use during crisis situations.  Create more community-based programs that employ active outreach and a harm reduction approach.

3. Improving Connection and Navigation 

      

Use technology and social media to increase awareness and availability of services, for example through:  A centralized website that lists all of the available services, includes a tool to suggest which may be right for each individual, what the associated costs may be, etc.  A text messaging service in addition to follow-up phone calls (Not all TAY want to get a follow-up phone call after crisis, but they still want some follow-up connection)  Enabling provider websites with the ability to book MHA appointments online Provide more support for youth transitioning out of the hospital and back into the home/community Start CAMHS-AMHS transition program earlier so that TAY are ready for the move. These transitions should be well planned and supportive. Enhance service availability by offering better hours for TAY (i.e. evenings and weekends) and more on-call mental health workers in EDs Inform TAY about the services available to them through a variety of platforms: the Internet, school agendas, flyers in recreation centres Introduce workshops designed for newcomers to assist them in adapting to their new setting and to inform them about available services Offer workshops for TAY with specific MHA issues to teach them about effective self-care and how to get along with peers and family Offer more programs to assist TAY in understanding their post-secondary options, engaging with their community, and finding employment (e.g. résumé writing, job search, entrepreneurship, interview skills, etc.)

60

4. Evaluation and Research

5. Advocating for Broader System Change  Encourage more people to share their stories and advocate for change  Need more education for providers, families and the public to break down the stigma surrounding MHA issues o Start these programs for people when they’re young, before biases and stigma are solidified o E.g. “What is [insert mental illness] and How Can I Help? seminars/workshops. One for families, one for friends, etc.  Offer flexible age categories for services  Continue to engage youth in determining problems and generating solutions

61

Appendix J – Proposed Training Content for Developing Youth Friendly Spaces Proposed Training Content for Service Providers to Support Capacity Building in the Development of Youth Friendly, non-judgemental environments that address the unique needs of TAY with MHA challenges Content  What does it mean to be Youth Positive? Practical strategies to work with youth to help them trust and engage with service providers.  How to make your service accessible to youth?  What does it mean to be sex positive and LGBTQ positive?  How do the social determinants of health and intersectionality of oppression affect mental health and addictions and how a youth may access programming and services  What are the developmental considerations for “emerging adults”?  A reflection on life stages, brain development and common issues during this time and the impact on mental health and addictions and accessing services.  How does trauma impact mental health and addictions?  Harm reduction vs abstinence based approach. What are the benefits and how to overcome the obstacles?  What types of policies and procedures are needed to help facilitate a youth positive approach? Development of the content: There are many organizations working with Transitional Aged Youth experiencing MH&A that could provide input into the content. As well there are organizations that have experience in creating youth positive environments. Together this information would help to inform the content. Youth Involvement It would be most effective if youth could also be involved in the development of the content. What do they want their service providers or trusted adults to know? Service Provider Involvement Depending on the goals of the project, a survey could be issued to participants in advance of the training to assess particular gaps or topics of interest to customize some of the training for greatest impact Delivery Face to face delivery has the most opportunity for having an impact, but could be a multifaceted delivery model that incorporates face to face and online training opportunities.

In person training: Develop the modules to be delivered all at once in 1 or 2 days or split into half days if that is easier for people to attend. Webinars: Utilize technology to develop a downloadable webinar with exercises so that people can access the content and do some self-reflection. 62

Webinars would last no more than an hour long and there would be several of them to address the content. YouTube videos: Create opportunities for youth to develop videos utilizing digital storytelling techniques which have a powerful message and would complement the content of the training Youth Involvement A youth panel and/or storytelling component of the training will increase the effectiveness and impact of the training. Rely on organizations that have experience working with youth to build their capacity to train both their peers and service providers.

63

Appendix K – Key Informant Interview Guide The Toronto Central LHIN recently convened a Child and Youth Mental Health and Addictions Advisory Table (co-chaired by Dr. Tony Pignatiello, SickKids and Karen O’Connor, CMHA) to oversee the development of strategic recommendations to address challenges faced by transitional aged youth experiencing mental health and addictions (MHA) challenges in the Toronto Central LHIN. Membership on this Advisory Table includes leaders from across the continuum of care and other sectors. This strategic planning exercise is designed to complement and not duplicate other local, regional, and provincial mental health and addictions initiatives. At the outset the Committee is conducting a comprehensive environmental scan to map these existing initiatives, to understand gaps and opportunities so that this planning table can address specific challenges of transitional aged youth. You have been identified by the Committee as a key informant in the area of child, youth, and young adult mental health (specifically, transitional aged youth). We would be most grateful if we could meet with you to help inform our environmental scan. Interview Questions The following questions will help guide our discussion (note: some questions may not be applicable to your particular role). 1. Please describe your role and give a brief overview of the types of services your organization provides (including transitional aged youth with mental health and addictions issues (children, youth and young adults). 2. From your perspective, what are the greatest challenges facing transitional aged youth with mental health and addictions issues? Please explain. 3. In what areas should the Committee focus on to address these challenges? Where are the greatest opportunities? Please explain. 4. Do you know of existing planning groups or initiatives currently underway, focused on child/youth mental health (and in particular transitional aged youth), that our Committee should be aware of to avoid duplication and identify potential synergies? 5. Do you know of any strategies/initiatives/service delivery models/programs that have successfully addressed challenges faced by transitional aged youth with MHA challenges? 6. Do you have suggestions on subject matter experts and existing youth/young adult and/or family groups that we should engage (with a focus on transitional aged youth/young adults with MHA challenges)? 7. Do you have recommendations on studies/literature that would be helpful for the Committee to review? 8. Other comments/suggestions to help inform the environmental scan?

64 | Page

Footnotes i

Leavey, J., Goering, P., Macfarlane, D., Bradley, S., Cochrane, J. (2000). The gap: Moving toward youth-centred mental health care for transitional aged youth (16-24). Centre for Addiction and Mental Health

Mental Health Commission of Canada. (2015). Executive summary: Taking the next step forward: Building a responsive mental health and addictions system for emerging adults. ii

Harpaz-Rotem, I., Leslie, D., Rosenheck., R. (2004). Treatment retention among children entering a new episode of mental health care. Psychiatric Services, 55(9): 1022-1028. iii

iv

Government of Canada. (2006). The human face of mental health and mental illness in Canada.

v

Leavey, J., Goering, P., Macfarlane, D., Bradley, S., Cochrane, J. (2000). The gap: Moving toward youth-centred mental health care for transitional aged youth (16-24). Centre for Addiction and Mental Health, 7. vi

Government of Canada. (2006). The human face of mental health and mental illness in Canada.

vii

Statistics Canada. (2003). Canadian community health survey: Mental health and well-being.

viii

Ibid.

ix

Cheung, A., Bennett, K., Bullock, H., Soberman, H., Kozloff, N. (2010). Evidence on tap: Understanding service delivery needs for youth with concurrent disorders. Centre for Addiction and Mental Health and McMaster University. Richards, K., Vostanis, P. (2004). Interprofessional perspectives on transitional mental health services for young people aged 16-19 years. Journal of Interprofessional Care, 18(2): 115-128. x

xi

McGorry, P., Edwards, J., Mihalopoulos, C., Harrigan, S., Jackson, H. (1996). EPPIC: An evolving system of early detection and optimal management. Schizophrenia Bulletin, 22(2): 305-326. xii

U.S. Department of Health and Human Services. (1999). Mental health: a report of the surgeon general. U.S. Department of Health and Human Services, Substance Use and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health. RBC Children’s Mental Health Project. (2013). Silent families, suffering children and youth: An RBC white paper on the findings from the 2012 RBC children’s mental health parents poll. xiii

Rickwood, D., Deane, F., Wilson, C., Ciarrochi, J. (2005). Young people’s help-seeking for mental health problems. Australian e-Journal for the Advancement of Mental Health, 4(3). xiv

xv

Harpaz-Rotem, I., Leslie, D., Rosenheck., R. (2004). Treatment retention among children entering a new episode of mental health care. Psychiatric Services, 55(9): 1022-1028. xvi

Richards et al., Interprofessional perspectives on transitional mental health services.

xvii

Youth Advisory Committee of the Mental Health Commission of Canada. (2010). Evergreen: A child and youth mental health framework for Canada. xviii

Leavey et al., The gap.

xix

Chaim, G., Henderson, J., Brownlie, E. (2013). Youth services system review. Centre for Addiction and Mental Health.

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Children’s Mental Health Ontario. (2013). Easing transitions for children, youth and emerging adults.

xx

xxi

Ibid.

Joint Commissioning Panel for Mental Health. (2013). Guidance for commissioners of mental health services for young people making the transition from child and adolescent to adult services, 3. xxii

xxiii

Paone, M., Whitehouse, S. (2011). ON TRAC Part 1: A transition initiative for youth and young adults with chronic health conditions and/or special needs in BC. xxiv

Ibid.

xxv

Children’s Mental Health Ontario, Easing transitions for children.

xxvi

Leavey et al., The gap.

Haber, M., Karpur, A., Deschênes, N., Clark, H. (2008). Predicting improvement of transitioning young people in the partnerships for youth transition initiative: Findings from a multisite demonstration. Journal of Behavioral Health Services & Research, 35(4): 488-513. xxvii

xxviii

Ibid., 489.

xxix

Fadden, G., Bebbington, L., & Kuipers, L. (1987). The burden of care: The impact of functonsl psychiatric illness on the patient’s family. British Journal of Psychiatry, 150: 285-292. xxx

Friedrich, R., Lively, S., & Rubenstein, L. (2008). Siblings’ coping strategies and mental health services: A national study of siblings of persons with schizophrenia. Psychiatric Services 59(3): 261-267. xxxi

Chaim et al., Youth services system review, 59.

Gilmer, T., Ojeda, V., Fawley-King, K., Larson, B., Garcia, P. (2012). Change in mental health service use after offering youth-specific versus adult programs to transition-age youths. Psychiatric Services, 63(6): 592-596. xxxii

xxxiii

Joint Commissioning Panel for Mental Health, Guidance for commissioners.

xxxiv

Richards et al., Interprofessional perspectives on transitional mental health services.

xxxv

Bukstein, O., Horner, M. (2010). Management of the adolescent with substance use disorders and comorbid psychopathology. Child and Adolescent Psychiatric Clinics of North America, 19: 609-623. xxxvi

Joint Commissioning Panel for Mental Health, Guidance for commissioners.

xxxvii

Leavey et al., The gap.

xxxviii

Mental Health Commission of Canada. (2015). Executive summary: Taking the next step forward: Building a responsive mental health and addictions system for emerging adults. xxxix

xl

Leavey et al., The gap.

McGorry et al., EPPIC: An evolving system of early detection.

xli

Mehta, S., & Farina, A. (1988). Associative Stigma: Perceptions of the difficulties of college-aged children of stigmatized fathers. Journal or Social Clinical Psychology, 7: 192-202.

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xlii

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