Improving Transitions in Care for Children and Youth With Mental Health Concerns

Study Overview
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Brief Summary
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The overarching goal of this project is to improve timely access to appropriate mental health (MH) care for children and youth. The investigators will conduct and rigorously evaluate implementations of this pathway in four exemplar hospitals and associated CMHA dyads within a local health region. Outcomes-based validation of this pathway is important for effective adoption in other communities. A multiple baseline study design and conduct interrupted time-series analysis will be used to evaluate whether the EDMHCP has resulted in improved health care utilization, medical management, and health sector coordination. To ensure EDMHCP feasibility in various settings, implementation will occur in four exemplar hospital-community dyads with different workflows and patient populations.

Detailed Description
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Commissioned by the Ontario Ministries of Health and Long Term Care(MOHLTC) and Child and Youth Services(MCYS), an expert-developed clinical pathway(CP) has been created with two main goals: 1) to guide risk assessment and disposition decision-making for children and youth presenting to the emergency department(ED) with MH concerns, and 2) to ensure seamless transition to follow-up services with community MH agencies(CMHAs) and providers. This pathway, referred to as the EDMHCP, is unique in undertaking to provide a seamless transition of care for children/youth and caregivers between hospital EDs and CMHAs. Working with 4 exemplary hospital EDs and 2 Community Mental Health Agencies across Eastern Ontario, the investigators will conduct a 3-year mixed methods health services research project with three components to i) implement the EDMHCP using a theory driven, evidence-based approach, ii) evaluate EDMHCP effectiveness through measurement of relevant outcomes, and iii) conduct a process evaluation to document and assess the EDMHCP implementation strategy against the outcomes achieved. This 3 year study will take place in five different phases, which include: Preparation: Qualitative interviews with ED team members and strategy development Implementation: Working with each ED team to implement the clinical pathway (including standardized assessments) within 8 months Post-implementation: Qualitative interviews with ED team members Data collection: 9-month pre/post chart audits of patients with mental health and caregiver satisfaction surveys Follow up: to discuss findings, database creation, and dissemination strategy. To ensure the findings directly impact relevant service delivery areas, the investigators have specifically recruited study team members with decision-making authority and/or influence on delivery of care for children and youth with MH concerns. This project will provide an implementation model for the EDMHCP to be used in any ED and CMHA setting, and will demonstrate decreased wait times and increased access with EDMHCP adoption. The findings will guide policy decision-making on access to timely and appropriate MH care and add to current knowledge of implementation science. In addition to knowledge translation via team member dissemination within their areas of influence, the investigators plan to disseminate the findings through presentation at scientific and healthcare conferences, and publication in relevant peer-reviewed journals.

Official Title
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Improving Transitions in Care for Children and Youth With Mental Health Concerns: Implementation and Evaluation of an Emergency Department Mental Health Clinical Pathway

Conditions
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Mental Health

Intervention / Treatment
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* Other: Implementation Phase


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Ages > 5.99 and < 18 years Presented to the ED of the four chosen hospitals within a selected 8 month time frame (between January, 2016 to May 2017) Mental health issue as their primary complaint (all complaints identified at triage as involving MH [psychosocial, emotional, behavioural]) Proficient in English. Exclusion Criteria: CTAS of 1 (Resuscitation) Patient is not medically stable Intubation/PICU care required Direct admission to hospital for ongoing medical management and observation Patients presenting with head injury or post-concussional syndrome

Ages Eligible for Study
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Minimum Age: 6 Years
Maximum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Dyads receiving the Implementation Phase<br>Dyad 1 (CHEO-YSB) Dyad 2 (CGH-CCH) Dyad 3 (WDMH-CCH) Dyad 4 (QCH-YSB) | Other: Implementation Phase<br>* Core Components of the implementation intervention include: Hospital and CMHA project commitment Site champion teams (from hospital and CMHA) Memorandum of Agreement between Hospital and CMHA Pre-intervention site visits Education sessions Posters/reminders Instructional videos (HEADS ED video) Completed pathway implementation includes EDMHCP site-customization and committee approvals, consequent planning and agreements among ED-CMHA partners, delivery of at least two educational workshops, and EDMHCP availability in the ED. An 8-month period for EDMHCP implementation, with negotiated interim target dates was set for each site.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of patients receiving post-ED follow-up on the Services for Children and Adolescents Parent Interview questionnaire | The primary clinical outcome is the proportion of patients that receive the post ED follow-up as per the clinical pathway recommendations as measured by the Services for Children and Adolescents Parent Interview questionnaire | 24 hours or 7 days | 
| Proportion of patients with documented mental health recommendations in the medical chart | The primary process outcome is the proportion of patients with documented MH-specific recommendations (as defined by the project team) in the medical chart. | 24 hours or 7 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of completed CP assessment forms filed in the health record to determine clinical pathway uptake in the Emergency Department | CP uptake in the ED will be measured through audits as the proportion of completed clinical pathway assessment forms filed in the health record | 9 months | 
| Patient perspectives of post-ED mental health service using The Services for Children and Adolescents-Parent Interview | Post ED uptake of recommended community MH services will be measured by The Services for Children and Adolescents-Parent Interview | 7-10 days | 
| Alignment of HEADS-ED assessment and mental health services | Alignment of recommended services documented in the patients health record (audit) to the HEADS-ED mental health screening tool assessment | 7-10 days | 
| Decreased length of stay | ED length of stay will be obtained from health record and NACRS administrative database | 26 months | 
| Patient satisfaction with ED visit measured by the Client Satisfaction Questionnaire | Patient/caregiver satisfaction with the ED visit will be measured by the Client Satisfaction Questionnaire | 7-10 days | 
| Decreased number of hospital admissions obtained from health record and NACRS administrative database | Hospital Admission will be obtained from health record and NACRS administrative database | 26 months | 
| Decreased number of ED Revisits from the health record and NACRS administrative database | ED revisits will be obtained from the health record and NACRS administrative database | 10 day and 3 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Clinical pathway, Mental Health, Emergency Department, Paediatric, Risk assessment, Service integration, Transitions in care, Implementation, Scoring tools, Clinical Pathway Evaluation