Clinical trial NCT02590302: Improving Transitions in Care for Children and Youth With Mental Health Concerns
Official title: Improving Transitions in Care for Children and Youth With Mental Health Concerns: Implementation and Evaluation of an Emergency Department Mental Health Clinical Pathway
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: NA
Conditions: Mental Health
Keywords: Clinical pathway
Mental Health
Emergency Department
Paediatric
Risk assessment
Service integration
Transitions in care
Implementation
Scoring tools
Clinical Pathway Evaluation
Lead sponsor: Children's Hospital of Eastern Ontario
Sponsor class: OTHER
Collaborators: name: Canadian Institutes of Health Research (CIHR)
name: Ontario Ministry of Health and Long Term Care
name: Winchester District Memorial Hospital
name: Queensway Carleton Hospital
name: Youth Services Bureau
name: Cornwall Community Hospital
First posted: 2015-10-29
Enrollment: 3095
Sex: ALL
Minimum age (years): 6
Maximum age (years): 18
Standard ages: CHILD
ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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: 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.

Eligibility criteria: 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

Primary outcomes:
measure: Proportion of patients receiving post-ED follow-up on the Services for Children and Adolescents Parent Interview questionnaire
timeFrame: 24 hours or 7 days
measure: Proportion of patients with documented mental health recommendations in the medical chart
timeFrame: 24 hours or 7 days
Secondary outcomes:
measure: Proportion of completed CP assessment forms filed in the health record to determine clinical pathway uptake in the Emergency Department
timeFrame: 9 months
measure: Patient perspectives of post-ED mental health service using The Services for Children and Adolescents-Parent Interview
timeFrame: 7-10 days
measure: Alignment of HEADS-ED assessment and mental health services
timeFrame: 7-10 days
measure: Decreased length of stay
timeFrame: 26 months
measure: Patient satisfaction with ED visit measured by the Client Satisfaction Questionnaire
timeFrame: 7-10 days
measure: Decreased number of hospital admissions obtained from health record and NACRS administrative database
timeFrame: 26 months
measure: Decreased number of ED Revisits from the health record and NACRS administrative database
timeFrame: 10 day and 3 months
Other outcomes:
Locations:
city: Ottawa
country: Canada
facility: Children's Hopsital of Eastern Ontario
state: Ontario
city: Winchester
country: Canada
facility: Winchester District Memorial Hospital
state: Ontario
Study officials:
affiliation: Children's Hospital of Eastern Ontario
name: Mona Jabbour, MD
role: PRINCIPAL_INVESTIGATOR
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