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A Primary Care Mental Health Pathway for Children and Youth: A Mental Health Services Quality Improvement Initiative in Ontario
Abstract
We introduce the innovative components of a primary care pathway for child and youth mental health (MH) in Ontario. We share our experiences with developing and implementing the pathway that supports inter-provider communication, standardized screening, timely access to community MH services, and is adaptable to different services and settings.
... Lightbody et al. (21) demonstrated by using the HEADS-ED tool as part of a screening bundle within an Alberta ED, 90% of patients referred to urgent care received an appointment within 4 days (96 h). While initially created for ED physicians, the HEADS-ED is widely used in EDs (14,15,22,23), as well as Canadian hospital intake (24) and primary care settings (25,26) to guide care to community MH services, concurrent MH and addiction services, or more urgent care services. ...
Objectives
Communimetric screening tools convey functional impairment and action required, helping clinicians identify and communicate patient’s needs and actions within a measurement framework. We examined the feasibility of using the HEADS-ED Under 6, a communimetric mental health (MH) and developmental screening and triage tool for children under 6, within 1Call1Click.ca, a regional coordinated access and navigation program in Eastern Ontario. We explored utility validity to understand how the HEADS-ED Under 6 is used to help intake workers screen, inform their level of need decision, and establish a cut-off for recommending interventions targeting moderate levels of need or higher.
Methods
Using a prospective cohort design, intake workers at 1Call1Click.ca screened all children under 6 using the HEADS-ED Under 6 from June 2021 to August 2023. Correlations and an Analysis of variance examined how total scores were associated with the level of need, and Receiver Operator Curve analysis examined sensitivity and specificity for identifying moderate levels of need or higher.
Results
In total, 589 children under 6 were screened with the HEADS-ED Under 6. Utility validity was demonstrated by significant associations between level of need and HEADS-ED Under 6 domains and total scores. A total score of ≥6 supported decision-making for moderate levels of need or higher (Area Under Curve = 0.807).
Conclusions
The HEADS-ED Under 6 is a brief, easy, and valid screening tool, that can be used by clinicians to identify the level of action/impairment, communicate the severity of MH and developmental needs, and determine the level of need for services.
Findings from a novel Primary Care (PC) Mental Health (MH) pathway for children and young people in Northern Ontario, Canada are presented. Overall, 166 MH referrals from PC to a community-based child and youth MH and addictions agency (CB-CYMHA) occurred, with outstanding PC uptake (100%) and faxing referral outcomes (99%) from the CB-CYMHA to the PC provider. Half of referral outcomes (50%) were returned within 2 weeks and 83% of contacted clients reported satisfaction with services received. This successful pilot serves as an example for care pathway improvements and mobilizes knowledge for other pathway sites across Ontario.
Background
While the emergency department (ED) is often a first point of entry for children and youth with mental health (MH) concerns, there is a limited capacity to respond to MH needs in this setting. Child MH systems are typically fragmented among multiple ministries, organizations, and providers. Communication among these groups is often poor, resulting in gaps, particularly in transitions of care, for this vulnerable population. The evidence-based Emergency Department Mental Health Clinical Pathway (EDMHCP) was created with two main goals: (1) to guide risk assessment and disposition decision-making for children and youth presenting to the ED with MH concerns and (2) to provide a streamlined transition to follow-up services with community MH agencies (CMHAs) and other providers. The purpose of this paper is to describe our study protocol to implement and evaluate the EDMHCP.
Methods/design
This mixed methods health services research project will involve implementation and evaluation of the EDMHCP in four exemplar ED-CMHA dyads. The Theoretical Domains Framework will be used to develop a tailored intervention strategy to implement the EDMHCP. A multiple baseline study design and interrupted time-series analysis will be used to determine if the EDMHCP has improved health care utilization, medical management of the MH problems, and health sector coordination. The primary process outcome will be the proportion of patients with MH-specific recommendations documented in the health record. The primary service outcome will be the proportion of patients receiving the EDMHCP-recommended follow-up at 24-h or at 7 days. Data sources will include qualitative interviews, health record audits, administrative databases, and patient surveys. A concurrent process evaluation will be conducted to assess the degree of variability and fidelity in implementation across the sites.
Discussion
This paper presents a novel model for measuring the effects of the EDMHCP. Our development process will identify how the EDMHCP is best implemented among partner organizations to deliver evidence-based risk management of children and youth presenting with MH concerns. More broadly, it will contribute to the body of evidence supporting clinical pathway implementation within novel partnerships.
Trial registration
ClinicalTrials.gov (NCT02590302)
To document with whom family physicians communicate when evaluating adolescents with mental health problems, to whom they refer these adolescents, and their knowledge and perceptions of the accessibility of mental health services in their communities.
Mailed survey completed anonymously.
Province of Quebec.
All general practitioners who reported seeing at least 10 adolescents weekly (n = 255) among 707 physicians who participated in a larger survey on adolescent mental health care in general practice.
Whether family physicians communicated with people (such as parents, teachers, or school nurses) when evaluating adolescents with mental health problems. Number of adolescents referred to mental health services during the last year. Knowledge of mental health services in the community and perception of their accessibility.
When asked about the last 5 adolescents seen with symptoms of depression or suicidal thoughts, depending on type of practice, 9% to 19% of physicians reported routinely communicating with parents, and 22% to 32% reported not contacting parents. Between 16% and 43% of physicians referred 5 adolescents or fewer to mental health services during a 12-month period. Most practitioners reported being adequately informed about the mental health services available in their local community clinics. Few physicians knew about services offered by private-practice psychologists, child psychiatrists, or community groups. Respondents perceived mental health services in community clinics (CLSCs) as the most accessible and child psychiatrists as the least accessible services.
Few physicians routinely contact parents when evaluating adolescents with serious mental health problems. Collaboration between family physicians and mental health professionals could be improved. The few referrals made to mental health professionals might indicate barriers to mental health services that could mean many adolescents do not receive the care they need. The lack of access to mental health services, notably to child psychiatrists, reported by most respondents could explain why some physicians choose not to refer adolescents.
Children and youth presenting to the emergency department with mental health concerns present a challenge for clinicians and system capacity. Addressing a significant system gap and sparse strategies in the literature, representative leaders from hospital and community agencies developed a novel pathway to guide efficient and doable risk assessment and ensure timely transition to appropriate community mental health services. This article describes and reflects on our innovative Emergency Department Clinical Pathway for Children and Youth with Mental Health Conditions that bridges traditional barriers between hospital and community settings to address mental health needs for this population.
The American Academy of Pediatrics called for action for improved screening of mental health issues in the emergency department (ED). We developed the rapid screening tool home, education, activities/peers, drugs/alcohol, suicidality, emotions/behavior, discharge resources (HEADS-ED), which is a modification of "HEADS," a mnemonic widely used to obtain a psychosocial history in adolescents. The reliability and validity of the tool and its potential for use as a screening measure are presented.
ED patients presenting with mental health concerns from March 1 to May 30, 2011 were included. Crisis intervention workers completed the HEADS-ED and the Child and Adolescent Needs and Strengths-Mental Health tool (CANS MH) and patients completed the Children's Depression Inventory (CDI). Interrater reliability was assessed by using a second HEADS-ED rater for 20% of the sample.
A total of 313 patients were included, mean age was 14.3 (SD 2.63), and there were 182 females (58.1%). Interrater reliability was 0.785 (P < .001). Correlations were computed for each HEADS-ED category and items from the CANS MH and the CDI. Correlations ranged from r = 0.17, P < .05 to r = 0.89, P < .000. The HEADS-ED also predicted psychiatric consult and admission to inpatient psychiatry (sensitivity of 82% and a specificity of 87%; area under the receiver operator characteristic curve of 0.82, P < .01).
The results provide evidence to support the psychometric properties of the HEADS-ED. The study shows promising results for use in ED decision-making for pediatric patients with mental health concerns.
Paving the path to connected care: Strengthening the interface between primary care and community-based child and youth mental health services
- M Cappelli
- S L Leon
Cappelli, M., & Leon, S. L. (2017). Paving the path to connected care: Strengthening the interface between primary
care and community-based child and youth mental health services. Ottawa, ON: Ontario Centre of Excellence
for Child and Youth Mental Health.