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International Journal of Mental Health and Addiction
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ORIGINAL ARTICLE
Improving Access toChild andYouth Addiction andMental
Health Services inNew Brunswick: Implementing
One‑at‑a‑Time Therapy Within anIntegrated Service Delivery
Model
LauraM.Harris‑Lane1· AleshaC.King1· StéphaneBérubé2· KatieBurke2,6·
AnnMarieChurchill3· PeterCornish3· AlexiaJaouich3· MylèneMichaud5·
AnneLosier2· JaiShah4· JoshuaA.Rash1
Accepted: 24 May 2024
© The Author(s) 2024
Abstract
This study examines the process of implementing One-at-a-Time (OAAT; i.e., single-ses-
sion) therapy into child and youth addiction and mental health services in New Brunswick.
The implementation process was retrospectively mapped onto implementation science
frameworks. Providers were recruited to participate in research associated with the system
change, and completed surveys to assess readiness for implementation. Client satisfaction
and system-outcomes were measured through surveys and system indicators, respectively.
Key implementation considerations included age of consent for services, implementation
within an integrated service delivery model, and mapping the client journey to conceptual-
ize changes in service delivery. Providers (N = 214) felt that OAAT therapy was acceptable
and appropriate to implement into practice, and would lead to observable short-term out-
comes. During the implementation (April–December 2022), 2266 sessions were delivered,
resulting in a 62% waitlist reduction. Most clients who completed the satisfaction survey
(N = 518) reported benefit. This study elucidates the successful implementation of OAAT
therapy for children and youth, and can serve as a heuristic for comparable practice change
initiatives.
Keywords Child· Adolescent· Mental health services· Implementation science· Single
session therapy
Evidence suggests that 20% of Canadian children and youth live with a mental health dis-
order (Georgiades etal., 2019), with global estimates that only 43% of young people in
high-income countries receive treatment (Friedman etal., 2015). Low mental health liter-
acy, stigma, and limited availability of services have been cited as the most prevalent barri-
ers to accessing services (Moroz etal., 2020; Radez etal., 2021). The average wait time to
access child and youth addiction and mental health services (A&MHS) in Canada’s largest
province was 67days in 2020 (Children’s Mental Health Ontario, 2020), with one Cana-
dian province reporting a 33% increase in demand for services among adolescents between
Extended author information available on the last page of the article
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International Journal of Mental Health and Addiction
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2015 and 2020 (Government of New Brunswick, 2021). Challenges in accessing timely
services have resulted in increased demands on Emergency Departments, as visits for child
and youth mental health and addiction concerns increased by almost 90% between 2007
and 2017 (Chiu etal., 2020). Recent qualitative research on youth and parent experiences
accessing mental health and addiction services in Canada highlighted the frustrations and
toll of fragmented services with protracted wait times (Kourgiantakis etal., 2023; Zifkin
etal., 2021).
The long-term impacts of unaddressed mental health concerns in childhood can
have detrimental impacts on education attainment (Breslau etal., 2008), engagement
in higher-risk behaviors (e.g., sexual health; Harmanci etal., 2023), disability-adjusted
life years (Patel etal., 2007), criminal justice-involvement (Beaudry et al., 2021), and
risk of suicide (Bilsen, 2018). In 2023, Canadian economists estimated that the invest-
ment in child and youth mental health would result in savings of $30 billion per annum
(The Conference Board of Canada, 2023). It is imperative that A&MHS are accessible
and effective given the significant and increasing burden associated with mental health
disorders among children and youth (Piao etal., 2022).
The New Brunswick Department of Health reviewed community A&MHS to create a
5-year interdepartmental action plan that identified five key areas: (1) increasing access
to care; (2) appropriately matching individuals to care; (3) improving population health;
(4) providing earlier intervention; and (5) reducing substance-related impacts (refer to
Supplemental Appendix A; Government of New Brunswick, 2021). Improving timely
access to A&MHS was identified as an immediate provincial priority. After review-
ing various frameworks, the Government of New Brunswick decided to co-design
and adopt a provincial stepped care model for the delivery of A&MHS using Stepped
Care 2.0 (SC2.0; Cornish, 2020). Moreover, implementing a One-at-a-Time (OAAT)
approach (akin to single-session therapy and a core component of the SC2.0 model) in
community A&MHS was identified as the best course of action to improve access to
care and reduce wait times.
SC2.0 is a flexible and collaborative model of A&MHS delivery that is guided by a
series of key principles, including prioritizing informed choice, and the preferences,
readiness, and needs of clients (Fig.1). As a planning tool for system change, the SC2.0
model organizes resources and supports along hierarchical steps that range from low- to
high-intensity, requiring varying levels of investment by service users and stakeholders
(Fig.2). The SC2.0 model is presented to clients as a continuum of care, including formal
and informal resources, to best meet their preferences, readiness, and needs. Clients and
providers can collaboratively adjust the intensity level and types of care received through
informed decision-making (Cornish, 2020). Additionally, clients can simultaneously avail
of supports and resources at varying intensities (e.g., self-help and peer support) (Cornish,
2020). A systematic review and meta-analysis on the usage of mental health care options
based on client preferences suggested that clients have increased engagement and therapeu-
tic alliance when using their preferred mental health and addiction treatment (Windle etal.,
2020), which can have significant impacts on client outcomes (Baier etal., 2020).
This model was chosen due to strong face validity, allowance for a comprehensive and
recovery-oriented continuum of services with varying levels of intensity, focus on rapid
access to care, and promotion of evidence-based practices (Carey etal., 2021). The SC2.0
model contains nine core components depicted in Fig.3. The first five components of the
SC2.0 model focus on system design and improvement, while the remaining four core
components center around the client’s care.
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An OAAT therapeutic approach, often referred to as single-session therapy, focuses on
the client’s top-of-mind concern. Each client encounter is treated as a whole, leverages
a solution-focused and strengths-based approach, and provides an opportunity for hope,
growth, and change (Hair etal., 2013). A meta-analysis of 50 randomized controlled trials
reported that OAAT therapy (i.e., single-session therapy) resulted in significant improve-
ments in psychological concerns of children and youth, with a moderate effect size
(g = 0.32; Schleider & Weisz, 2017). Specifically, an OAAT therapeutic approach was ben-
eficial for a variety of presenting concerns (e.g., anxiety, conduct disorder, self-esteem) at
varying levels of severity, and in community samples. Children and youth that received an
OAAT intervention had an increased likelihood of reporting improved outcomes compared
to a control group (Schleider & Weisz, 2017). These findings, paired with other research on
using OAAT approaches as a mechanism to increase timely access to care (i.e., reducing
waitlists and wait times; Harris-Lane etal., 2023; Thomas etal., 2021), continue to support
Fig. 1 Guiding principles of the Stepped Care 2.0 model
Fig. 2 Stepped Care 2.0 planning tool for system change
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International Journal of Mental Health and Addiction
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utility of implementing OAAT therapy in New Brunswick’s child and youth community
A&MHS. As a first step to implementing a provincial SC2.0 model, OAAT therapy was
implemented within child and youth A&MHS, which are delivered through an integrated
service delivery model (Settipani et al., 2019). Integrated service delivery models, such
as Integrated Youth Services, have gained traction internationally (i.e., Australia, Ireland,
England), with the aim of integrating often-siloed sectors (McGorry etal., 2013). TheNew
Brunswick integrated service delivery model (Government of New Brunswick, 2015)
includes a partnership between Health, Education and Early Childhood Development,
Social Development, and Justice and Public Safety. Services are offered in school- and
community-based settings, with the goal of eliminating gaps in service delivery, fostering
a growing environment suitable for children and youth with various needs, and developing
interventions tailored to the needs and preferences of children and youth. Services included
in theNew Brunswick integrated service delivery model include OAAT therapy, individual
and group counseling, substance use and gambling support, mental wellness education,
navigation for school supports and resources, and partnerships to facilitate referrals to out-
of-home care (e.g., inpatient treatment, child protection placement) where appropriate. The
collaborations between the four sectors enhance the delivery of services for children and
youth, as the interdisciplinary team meets regularly (e.g., weekly) to discuss cases. Chil-
dren, youth, and families are involved in all aspects of the planning, decision-making, and
follow-up (Government of New Brunswick, 2015).
Rationale andObjectives
This manuscript illustrates the steps taken to implement OAAT therapy within New Brun-
swick child and youth A&MHS. We aim to highlight the following: (1) key implementa-
tion considerations; (2) readiness among providers to implement OAAT therapy within a
SC2.0 continuum; and (3) client satisfaction, and system-related outcomes associated with
implementing OAAT therapy.
Fig. 3 Nine core components of the Stepped Care 2.0 model
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Methods
Ethical approval was sought and received from the Horizon Health Network ethics board
(Ref# 2021–3015), Vitalité Health Network ethics board (Ref# 2957), and Newfoundland
and Labrador Health Research Ethics Board (Ref# 2021.094). Participants provided informed
and written consent before participating in the associated research. Participation was vol-
untary, data were collected by research assistants who were not affiliated with participat-
ing healthcare networks or school districts, and only aggregate data were shared with the
government.
Procedures
Key Implementation Considerations
The process of implementing OAAT therapy into child and youth A&MHS was documented
through meeting minutes recorded from weekly and bi-weekly meetings, project charters
(i.e., a living document updated regularly), staffing notes, themes arising from check-ins
with program managers and clinical leads, and government presentations. Changes to imple-
mentation plans, as well as successes and challenges, were identified through documented
consultations with the core project team. Processes, contextual factors, implementation
determinants, and implementation strategies were identified, and retrospectively mapped
onto the Active Implementation Framework–Implementation Stages (AIF-IS; Fixsen etal.,
2005), Consolidated Framework for Implementing Change (CFIR; Damschroder et al.,
2022), and Expert Recommendations for Implementing Change (ERIC; Powell etal., 2015).
Readiness Among Providers toImplement OAAT Therapy
Providers who worked in child and youth A&MHS in Horizon Health Network, Vitalité
Health Network, and the seven School Districts were recruited to participate between October
2021 and April 2022. Study procedures mirrored those detailed in our study on implement-
ing OAAT therapy in adult A&MHS (Harris-Lane et al., 2023). Child and youth A&MHS
providers received communications from management (i.e., via email, staff meetings) that
outlined the initiative to implement OAAT therapy within the context of a provincial SC2.0
model. Providers were directed to a consent form on Qualtrics to learn more about the optional
research being conducted as part of this initiative. All child and youth A&MHS providers,
from varying professional backgrounds, were eligible to participate. Those who consented to
participate completed a demographic survey (T1) before receiving access to an online SC2.0
training course, followed by an OAAT therapy course. Providers who elected not to participate
were immediately redirected to the training courses. The SC2.0 and OAAT therapy courses
(detailed in Supplemental Appendices B and C, respectively) spanned 3–5h, and contained
videos, case studies, and self-reflection journal entries. After completing the asynchronous
courses, participants completed a post-course survey (T2) on the acceptability, feasibility, and
appropriateness of OAAT therapy. Participants completed a 1-month follow-up survey (T3)
with a comprehensive measure of organizational readiness. Providers received three $20 e-gift
cards for their participation, and had the option to participate in their preferred language (Eng-
lish or French).
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System‑Related Outcomes andClient Satisfaction
Providers documented each OAAT therapy session using the provincial Client Service Deliv-
ery System (CSDS). Key performance indicators were abstracted from CSDS and standard-
ized manual reports, and included the following: (1) number of OAAT therapy sessions deliv-
ered between April and December 2022; (2) provincial waitlists for child and youth A&MHS
during the implementation, and 6 months preceding it (i.e., November 2021 to December
2022); and (3) number of clients who returned for multiple sessions during the project imple-
mentation period. Refer to Harris-Lane etal. (2023) for a detailed description of procedures.
Child and youth clients who availed of an OAAT therapy session were offered the oppor-
tunity to complete a satisfaction survey by administrative or clinical staff. Parent or guardian
consent for participation was obtained for clients under the age of 16. Surveys were com-
pleted in approximately 5min and were administered between April and December 2022.
Measures
Key Implementation Considerations
Data were collected from a variety of sources within the child and youth A&MHS, includ-
ing (1) government reports and presentations, (2) field notes and meeting minutes, (3) doc-
umented discussions on implementation progress and areas of improvement, (4) staff chart-
ing and notes, and (5) documented consultation with core child and youth project team.
Readiness Among Providers toImplement OAAT Therapy
Acceptability, appropriateness, and feasibility were assessed using the Acceptability of
Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibil-
ity of Intervention Measure (FIM), respectively (Weiner etal., 2017). The AIM, IAM, and
FIM each contain four items with scores ranging from 1 (strongly disagree) to 5 (strongly
agree). Higher mean scores suggested greater acceptability, appropriateness, and feasibility.
Organizational readiness for implementation was assessed using the Readiness Diagnostic
Scale (RDS), adapted by the developers of the Readiness for Integrated Care Questionnaire
for use in this project (Scott etal., 2017). The RDS contains 51 items and 18 subscales (refer
to Supplemental Appendix D). Scale anchors range from 1 (strongly disagree) to 7 (strongly
agree), with higher mean scores suggesting greater readiness for implementation.
System‑Related Outcomes andClient Satisfaction
Data on the number of OAAT therapy sessions delivered, discrete client visits, and wait-
lists were abstracted from the CSDS and standardized manual reports. The client satis-
faction survey used in the implementation of OAAT therapy for adults (Harris-Lane
etal., 2023) was adapted for use with children and youth (refer to Supplemental Appen-
dix E). The adapted survey included 5 items on a 5-point Likert scale, whereby satisfac-
tion was depicted using images of facial expressions ranging from “very upset” to “not
upset.” These “smiley meters” have considerable validity and reliability in data collection
with child and youth populations (Read etal., 2002). The client satisfaction survey also
included an open-ended question, where clients could provide written feedback on their
experience. Demographic information was not collected for confidentiality purposes.
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Data Analysis
Key Implementation Considerations
Initiatives that occurred throughout the implementation process were mapped onto cor-
responding AIF-IS elements, CFIR domains, and ERIC strategies using a four-step pro-
cess. First, the research team reviewed documentation and created a timeline of New
Brunswicks’s actions and processes of implementing OAAT therapy into child and youth
A&MHS. Second, the timeline was reviewed and refined by members of the core project
team for accuracy. Third, two members of the research team (LH-L and JR) reviewed com-
ponent definitions within the AIF-IS, CFIR, and ERIC strategies to determine how steps
undertaken within the OAAT implementation steps aligned with each framework. Finally,
the implementation process with retrospectively mapped components was reviewed by the
broader team for consensus.
Readiness Among Providers toImplement OAAT Therapy
Descriptive statistics (i.e., frequencies, arithmetic means, standard deviations) were con-
ducted using IBM SPSS V28 to characterize the sample and understand providers’ per-
ceptions of readiness for implementing OAAT therapy. Data were missing at random, and
were not imputed due to the descriptive nature of analyses.
System‑Related Outcomes andClient Satisfaction
Client satisfaction with OAAT therapy sessions and system performance indicators were
analyzed using descriptive statistics. Client responses to the written survey question were
coded and synthesized thematically (Braun & Clarke, 2006). Emerging themes were
developed from patterns across participant responses in an iterative process and the cod-
ing scheme used was equivalent to coding performed for surveys administered to clients
accessing adult services (Harris-Lane etal., 2023).
Role ofFunding Source
This work was supported by the Canadian Institutes of Health Research (CIHR) under the
Transitions in Care Team Grant No. 423968. The funding source was not involved in the
project design, conduct, or reporting.
Results
Key Implementation Considerations
The implementation of OAAT therapy into child and youth A&MHS followed a similar
approach to the implementation process documented within adult A&MHS (Harris-Lane
etal., 2023). The unique complexities of implementing services for children and youth, and
particularly in the context of an integrated service delivery model, necessitated unique con-
siderations and adaptations. The full implementation process as aligned to the four stages of
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International Journal of Mental Health and Addiction
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the AIF-IS, CFIR determinants, and ERIC strategies is detailed in Supplemental Appendix
F. For brevity, we only describe the key learnings and implementation considerations unique
to child and youth A&MHS within the installation and initial implementation stages.
Installation
The installation stage offered a unique opportunity to leverage the successes and learn-
ings from the implementation of OAAT therapy in adult A&MHS, and adapt previous
efforts to fit the child and youth A&MHS context. The installation stage commenced by
hiring a senior health consultant in October 2021 who oversaw the implementation and
helped sustain the delivery of OAAT therapy. The senior health consultant was respon-
sible for conducting assessments of risk and readiness throughout the project and liaised
with implementation leads.
Between 2021 and 2022, the province followed a staffing plan and hired eight OAAT
clinical leads (i.e., implementation leads) who acted as champions in supporting and sus-
taining the implementation. These clinical leads provided clinical supervision to providers,
and served as a vital connection between the 44 teams and the senior health consultant.
Each clinical lead also delivered OAAT therapy sessions to enhance expertise and gain
personal experience with the successes and challenges of this form of service delivery.
The core project team cited that the unique perspectives of clinical OAAT leads—based on
their own delivery of service and consultations with providers—were critical in the imple-
mentation and sustainability of OAAT therapy. Further, additional 18.5 full-time equiva-
lent positions were created for the delivery OAAT therapy.
The provincial working group (i.e., implementation team) was established in October
2021 and included membership from the Department of Health, Directors from Horizon
and Vitalité Health Networks, child and youth A&MHS Managers, and Education and
Early Childhood Development Directors. Clinical OAAT leads were onboarded to the
working group as they were hired. Similar to the implementation of OAAT therapy into
adult A&MHS (Harris-Lane etal., 2023), feedback loops were established between stake-
holders who had a vested interest in the success of the implementation; refer to Fig.4.
The provincial working group met weekly to (1) adapt the implementation plan created for
implementing OAAT therapy into adult A&MHS, (2) revise operational guidelines to best
fit processes of delivering OAAT therapy in both adult and child and youth A&MHS, and
(3) review successes, challenges, and outcomes of ongoing readiness assessments.
Managers and clinical leads completed asynchronous online courses in SC2.0 and
OAAT therapy beginning in November 2021, with providers following shortly thereafter.
Approximately 400 healthcare and education providers were trained in this form of service
delivery, with 214 (54%) enrolling in the associated research. Additionally, providers com-
pleted a live OAAT therapy training with an expert in OAAT approaches in child and youth
A&MHS. While some providers expressed hesitancy towards the change in service deliv-
ery, completion of online and live courses and support from clinical leads were critical in
helping alleviate concerns.
Initial Implementation
Child and youth teams trialed integrating OAAT therapy into practice in November 2021,
with an expectation that all teams would offer OAAT therapy by May 2022. Readiness
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International Journal of Mental Health and Addiction
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assessments were conducted with the manager of each team between October and Novem-
ber 2021 to mark the beginning of implementing OAAT therapy into practice. These
assessments were used to explore operational approaches, challenges, and priorities.
Assessment results highlighted four key challenges: (1) staff capacity (n = 35); (2) avail-
ability of physical space (n = 27); (3) age of consent (n = 19); and (4) integration with inte-
grated service delivery processes (n = 13).
Concerns surrounding staff capacity were not unique to the implementation of OAAT
therapy in child and youth A&MHS (Harris-Lane et al., 2023); however, limited access
to available physical space presented a particular challenge. Adult A&MHS operated in
designated clinics while child and youth teams delivered services within schools, often
without reserved space. Notably, the ability to allocate space for OAAT therapy sessions
in child and youth A&MHS was beyond the decision-making power of leadership on the
provincial working group. In response, the core project team formed a task force with sen-
ior members of government leadership in healthcare and education.
Existing integrated service delivery processes created additional complexity and required
adaptation for the successful integration of OAAT therapy into practice. For instance, prior
to implementing OAAT therapy, child and youth teams would meet with integrated service
delivery partners to review new referrals before contacting the client. In these meetings, the
team would discuss if an intake assessment for services would be offered. However, follow-
ing implementation, OAAT therapy sessions were established as a standard first point of con-
tact, and integrated service delivery consultation meetings were held on an as-needed basis
after this initial therapeutic intervention. The core project team completed a client journey
mapping exercise with managers, clinical leads, and providers to facilitate changes in service
delivery. This exercise aligned with tools previously used in the research (Davies etal., 2023;
Fig. 4 Flow of information from core project team to providers implementing OAAT therapy in their prac-
tice. Notes: The Provincial Working Group included (1) the core project team, (2) directors in both health-
care and education and early childhood education sectors, (3) regional program managers, and (4) OAAT
clinical leads
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International Journal of Mental Health and Addiction
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McCarthy etal., 2016), and was used to support providers in conceptualizing the changes,
and identify potential barriers and facilitators to offering OAAT therapy sessions within exist-
ing policies. Refer to Supplemental Appendix G for further information. During the mapping
exercise, providers anticipated that processes for scheduling appointments (e.g., phone calls)
may need to be adapted to best meet youths’ preferences (e.g., texting, social media).
In addition to challenges with integrated service delivery processes, healthcare providers,
education providers, and community partners experienced early tensions due to the need for
an enhanced understanding of the referral process, and of the roles of themselves and their
collaborators in the delivery of OAAT therapy. The core project team held education sessions
with these stakeholders to clarify roles and expectations, and help mitigate these tensions.
Due to the complexities of child and youth A&MHS delivery, the Government ofNew
Brunswick shifted communications from “open access” or “drop-in services” to highlight
the “rapid access,” “low-barrier,” and “early intervention” nature of OAAT therapy. The
provincial working group determined that OAAT therapy sessions would be scheduled in
advance, with the goal of achieving a maximum wait time of 3days for scheduled OAAT
therapy sessions.
Beginning in April 2022, child and youth teams distributed client satisfaction surveys
to inform iterative improvements, and to better understand experiences with the service
among children, youth, and parents and guardians.
Readiness Among Providers toImplement OAAT Therapy
As characterized in Table1, child and youth providers (N = 214) enrolled in this study, with
213 providers completing T2 surveys, and 155 providers completing T3 surveys. There
were no significant differences in the demographics of providers from T1 to T3. Among
participants, 66.4% indicated English as their preferred language while 33.6% preferred
French. Providers worked in the two health authorities, Horizon Health Network (45.3%)
and Vitalité Health Network (25.2%), as well as the school districts (29.0%). The majority
of providers represented healthcare providers (68.7%) on the integrated child and youth
teams, and reported a professional background in social work (61.7%).
As detailed in Table2, providers agreed that OAAT therapy is an acceptable solution
to the challenges faced in child and youth A&MHS when delivered within the context of
a provincial SC2.0 model (MAIM = 4.16, SDAIM = 0.65), and was appropriate for clients, the
organization, and their practice (MIAM = 4.01, SDIAM = 0.67). Participants somewhat agreed
that implementing OAAT therapy was feasible and practical (MFIM = 3.73, SDFIM = 0.69).
Providers noted areas of strength in organizational readiness, including perceptions that
OAAT therapy was compatible with their practice, client needs, and the organization’s
mandate (M = 5.71, SD = 0.91). Providers also endorsed the belief that OAAT therapy
would lead to observable short-term outcomes (M = 5.53, SD = 0.89). In contrast, areas
of growth included concerns around staff capacity (M = 4.30, SD = 1.37) and insufficient
connections with other organizations that have implemented OAAT therapy (M = 4.16,
SD = 1.45). Table2 presents a detailed depiction of RDS components measured.
System‑Related Outcomes andClient Satisfaction
A total of 2266 OAAT therapy sessions were delivered to clients seeking child and youth
A&MHS between April and December 2022. Among the 1676 clients seeking care (April 2022
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Table 1 Summary of participant characteristics
* p < .05. **p < .01. ***p < .001
N/A not applicable, as data were not collected at that timepoint
T1 T3 Group differences
between T1 and
remaining T3
participants
Sample size Chi-square test
Characteristic N (%) N (%) χ2p
Language N/A N/A
English 142 (66.4%) N/A
French 72 (33.6%) N/A
Organization of work 7.06 .070
Horizon Health Network 97 (45.3%) 75 (48.1%)
Vitalité Health Network 54 (25.2%) 32 (20.5%)
School Districts 63 (29.5%) 49 (31.4%)
Work Setting 1.98 .371
Child and Youth Team (Healthcare) 147 (68.7%) 105 (67.3%)
Child and Youth Team (Education) 63 (29.4%) 49 (31.4%)
Other 4 (1.9%) 2 (1.3%)
Community setting 4.15 .042*
Urban 116 (54.5%) 91 (58.7%)
Rural 97 (45.5%) 64 (41.3%)
Profession 8.72 .190
Social work 132 (61.7%) 93 (59.6%)
Psychology 29 (13.6%) 22 (14.1%)
Education 13 (6.1%) 13 (8.3%)
Counselling 12 (5.6%) 9 (5.8%)
Nursing 12 (5.6%) 7 (4.5%)
Occupational therapy 9 (4.2%) 8 (5.1%)
Other 7 (3.3%) 4 (2.6%)
Level of education 8.80 .117
Doctorate 6 (2.8%) 6 (3.8%)
Master’s 71 (33.2%) 57 (36.5%)
Baccalaureate 126 (58.9%) 86 (55.1%)
Diploma 6 (2.8%) 5 (3.2%)
Other 5 (2.3%) 2 (1.3%)
Role 2.26 .520
Provider 166 (77.6%) 123 (78.8%)
Manager/provider 26 (12.1%) 16 (10.3%)
OAAT lead 11 (5.1%) 9 (5.8%)
Manager 11 (5.1%) 8 (5.1%)
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International Journal of Mental Health and Addiction
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to December 2022), 88.8% of clients used one session while 9.1% returned for a second session,
and 2.1% returned for three or more sessions. Prior to implementation (September 2021–March
2022), on average, 867 clients were waitlisted to receive care. As illustrated in Fig.5, this num-
ber was reduced by 62% to 330 waitlisted clients by December 2022, due to the delivery of
OAAT therapy sessions, review and consolidation of waitlists, and transition to CSDS.
Clients (N = 518) completed a satisfaction survey following their OAAT therapy ses-
sion. Before receiving a session, 61% of clients reported feeling upset/very upset about
their concerns, with only 7% of clients reporting feeling upset/very upset following the ses-
sion. Most clients reported feeling confident in their ability to manage their mental health
concern after the session (59%), satisfaction in how their concerns were addressed in the
session (89%), and satisfaction with the co-developed treatment plan (87%).
As detailed in Table3, five themes emerging from client (n = 104) comments. Specifi-
cally, clients felt that (1) the OAAT therapy session was a positive experience character-
ized by a strong therapeutic alliance with the provider, and resulted in enthusiasm towards
their recovery (n = 49), (2) the session equipped them with knowledge and tools that can
be applied in their day-to-day life (n = 17), (3) the OAAT therapy session was valued
and appreciated (n = 26), (4) they experienced improved wellbeing following the session
(n = 13), and (5) the OAAT therapy session did not match the clients’ expectations of care,
or adequately meet their needs at that time (n = 6).
Table 2 Descriptive statistics
for measures of acceptability,
appropriateness, feasibility, and
readiness
Measures and subscales M ± SD
Acceptability of Intervention Measure (AIM) 4.16 ± 0.65
Intervention Appropriateness Measure (IAM) 4.01 ± 0.67
Feasibility of Intervention Measure (FIM) 3.73 ± 0.69
Readiness Diagnostic Scale (RDS)
Compatibility 5.71 ± 0.91
Observability 5.53 ± 0.89
Program champion 5.36 ± 1.42
Priority 5.35 ± 1.14
Culture 5.33 ± 1.04
Simplicity 5.26 ± 1.04
Leadership 5.24 ± 1.18
Climate 5.08 ± 1.10
Supportive climate 5.01 ± 1.30
Innovation specific knowledge and skills 4.99 ± 1.25
Innovativeness 4.96 ± 1.25
Structure 4.95 ± 1.38
Ability to pilot 4.92 ± 1.52
Relative advantage 4.79 ± 1.30
Intra-organizational relationships 4.40 ± 1.49
Staff capacity 4.30 ± 1.37
Resource utilization 4.20 ± 1.58
Inter-organizational relationships 4.16 ± 1.45
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International Journal of Mental Health and Addiction
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Discussion
Following the rollout of the integrated service delivery model in 2015 and 2016, the
province of New Brunswick experienced a 33% increase in referrals for child and youth
A&MHS (Government of New Brunswick, 2021). The Government of New Brunswick
made it a priority to increase rapid access to care through the adoption of OAAT therapy,
and work toward a provincial SC2.0 model. The implementation of OAAT therapy into
child and youth A&MHS presented challenges due to the lack of literature on pragmatic
processes and considerations for implementing OAAT therapeutic approaches with this
population, particularly considering unique needs, such as parent/guardian consent. As
such, we aimed to begin to address this gap by documenting the process of implementing
OAAT therapy within child and youth A&MHS, detailing initial results, and highlighting
considerations for future implementers.
Surprisingly, almost no known literature has examined how to implement OAAT therapy
or its variations (i.e., single-session therapy) with children and youth, given the complexities
of such services, including parental consent and procedures inherent within the integrated ser-
vice delivery model. Young et al. (2012) noted select organizational considerations, includ-
ing (1) updating organizational guidelines and policies, (2) having a dedicated role to oversee
the implementation of OAAT therapy, and (3) ensuring staff have the support of managers.
Young etal. (2012) also highlighted standard implementation best practices (i.e., ongoing con-
sultations, senior leadership support, engaging champions) in the implementation of services
for children and youth. Outside of these recommendations, researchers have not addressed
pragmatic considerations (i.e., consent, integrated service models, changes in staffing roles)
for implementing OAAT therapy in child and youth A&MHS, and particularly at a system
level. This gap in literature presented challenges for the Department of Health in determining
evidence-informed strategies and best practices for implementing OAAT therapy within child
and youth A&MHS. As a result, the provincial working group elected to focus on providing
OAAT therapy by rapid access appointments, allowing lower-barrier access to care. A scoping
834 833 889 912 930
845
759
402 330
94
181 215
94 95
249
520
410
0
100
200
300
400
500
600
700
800
900
1000
Number of Waitlisted Clients Number of OAAT Therapy Sessions Delivered
Fig. 5 Number of waitlisted clients and OAAT therapy sessions delivered by month. Note: implementation
period of OAAT therapy occurred between April and December 2022
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International Journal of Mental Health and Addiction
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Table 3 Results of thematic analysis derived from child and youth client satisfaction survey comments
Description of finding Supporting quotation Number of endorsements (N = 104)
Theme 1: Clients had a positive experience with their OAAT therapy session
Clients described their OAAT therapysession as a positive
experience. Some clients indicated enthusiasm towards their
recovery, and felt they had a strong therapeutic alliance with
the provider
I’m quite excited to see how this’ll go for me. And I’m eternally appre-
ciative of [theclinician’s] support and guidance she has given me n = 49
[Provider] has great demeanor to talk with our teenager, she was great
delivering the message and providing guidance
This was a good experience and while I didn’t exactly g[e]t what I was
expecting it is very good and I would like to keep coming here
Theme 2: Clients felt equipped with resources to address their concern
Clients feltthat the session facilitated the development of
a treatment plan, andequipped them with knowledge and
tools that can be applied in their day-to-day life
This is the first time I have left with a solid plan with timelines and
objectives, [theclinician] was able to really identify succinctly where
help was needed
n = 17
Liked how he listened to me and gave me really good ideas on how to
work on my anxiety. We came up with a good plan
Theme 3: Clients perceived value in attending an OAAT therapy session, and were appreciative of what OAAT sessions can offer
Clients expressed value and appreciation for the OAAT
therapy session
Very glad that this program is available n = 26
Appreciate the interest in having an appointment and that this meeting
included all family members (parents and my son)
Theme 4: Clients felt that the OAAT therapy session helped improve their well-being and recovery journey
Clients reported improved wellbeing immediately after
attending the OAAT therapy session. Sessions were
described as helpful in developing client’s confidence and
resolving concerns
This was extremely beneficial. I appreciate being able to talk to someone
& to have a course of action n = 13
It was great to sit and talk to someone in-depth about my problems and
concerns ve[r]y thankful for a long “vent session” would recommend
to anyone nee[d]ing advice or someone to just listen and talk to if
needed in the moment
This meeting gave our daughter confidence that she is taking steps to
improve the obstacles in her daily life
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International Journal of Mental Health and Addiction
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Table 3 (continued)
Description of finding Supporting quotation Number of endorsements (N = 104)
Theme 5: Client’s needs or expectations were not met during the OAAT therapy session
A minority of clients reported that the OAAT therapy session
did not match their expectations of care, and did not believe
the session had adequately addressed their needs at that
moment
Felt like the advice my friends would give me and didn’t actually help n = 6
Not enough resources. No set plan continuous help/counselling
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International Journal of Mental Health and Addiction
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review on implementation science frameworks, models, and theories used in child, youth, and
family services highlighted that the AIF-IS and CFIR are commonly used (Albers etal., 2017).
Our study can serve as a starting point for applying best practices in implementation science
(i.e., AIF-IS, CFIR, ERIC strategies) to implement OAAT therapy for children and youth.
The structure of implementation oversight and decision-making presented in Fig.4 was
vital in addressing contextual challenges during the implementation of OAAT therapy into
child and youth A&MHS. Results from the risk and readiness assessments highlighted key
concerns (e.g., insufficient staffing, lack of physical space) of frontline providers, OAAT
clinical leads, and managers, which were discussed among the provincial working group.
While staffing concerns were also raised as a potential barrier in the adult implementation
(Harris-Lane etal., 2023), challenges accessing physical space to offer OAAT therapy ses-
sions was unique to the child and youth sector. Allocating space for OAAT therapy sessions
fell beyond the decision-making power of the provincial working group which precluded the
use of the ERIC strategy “change physical structures” (Powell etal., 2015). A task force was
established with senior government leaders with the ability to address spacing concerns.
This innovative solution highlights the importance of engaged and motivated leadership.
In addition to the barriers identified in the readiness assessments, challenges emerged with
the climate (Damschroder etal., 2022) associated with implementing OAAT therapy within an
integrated service delivery model. Difficulties with interdisciplinary collaboration have been
well-documented in previous literature (Vinicor, 1995), and are particularly common in inte-
grated service delivery models (Nooteboom et al., 2021). As such, it was unsurprising that
tensions surfaced between professions during the initial implementation. The provincial work-
ing group’s approach to educate provider groups on the respective roles in the operations and
delivery of OAAT therapy aligns with interprofessional education—a best practice for collab-
oration (Atkins etal., 2017; Canadian Interprofessional Health Collaborative, 2010). This was
further supported by scoping review on strategies to enhance interprofessional collaboration,
as education on respective roles in the service delivery change was identified as a key strategy
for improving communication and shared decision-making between professions (Sirimsi etal.,
2022). Given the inherent alignment between integrated service delivery and SC2.0 frame-
works, implementing OAAT therapy within a continuum of care requires enhanced interpro-
fessional collaboration and a deeper understanding of each role within the system. Ultimately,
strong interprofessional collaboration facilitates easier transitions in care across the continuum
and ensures that children and youth receive the right service at the right time. Future imple-
menters may consider other strategies detailed in the Sirimsi etal. (2022) review (e.g., develop
a shared vision, set formal and informal meetings, and use structured guidelines).
A critical learning from this implementation was the value of completing a client journey
mapping exercise to conceptualize ongoing changes to service delivery processes, particu-
larly within complex systems. This technique has been used in past healthcare initiatives to
increase clinical effectiveness, and improve patient experiences and healthcare delivery by
creating a narrative timeline of what a patient would encounter as they navigate the system
(Ly etal., 2021; McCarthy etal., 2020). The two most common reasons client journey map-
ping is used is for health service redesign and developing a more nuanced understanding of
the client’s journey through the health system (Davies etal., 2023), both of which were pre-
sent in the current study. In alignment with core components of SC2.0 (Carey etal., 2021),
client journey mapping offers a client-centered approach to iterative improvements to ser-
vice delivery processes. Client journey mapping also facilitates provider feedback and prac-
tice improvements by visualizing the client experience, and pinpointing areas of strength
and weakness (Simonse etal., 2019). This exercise has benefitted multidisciplinary teams
in conceptualizing challenges that may arise from differing perspectives and developing
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International Journal of Mental Health and Addiction
1 3
creative solutions to address shortcomings in pathways (McCarthy et al., 2020). McCarthy
et al. (2020) demonstrated this in a case study where a client journey map exercise was used
in collaboration between medical and technological teams when designing interventions.
Collaboration between specialties allowed for a shared understanding of processes and the
development of creative solutions to address limitations in patient pathways. Such inter-
disciplinary collaboration can be advantageous for integrated systems like New Brunswick,
where healthcare and education providers work closely together to provide integrated ser-
vices for children and youth.
An area for improvement highlighted within the client journey mapping exercise, and
risk and readiness assessments, was the providers’ concern that youth may not call to book
an OAAT therapy appointment. Previous research has highlighted the utility of providing
online scheduling systems, as youth often prefer to schedule appointments online (DeJon-
ckheere etal., 2020; Lawrence etal., 2024). TheGovernment of New Brunswick took this
into consideration during the implementation.
Limitations andFuture Research
Similar to Harris-Lane et al. (2023), results detailed in this manuscript should be inter-
preted with consideration of the following limitations. First, implementation processes in
New Brunswickwere retrospectively aligned with implementation science models, frame-
works, and strategies. It is difficult to determine the extent of benefits that these frame-
works could have in guiding similar implementations. Moreover, some elements of the
implementation process overlapped or occurred in a different implementation stage than
originally included in the AIF-IS (e.g., building an implementation team occurred in the
installation rather than exploration stage). Notably, however, team members from Memo-
rial University and Stepped Care Solutions brought implementation science expertise to the
planning, preparation, and initial implementation, and implementation science in practice
is not often linear and sequential (Nilsen, 2020). Future research on the implementation of
OAAT therapy (and its equivalents) would benefit from a-priori application of implemen-
tation theories, frameworks, and models (i.e., using a logic model). The prospective use
of the AIF-IS, CFIR, and ERIC strategies could help further mitigate potential risks, and
prompt additional considerations on adapting strategies to best meet the needs of clients,
providers, leadership, and the system.
Second, fidelity to the OAAT therapeutic approach was not measured, which may impact
the validity of findings. It is possible that OAAT therapy is not being delivered as intended at
all sites. Future research should integrate measures of fidelity, given the importance (Gearing
etal., 2011). Potential elements of an assessment of fidelity to an OAAT therapeutic approach
could include the following: (1) was the session treated as a whole, complete in and of itself;
(2) was the OAAT therapeutic approach introduced to new clients; (3) was a realistic outcome
for the session established; (4) did the provider focus on and emphasize the client’s strengths;
(5) was the client offered formal and informal resources and supports that span the continuum
of care; (6) was an action plan developed; and (7) was the client reminded that they can access
another session in the future if and when they need it.
Third, provider perceptions and client experiences were measured using self-report.
While the response rate for the client satisfaction survey was low, the response rate among
providers was high (> 50%) and likely representative. Our research highlights the over-
arching value of implementing OAAT therapy to improve access to addiction and mental
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International Journal of Mental Health and Addiction
1 3
healthcare for children and youth; however, it is imperative for future research to explore
the implementation and delivery of OAAT therapy sessions through a lens of health equity
and intersectionality. Specifically, through the lens of the health equity implementation
framework (Woodward etal., 2021), future research should examine (1) if service users are
representative of theNew Brunswick population and if there are underrepresented groups,
(2) barriers and facilitators to accessing OAAT therapy among diverse populations, and (3)
if children and youth feel that they received appropriate, sensitive, and relevant care.
Conclusions
This study begins to address a critical gap in the literature on the pragmatic process of
implementing of OAAT therapy (and its equivalents) into child and youth A&MHS, par-
ticularly within an integrated approach to service delivery. Findings from the current study
can be used to help inform future implementations and guide implementers in considering
factors unique to child and youth A&MHS in alignment with evidence-based implementa-
tion science frameworks and models.
Supplementary Information The online version contains supplementary material available at https:// doi.
org/ 10. 1007/ s11469- 024- 01339-4.
Author Contribution Acquisition of funding: JAR, PC; conceptualization: AC, AJ, JAR, KB, LH-L, PC,
SB; methodology: AC, AJ, JAR, KB, LH-L, PC, SB; data curation: AL, JAR, KB, LH-L, MM, SB; for-
mal analysis: AK, AL, JAR, KB, LH-L, MM; writing—original draft: AK, JAR, LH-L; writing—reviewing
and editing: AC, AJ, AK, AL, JS, KB, MM, PC, SB; project administration: AL, JAR, KB, LH-L, MM,
SB. supervision: JAR. All authors provided important intellectual content, contributed to interpretation, and
have reviewed and approved the final version of this manuscript.
Funding This work was funding by the Canadian Institutes of Health Research (CIHR) under the Transitions in
Care Team Grant No. 423968. The funding source was not involved in the project design, conduct, or reporting.
Data Availability De-identified data will be made available to researchers who provide a methodologically
sound proposal for the purpose of achieving the aims of the approved proposal. Data sharing will be enacted
with a data-transfer agreement between the sending and receiving institutions. Proposals should be directed
to Joshua Rash (jarash@mun.ca).
Declarations
Ethics Approval and Consent to Participate Ethical approval was sought and received from Horizon and
Vitalité Health Networks ethics boards (Ref# 2021–3015 and Ref# 2957, respectively) and the Newfoundland
and Labrador Health Research Ethics Board (Ref# 2021.094; Ref# 2022.048). All procedures followed were
in accordance with the ethical standards of the responsible committee on human experimentation (institu-
tional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was
obtained from participants included in this study.
Conflict of Interest P. Cornish is the founder and former president of Stepped Care Solutions, and receives
financial compensation for consulting services. A. Churchill and A. Jaouich are employed with Stepped
Care Solutions. Stepped Care Solutions is a not-for-profit mental health system consultancy group and is the
developer of the Stepped Care 2.0 model. Stepped Care Solutions developed the Stepped Care 2.0 and One-
at-a-Time therapy courses, and provided online training as an in-kind contribution to the project. As a result
of competing interests, Cornish, Churchill, and Jaouich were not involved in data collection and analyses in
order to minimize potential for bias. The other authors declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long
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1 3
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly
from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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International Journal of Mental Health and Addiction
1 3
Authors and Aliations
LauraM.Harris‑Lane1· AleshaC.King1· StéphaneBérubé2· KatieBurke2,6·
AnnMarieChurchill3· PeterCornish3· AlexiaJaouich3· MylèneMichaud5·
AnneLosier2· JaiShah4· JoshuaA.Rash1
* Joshua A. Rash
jarash@mun.ca
1 Department ofPsychology, Memorial University ofNewfoundland, 230 Elizabeth Ave, St.John’s,
NLA1B3X9, Canada
2 Addiction & Mental Health Services, Department ofHealth, Government ofNew Brunswick,
Fredericton, NB, Canada
3 Stepped Care Solutions, MountPearl, NL, Canada
4 Department ofPsychiatry, McGill University, Montreal, QC, Canada
5 Quality Improvement, Department ofHealth, Government ofNew Brunswick, Fredericton, NB,
Canada
6 Organizational Change Management Practice, Mariner Innovations, Halifax, NS, Canada
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