Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study.

OBJECTIVE: To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service. DESIGN: A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics. SETTING: Child and adolescent outpatient mental health service, Nova Scotia, Canada. PARTICIPANTS: IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12-18 years) and caregivers of clients (aged 3-18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13-18 years (mean 15.7 years), 10 caregivers of clients aged 5-17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians. RESULTS: During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of 'outer setting' (eg, external policies, client needs and resources), 'inner setting' (eg, communications within the service), 'individual characteristics' (eg, personal attributes, knowledge and beliefs about virtual care) and 'intervention characteristics' (eg, relative advantage of virtual or in-person care). CONCLUSIONS: Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

Implementation of a Knowledge Management System in Mental Health and Addictions: Mixed Methods Case Study.

BACKGROUND: Mental health and addictions (MHA) care is complex and individualized and requires coordination across providers and areas of care. Knowledge management is an essential facilitator and common challenge in MHA services. OBJECTIVE: This paper aimed to describe the development of a knowledge management system (KMS) and the associated processes in 1 MHA program. We also aimed to examine the uptake and use, satisfaction, and feedback on implementation among a group of pilot testers. METHODS: This project was conducted as a continuous quality-improvement initiative. Integrated stakeholder engagement was used to scope the content and design the information architecture to be implemented using a commercially available knowledge management platform. A group of 30 clinical and administrative staff were trained and tested with the KMS over a period of 10 weeks. Feedback was collected via surveys and focus groups. System analytics were used to characterize engagement. The content, design, and full-scale implementation planning of the KMS were refined based on the results. RESULTS: Satisfaction with accessing the content increased from baseline to after the pilot. Most testers indicated that they would recommend the KMS to a colleague, and satisfaction with KMS functionalities was high. A median of 7 testers was active each week, and testers were active for a median of 4 days over the course of the pilot. Focus group themes included the following: the KMS was a solution to problems for staff members, functionality of the KMS was important, quality content matters, training was helpful and could be improved, and KMS access was required to be easy and barrier free. CONCLUSIONS: Knowledge management is an ongoing need in MHA services, and KMSs hold promise in addressing this need. Testers in 1 MHA program found a KMS that is easy to use and would recommend it to colleagues. Opportunities to improve implementation and increase uptake were identified. Future research is needed to understand the impact of KMSs on quality of care and organizational efficiency.

Choice and Partnership Approach to community mental health and addiction services: a realist-informed scoping review.

OBJECTIVES: The Choice and Partnership Approach (CAPA) was developed to create an accessible, child-centred and family-centred model of child and adolescent mental health service delivery that is adaptable to different settings. We sought to describe the state of evidence regarding the extent, outcomes and contextual considerations of CAPA implementation in community mental health services. DESIGN: Scoping review. DATA SOURCES: Published and grey literature were searched using MEDLINE, Embase, CINAHL, PsycINFO, Scopus and Google to 13 and 20 July 2022, respectively. ELIGIBILITY CRITERIA: We included reports focused on the implementation, outcomes (clinical, programme or system) or a discussion of contextual factors that may impact CAPA implementation in either child and adolescent or adult mental health services. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a codebook that reflected the five domains of the Consolidated Framework for Implementation Research (CFIR) and reviewed for agreement and accuracy. Data were synthesised according to the five CFIR domains. RESULTS: Forty-eight reports describing 36 unique evaluations were included. Evaluations were observational in nature; 10 employed pre-post designs. CAPA implementation, regardless of setting, was largely motivated by long wait times. Characteristics of individuals (eg, staff buy-in or skills) were not reported. Processes of implementation included facilitative leadership, data-informed planning and monitoring and CAPA training. Fidelity to CAPA was infrequently measured (n=9/36) despite available tools. Health system outcomes were most frequently reported (n=28/36); few evaluations (n=7/36) reported clinical outcomes, with only three reporting pre/post CAPA changes. CONCLUSIONS: Gaps in evidence preclude a systematic review and meta-analysis of CAPA implementation. Measurement of clinical outcomes represents an area for significant improvement in evaluation. Consistent measurement of model fidelity is essential for ensuring the accuracy of outcomes attributed to its implementation. An understanding of the change processes necessary to support implementation would be strengthened by more comprehensive consideration of contextual factors.

The Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol.

INTRODUCTION: Early identification and appropriate treatment of child and adolescent mental health disorders can often be hampered by patchwork services with poorly planned or unclear pathways. The Choice and Partnership Approach (CAPA) is an evidence-based transformational model of community (community-based or outpatient) mental health and addictions services for children and adolescents that aims to better match services to needs and to improve timely access to care. CAPA has been variably implemented across jurisdictions but has not been comprehensively evaluated for its impact on system and client outcomes. Our research question is, 'To what degree does CAPA work, for whom and under what circumstances?'. The purpose of this review is twofold: (1) to gain an understanding of the extent and outcomes of the implementation of CAPA in community mental health and addictions services; and (2) to identify the role of context as it influences the implementation of CAPA and resulting client and system outcomes. METHODS AND ANALYSIS: We will conduct a realist-informed scoping review of the literature related to CAPA in either child and adolescent or adult community mental health and addictions services. Relevant studies, reports and documentation will be identified by searching the following online databases: MEDLINE, Embase, CINAHL, PsycINFO, Academic Search Premier, ERIC, Web of Science, Cochrane, Dissertations Abstracts, NCBI Bookshelf, PubMed Central and the Canadian Health Research Collection. The search strategy was developed by a health sciences library scientist and informed by a multidisciplinary team comprising methodological and content knowledge experts. The search will gather evidence from multiple online databases of peer-reviewed literature and grey literature repositories. All articles will be independently assessed for inclusion by pairs of reviewers. The key themes derived from a thematic analysis of extracted data will be presented in a narrative overview. ETHICS AND DISSEMINATION: Research ethics review is not required for this scoping review. The results will be disseminated through meetings with stakeholders (including clients and families, clinicians and decision-makers), conference presentations and peer-reviewed publication. The results of this review will inform an overarching programme of research, policy and quality indicator development to ultimately improve mental health and addictions care and subsequent mental health outcomes for children and adolescents.

Improving Access to Child and Adolescent Mental Health Care: The Choice and Partnership Approach.

OBJECTIVE: The Choice and Partnership Approach (CAPA) is designed to improve access and quality of pediatric mental health care. We tested whether CAPA improved access in an academic pediatric hospital. METHOD: We used de-identified administrative data to compare access pre- (2011) and post-CAPA (2013). RESULTS: Wait time to first appointment in 2011 was 225.3 days (95% CI = [211.0, 239.6], N = 364), compared to 93.0 days (95% CI = [89.2, 96.8], N = 838) in 2013 (p<.001). Mean wait time between the first and second appointments was 59.2 days (95% CI = [46.5, 71.9], N = 86) in 2011, compared to 95.9 days (95% CI = [90.3, 101.5], N = 487) in 2013 (p < .001). However, overall mean wait time from referral to second appointment decreased from 271.2 days (95% CI = [236.5, 305.9], N = 86) in 2011 to 168.9 days (95% CI = [161.6, 176.2], N = 487) in 2013 (p < .001). Provider productivity increased from 32.6 to 57.0 first appointments/FTE/year. Depending on the question, 65 to 95% of parents and children gave positive answers about CAPA. CONCLUSIONS: CAPA implementation was associated with more patients served, decreased waiting time to first appointment, and higher productivity.

OBJECTIF: L'approche choix et partenaires (CAPA) est destinée à améliorer l'accès et la qualité des soins de santé mentale pédiatriques. Nous avons vérifié si CAPA améliorait l'accès dans un hôpital pédiatrique universitaire. MÉTHODE: Nous avons utilisé des données administratives dépersonnalisées pour comparer l'accès avant 2011 et après-CAPA (2013). RÉSULTATS: Le temps d'attente pour un premier rendez-vous en 2011 était de 225,3 jours (IC à 95% = [211,0, 239,6], N = 364), comparé à 93,0 jours (IC à 95% = [89,2, 96,8], N = 838) en 2013 (p < 0,001). Le temps d'attente moyen entre le premier et le deuxième rendez-vous était de 59,2 jours (IC à 95% = [46,5, 71,9], N = 86) en 2011, comparé à 95,9 jours (IC à 95% = [90,3, 101,5], N = 487) en 2013 (p < 0,001). Cependant, le temps d'attente moyen global de l'aiguillage au deuxième rendez-vous est passé de 271,2 jours (IC à 95% = [236,5, 305,9], N = 86) en 2011 à 168,9 jours (IC à 95% = [161,6, 176,2], N = 487) en 2013 (p < 0,001). La productivité des prestataires a augmenté de 32,6 à 57,0 premiers rendezvous/ETP/année. Dépendamment de la question, 65 à 95% des parents et des enfants ont donné des réponses positives à l'endroit de CAPA. CONCLUSIONS: La mise en oeuvre de CAPA était associée à plus de parents servis, à un temps d'attente réduit pour le premier rendez-vous, et à une plus grande productivité.

A Scoping Review of Emergency Department Discharge Instructions for Children and Adolescents With Mental Disorders.

BACKGROUND: Although most young people under the age of 25 years with mental health presentations to the emergency department (ED) are discharged home, several studies suggest discharge instructions are inadequate. We conducted a scoping review to characterize and map the literature, identify research gaps, and prioritize targeted areas for future reviews for ED discharge instructions for young people with mental disorders. METHODS: Our review was conducted in an iterative approach with 6 stages including identifying the research question, identifying relevant studies, study selection, data extraction, collaring and summarizing, and stakeholder engagement. We characterized the available information on discharge instruction interventions using the Behavior Change Wheel. RESULTS: Of the 805 potential publications screened, 25 were included for extraction. Nine of the 25 articles focused on suicide or self-harm, 6 were on mental health in general or mixed groups, and 9 focused on alcohol, tobacco, or substance use in general. Five studies included younger children (ie, less than 12 years) but ages ranged significantly among studies. Education and persuasion were intervention functions most commonly reported in publications (n = 13 and n = 12, respectively). From the policy categories, recommendations regarding service provision were most frequently made from four publications. Descriptions of theory were limited in publications. CONCLUSIONS: The available literature regarding discharge instructions in the ED for youth with mental disorders is focused on certain content areas (eg, self injurious behaviors, substance use) with more work required in chronic mental disorders that make up a significant proportion of ED visits. Research that extends beyond education and with theoretical underpinnings to explain how and why various interventions work would be useful for clinicians, policy-makers, and other researchers.

Integrated knowledge translation in mental health: family help as an example.

OBJECTIVE: To describe and provide an example of integrated knowledge translation. METHODS: We review the elements of integrated knowledge translation and describe the Family Help Program, a distance treatment program for child mental health as an example of integrated knowledge translation. RESULTS: Family Help, a distance treatment program for child mental health, was developed with a grant from the Canadian Institutes of Health Research (CIHR). One of the requirements of the grant was involvement of community partners. This partnership resulted in a form of integrated knowledge translation (KT). To be successful, integrated KT requires the engagement of all partners and maintenance of mutual respect. The grant met its objectives and several distance treatments for child mental health were developed and evaluated. Integrated KT was effective in supporting the transfer of this research project into clinical practice and Family Help is now employed in several collaborating health districts. CONCLUSION: Integrated KT in the early phases of research has significant advantages when the purpose is inclusion of key stakeholders' (e.g. decision makers and consumers) knowledge to yield an effective product and facilitate uptake into clinical practice.

Stress in rural Canada: a structured review of context, stress levels, and sources of stress.

We conducted this review to organize studies on stressors, stress, and health of rural Canadians. An organizing framework of the pathway from psychosocial stressors (i.e., determinants of health) through perceived stress and physiological impacts to health outcomes was used (1) to situate the rural experience of stress within the individual using the existing reports on community and societal stressors and (2) to synthesize existing research on individual stress for rural residents. The emergent themes from the review indicated that stressors can be grouped as individual factors, relationship characteristics, health, work and education, community, finances, and the environment. We conclude by proposing that research measuring stressors of rural Canadians needs to be undertaken in order to understand the connections between health and stress for this population.