Acute mental health and addiction services integrate at both the point of intake, referral and admission and the point of discharge in order to support a seamless and continuous service to people experiencing mental health emergency, and their families. Individuals requiring access to acute care will be treated with respect and dignity. Service will be client and family centered, always considering the least intrusive intervention, safety being the determining factor.

Acute mental health and addiction services are a component of the larger, comprehensive system of service for people with mental illness and addictions. Acute services are designed for immediate but short term assessment and intervention that is meant to address risk and stabilize acute symptoms. Therefore strong links and agreement with continuous and specialized inpatient and community services are essential to ensure integration. Hospital based and community partners will work collaboratively to cultivate an acute care system that is accessible, seamless, equitable and provides continuity of care from admission to discharge

The Regional Acute Mental Health and Addiction Service regionalizes access and accountability related to mental health and addiction services in the North Simcoe Muskoka LHIN. The regional model, was developed by a representative steering committee, comprising leaders from the relevant schedule one hospitals then ongoing project implementation was supported by an advisory body, known as the Operations Team, that comprised members from scheduled and non-scheduled hospitals, community mental health and addiction programs and consumer/survivor and family groups. Costs to support the project, and ensure central administrative and clinical leadership have been jointly funded by Network 1 hospitals and the Canadian Mental Health Association – Barrie Simcoe Branch.

In addition to establishing central administrative and clinical leadership for acute mental health and addiction services, three key deliverables are identified by this service: develop and implement an acute bed registry; establish common referral and admission guidelines and standards of practice; and to develop and implement a psychiatry on-call service. Additional anticipated outcomes include examining staffing resources assigned to mental health and addiction services in the Network to consider synergies or resource-sharing as well as considering clinical profiles of people treated in the system to consider trends and opportunities for specialization or service enhancements.

A separate deliverable, involves engaging key acute partners such as emergency departments and crisis services as well as the broader community partners, relevant to acute services, related to referral and admission, discharge effectiveness and assuring a full network of service alternatives for people living with mental health and addiction problems.

Joint training and education has resulted in team-building and enhanced service networks, especially related to crisis workers collectively and crisis workers together with hospital emergency clinicians. Draft “Clinical Information Sharing Guidelines” for the Region have emerged from these sessions which articulate the importance of the circle of care and will assure both continuity of care and risk management.

All partners agree that the regional acute service must be sustained. In the next year, administrative leadership is required to a) facilitate local leadership and compliance with regionalization, including HR synergy; b) complete ongoing evaluation, initiate and respond to evaluation reports, according to the evaluative framework, and; c) maintain the communication strategy and complete policy development with respect to acute mental health and addiction services. and resource sharing, d) promote, deliver, assure joint training and team building amongst acute clinicians; and e) represent the consolidated acute service in terms of planning, development and monitoring of mental health and addiction services in the region, including promotion of integration between mental health and addiction services, identification of un/underserved populations and relevant proposal initiation.

Ongoing resource-support for the role of Clinical Director is essential in order to completely implement, maintain and evaluate the Psychiatry on Call service provided by Schedule 1 hospitals and initiate common Standards of Practice – which is deferred due to resourcing of the Clinical Director position from 0.6 FTE which was recommended by the Steering Committee and the 0.2 FTE position which was available.

A proposed sustainability model is:

Principles for Sustainability:

• Hospitals and community programs are jointly responsible to sustain the service
• Outcomes must assure access and best practice compliance
• Partner satisfaction is important to retain excitement with current direction
• Psychiatry on-call will be available to all regional ER partners
• Crisis and ER services are key partners related to referral/admissions
• Acute service competence and community capacity is critical to discharge effectiveness
• System Accountability will be assured
• Acute Bedded programs will be accessible 24/7

Conclusion:

The decision to assign resources to regionalize acute mental health and addiction services has yielded important results. Acute services comprise hospital and community programs where clinical cultures and processes vary – establishing relationships that focus on the best outcomes for people requiring acute services has been a significant motivator in terms of adopting changes in structure and practice with all services. Feedback regarding the project, its process and its outcomes have all been positive – although some areas have felt the changes required more time and consultation prior to implementation. No doubt for some people change will always be too quick, or too slow!

The gains achieved in year one must be sustained if full system integration is expected. The bed registry clearly addresses issues of access and provides capacity to monitor and evaluate access, timeliness and service utilization. A strong and integrated crisis service, with common practices and protocols, supports sound clinical decision-making based on BPG’s and assures appropriate resource utilization, including local resources near the to person’s home. Regional access to psychiatry on-call service also supports decision-making by physicians in emergency departments. Common referral and admission guidelines assure that acute bedded programs practice consistently and follow BPGs.

Considerable precision now exists with respect to accessing acute beds, including deflecting and deferring admission where appropriate, occupancy management and accessing appropriate local community resources. Precision regarding effective discharge planning and practice, which is a critical component in bed utilization and management strategies, is well underway and requires implementation support in the coming year. The existing evaluation plan, which includes robust measures to assess compliance with agreed upon referral and admission protocols, will need to be revised to include similar robust measures regarding discharge.

Centralizing intake is recommended to improve data quality, efficiency and consistency but will require negotiation regarding resource allocation. Physician/psychiatrist engagement is critical to implementing and sustaining change; FFS agreements are experienced as limiting for physicians in terms of attending meetings and participating in non-clinical activities – improving access to sessional funds for physicians and psychiatrists needs to be considered.

Finally, there is a palpable shift in thinking regarding collaborative service. Healthy and productive debate regarding shared responsibilities for assessing, supporting and intervening with the person in crisis has begun between crisis service, ER’s and bedded programs. There is clear commitment regarding shared assessment and intervention responsibilities and strategies for people with both mental health and addiction problems. Joint training and opportunities to bring together the service partners has fostered this spirit of collaboration.

The “team” of service providers is excited about the new relationships and happy to be working together for a single purpose.

Appendix 1

North Simcoe – Muskoka Regional Acute Mental Health and Addiction Service: Acute Bed Registry

The Acute Bed Registry (ABR) was constructed by the MHCP IT department, specifically Norm Petroff. There was extensive consultation and functional development considered both ease of access and utilization as well as evaluation and system reporting.

The ABR has three key functions:

1. Bed location – a broad number of users can access the Facilities page of the ABR to determine where acute beds are available. All acute beds, including community crisis beds at 2 sites, residential withdrawal management: assessment beds; as well as schedule 1 beds at 3 sites. When a bed is located the referral is initiated during telephone discussion. The hours of operation are 8AM to 8PM at the 3 scheduled sites and 24/7 at the Crisis Bed and WMS sites.

2. Referral Management – intake workers at each bedded site input relevant information including: name; address, including postal code; health card number, DOB, citizenship, notice regarding the completion of a crisis assessment and access to POC, legal status and very basic clinical information. The referring facility faxes the Risk Screening Report and Medical Clearance to the receiving facility and decisions are made regarding transfer and assessment for admission. Intake workers must “agree” by clicking an icon to indicate that they have read and accept privacy agreements and consequences regarding the personal health information they have access to.

When a decision is made to transfer the person, the intake worker “awards a bed” (at this time the bed is removed from availability) and after the transfer, when the assessment is complete, the Intake worker “admits” the person. From the time of referral to the award of the bed, a 4 hour period is allocated – delays beyond 4 hours must be explained and will be reported on. Similarly, delays longer than 4 hours from the time of award to the time of admission must also be explained and reported on. On discharge, basic detail regarding: date/time of discharge; anticipatory crisis planning; referral and wait times for follow up; and transportation is entered into the ABR, then the person is discharged and the bed is automatically made available.

1. Monitoring/Reporting and Evaluating the Service – The ABR generates reports describing: access, timeliness, service utilization, wait times and delays; barriers to transfer decisions; discharge placements and wait times; and estimated costs associated with transportation. These reports form the basis of the evaluation framework for the RAS.

The bed registry requires only basic computer literacy and ample training and support has been provided. The registry is also a tool to contain information required to initiate referrals and support the referral process. For instance, an example of an accurately completed Form 1 is linked to the Facilities page of the ABR, there is a link to a step-by-step guide to using the registry to make a referral, and there is a link to the Ministry forms which may be required.

Appendix 2

Summary Report: Psychiatry on Call

Submitted by Dr. M. Pigeon

This report has to do with what we consider the possible, the best fit in terms of establishing an On-Call system for our Region.

Admittedly this was not the ideal mandate as enounced in the Principals of the Chiefs-of-Staff and the Chief Executive Officers. Yet we are constrained by the reality that the funding of each of the Scheduled facilities cannot be overlapped now. Indeed the Ontario Medical Association is considering funding on a Regional basis. If that were to pass our recommendations could be modified and hence the present recommendations could be seen as a transitional phase. However we would have a functional system while we are waiting.

Given the OMA is developing a new agreement for HOCC funding early in 2008, we will advocate to the Ontario Medical Association in this regard to favour our position.

At present then, the Hospital On Call Coverage stipends are allocated to specific Psychiatrists who sign an exclusive contract to with a specific Schedule 1 facility namely 1) the Orillia Soldier's and Marine Hospital and 2) the Royal Victoria Hospital.

MHCP is not eligible to apply for OMA HOCC funds Though our suggestion is not be fully compliant with the requirements of the original mandate of the On-Call Principals which rests principally on the standard of one single Psychiatrist for the entire Region, we nevertheless would maintain some of its ideals. We would point out that the document itself points to the need to adapt the Principals to the circumstances. And that has been the case in other LHIN’s.

The reasoning has been that if the Huronia District Hospital could be the Administrator of the POC for the Acute Admission Program then we could apply for HOCC funding and attract Psychiatrists to participate in the same requirements as other facilities: intra and extramural consultation which is a step above the present requirements for the Psychiatrists at the MHCP.

In a sense this requires a redefinition of the concept of a Regional Service since each facility would be responsible, groso modo, for its own segment of the Region though the partitions would be somewhat permeable as is necessary and made that much more so because of the Bed Registry which encompasses the entire Region. Therefore all patients would be well served.

Below are principles and conditions provided to the Ontario Medical Association for review and feedback before the application is submitted.

Proposal regarding Psychiatry On-Call Service (POC): Midland/Collingwood (draft)

1. Preamble:

This call schedule is submitted by Huronia District Hospital (HDH) of the North Simcoe Hospital Alliance. Psychiatrists included in the call schedule are employees of the Ministry of Health and Long Term Care at the Mental health Centre Penetanguishene (MHCP). The MHCP provides schedule 1 service to both HDH and the Collingwood General and Marine Hospitals (CGMH). The psychiatrists on the call schedule have privileges to practice at the HDH and CGMH.

2. Principles for the service:

• Telephone consultation to emergency department physicians
• telephone access using a land line; through MHCP – physician-on-call
• The Risk Screening Report¹must be completed by an ER clinician
• Full medical assessment must be completed before the POC is accessed.
• A full Crisis Assessment is preferred, pending availability of a crisis worker to the Emergency Department.

3. Access:

• On-call consultation will be provided to: Huronia District Hospital and Collingwood General & Marine Hospital; RVH and OSMH provide on-call services to other ER’s in the NS-M LHIN
• Access is through the MHCP 1^st on-call physician, who may address concerns that he or she feels are within their scope.
• Due to privacy requirements related to the clinical nature of the consultation, all discussions must occur on a “land-line” not a cell phone. Therefore a turn around time for the POC to return the call to the ERP is 20 minutes.

4. Scope:

• Consultation regarding clinical-legal matters
• Confirmation regarding need for referral/admission
• Consultation regarding clinical management Support for admission of extremely aggressive, disruptive referral

5. Schedule:

• Five MHCP psychiatrists will provide POC on a weekly rotation (will be attached in final version).
• The POC week will begin Tuesdays; holiday Mondays will be equally distributed in the schedule