Developing Rapid Access to Concurrent Disorders Treatment

1. Developing Rapid Access to Concurrent Disorders Treatment By: Vivian Demian, MSW, RSW, MBA Program Director for Mental Health Jillian Wirzman, RN, BScN, MS Professional Practice Clinician

3. How it all began? In a 15 month period between 2008-2009 we experienced several suicides within the program (both adults and adolescents). Was this a high number of suicides for a program of our size; 46 Inpatient Beds (36 adult and 10 paediatric) 14 Outpatient Clinics 17 Psychiatrists Over 45,000 visits a year ?

4. Process for Review under QCIPA We conducted an internal Critical Incident Review on each suicide under QCIPA. Director of Quality and Risk Director of Mental Health and Chief of Psychiatry All front line staff (inpatient and outpatient) and Psychiatrist's involved in the patients care. Implemented all Critical Incident Review recommendations. QCIPA review conducted by Director of Quality of Risk, Director, Chief and all front line staff and psychiatrists that were involved with the patient. Recommendations included QCIPA review conducted by Director of Quality of Risk, Director, Chief and all front line staff and psychiatrists that were involved with the patient. Recommendations included

5. External Consultation Sought By March 2009, at the discretion of the Director and the Chief of Psychiatry, Dr. Paul Links, Arthur Sommer Rotenberg Chair in Suicide Studies, St. Michael�s Hospital was sought for an external review. We wanted to get an external perspective on the issue and to ensure that we were doing everything possible to prevent future suicides.

6. Lessons Learned from Dr. Links �There is no reasonable estimate of the number of suicides to be expected in a large mental health program. We do know the number is not expected to be zero as individuals with previous contact with the Emergency Department for suicidal behaviour or previous inpatient admissions are 50-100 times more likely to die by suicide than individuals in the general population.�

7. Lessons Learned from the CIR Inadequate community support for addiction services within Halton. Patients can wait up to 6-months from time of referral to the time they receive services for their substance use/ abuse! Community partners did not feel that they were funded to deal with �crisis referrals� and were not able to prioritize our referrals. OTMH in partnership with our local addiction agency, offered one program for patients with Concurrent Disorders, which was poorly utilized and only offered a 10-week closed psychoeducation group. Staffing for the program was .40FTE (2 days a week)

8. Funding for the MH LHIN for Mental Health and Addiction Services Worst funded LHIN within the Province!!!

9. The Magnitude of the Problem Suicide is a huge global problem WHO estimates 815,000 deaths by suicide in 2000 (increase of 60% over a generation) In Canada, mortality rate per 100,000 = 11.3 17.9 for men 5.0 for women 4,000 suicide victims each year Male to female ratio = 4:1 (Sakinofsky, 2007)

11. Epidemiology of Suicidality in Children and Adolescents Suicide rate for children per 100,000: under 14 = 0.9 15-19 = 12.9 * escalation during middle teens Rates of completed suicide increase markedly in late adolescence and into early 20s as a result of comorbid mood and substance use disorders Adolescent suicide - 90% have an associated psychiatric disorder Most prevalent diagnosis is Depressive Disorders (Steele & Doey, 2007)

12. Risk Factors in Youth Substance abuse is a significant risk factor for completed suicide (Shaffer, et al. 1996; Marttunen, et al. 1991) High prevalence of comorbidity with mood, anxiety and SUD in completed suicide (Power et al., 2003). Link between marijuana use and suicidal behaviour (Rey et al., 2004) (Steele & Doey, 2007)

13. Epidemiology of Suicidality in the Elderly In 2000 Canadians aged 65 years or older completed suicide at a rate of 10.4 per 100,000 (Grek, 2007) 16.9 per 100,000 in men (65-74) to 4.9 per 100,000 in women 22.7 per 100,000 in men (75+) to 2.8 per 100,000 in women This population less likely to volunteer information and require a discussion about their perception on the worth of his/her life (Grek, et al. 2007)

14. The Challenges Diagnosis of Concurrent Disorder was not being captured. The need to develop a Concurrent Disorder Program across the continuum with NO NEW FUNDING! Staff Resistance Community Resistance Standardizing services during a time of crisis A high number of the suicides had a Concurrent Disorder but this was not being capturedA high number of the suicides had a Concurrent Disorder but this was not being captured

15. Addressing Staff Resistance Among people who have� Anxiety disorder in their lifetime, 24% will have a substance use disorder in their lifetime. Major depression in their lifetime, 27% will have a substance use disorder in their lifetime. Bipolar disorder in their lifetime, 56% will have a substance use disorder in their lifetime. Schizophrenia in their lifetime, 47% will have a substance use disorder in their lifetime. Reiger, D.A., Farmer, M.E. & Rae, D.S. (1990) Concurrent Disorders (CAMH, 2009) Resistance of staff Additional workload �we can�t take on any more patients� and �this is not our area of expertise� So the take home message was WE ALREADY SERVICE THESE PATIENTS! Education / training for key front line staff. Suicide risks involved with the Concurrent Disorder population. The most common combinations are: substance use disorders + anxiety disorders and substance use disorders + mood disorders Among people who have had an anxiety disorder in their lifetime, 24 per- cent will have a substance use disorder in their lifetime. Among people who have had major depression in their lifetime, 27 per cent will have a substance use disorder in their lifetime. Among people who have had bipolar disorder in their lifetime, 56 per cent will have a substance use disorder in their lifetime. Among people who have had schizophrenia in their lifetime, 47 per cent will have a substance use disorder in their lifetime. Resistance of staff Additional workload �we can�t take on any more patients� and �this is not our area of expertise� So the take home message was WE ALREADY SERVICE THESE PATIENTS! Education / training for key front line staff. Suicide risks involved with the Concurrent Disorder population. The most common combinations are: substance use disorders + anxiety disorders and substance use disorders + mood disorders Among people who have had an anxiety disorder in their lifetime, 24 per- cent will have a substance use disorder in their lifetime. Among people who have had major depression in their lifetime, 27 per cent will have a substance use disorder in their lifetime. Among people who have had bipolar disorder in their lifetime, 56 per cent will have a substance use disorder in their lifetime. Among people who have had schizophrenia in their lifetime, 47 per cent will have a substance use disorder in their lifetime.

16. FACT! 53% of people diagnosed with a substance use disorder will also have a mental health disorder at some point in their lives. This is close to four times the rate found in people who do not have a lifetime history of a substance use disorder. CAMH Concurrent Disorders Program

17. Training/ Education of Staff St. Joseph�s Health Center, Toronto (Michael Dean) � conducted a 4- half day workshops on understanding addictions, stages of change, Motivational Interviewing, and the current addiction system. � day observation at Withdrawal Management. Dr. Mel Khan, Addiction Medicine Physician and Nadine Smith, Advance Nurse Practitioner presented at our annual Mental Health Retreat. Conducted training on completion of Ministry Assessment Tools. Dr. Alison Arnot, Addiction Medicine Physician with ACDC � CVH presented � workshop on Concurrent Disorders. Wayne Skinner � 2 day workshop for 25 of our staff on Advance Treatment of Concurrent Disorders.

18. Development of the Concurrent Disorders Program- 7 Changes! Crisis Team � Emergency Department Assessment - level of risk. Seeking patients in withdrawal. Motivational Interviewing. COAST form developed. Informing patients that COAST will be contacted if they do not attend appointment. Dr. Links �The availability of the COAST team to follow up on patients that are non-compliant with follow up again is a warranted response to the patients with recent suicide attempts.�

19. Crisis Team Better communication between the Crisis Team and the ambulatory services. We now document on-line and the chart is accessible by the crisis team, inpatient units and the ambulatory services. Crisis contacts ambulatory therapists to advise them of ED visit. Weekly report on wait time for all services. Referral to the Mental Health Urgent Care Clinic.

20. The New Mental Health Urgent Care Clinic Developed in July 2009 Objective � to assessment patients who are deemed a risk of suicide within 7-days of referral and to conduct up to 3 follow up sessions. Psychiatrist sought from within the department and also works closely with the crisis team/ Emergency physician during business hours OUTSTANDING SUCCESS! Decreased repeat ED visits Provides better patient care Avoids unnecessary admissions

21. Concurrent Disorders Program for Adolescents Suicide Clusters of Adolescents in Oakville. 9 adolescent suicides in 3 schools over a 3-year period. At least 5 of the 9 adolescents had a Concurrent Disorder. Partnered with our local Addiction Agency (ADAPT) to run a Concurrent Disorders Group for adolescents being treated by the outpatient clinic. Using the CAMH model �Youth, drugs and Mental Health.� This is a 6-week group that is offered to enhance the current service delivered. Next Step: Offer a psychoeducation group for parents whose youth have a Concurrent Disorder. Chief of Psychiatry worked closely with the Halton School Board to provide education and support to front line staff and administration. Chief of Psychiatry worked closely with the Halton School Board to provide education and support to front line staff and administration.

22. The Bridge to Recovery Program Began in July 2009, the group is intended to bridge clients to other services. We serve those who need support and are awaiting intensive/specialize treatment. Theoretical Approach: Harm Reduction, CBT, Psychoeducational.  Open group occurring twice a week for 1.5 hours for a total of 12 sessions. Clients can attend for as long as necessary. All clients have a case manager to co-ordinate care. Group size is between 3 to 10 people with slightly more women. Topics include the following: Addressing Denial, Managing Cravings and Urges, Relaxation Training, Medical Perspective, Recovery Thinking. The feedback has been positive. �Bridges gave me hope.�

23. Objective of the Bridges Program Access to early intervention.  Assists clients to understand the relationship between substances and mood. Decrease visits to ER and hospitalizations. Allows clients to work towards stabilization and the small group format assists with de-sensitizing clients. Encourages clients to start to consider a recovery focus and work towards establishing a healthy daily structure. Clients have support.

24. Referral and Discharge Process There are many entry points: Emergency Department, In-patient Unit, Outpatient programs, Central Intake, Addiction Medicine Specialist, Health and Hope (Concurrent program) at HHS. Clients are discharged and referred to residential/day programs, Health and Hope, ADAPT, AA, NA, Equilibrium (Mood Disorders Support Group).

25. How Does it Work? Staff work load has not dramatically increased. Groups are facilitated amongst 4 staff. Staff are better equipped to address the addiction component due to ongoing education/training. The population supported in Bridge to Recovery Group are the same client we see in Outpatient services. We have become better at meeting the needs of clients who walk through our doors.

26. Internal Benefit Four staff rotate schedule. Increased contact with other programs/staff. Richer discussion about clients care and better able to address needs because of increase training. Treatment is quickly accessible to the client. Staff feel better equipped to deal with Concurrent Disorder presentation

27. Adult Inpatient Unit Lessons Learned: Imperative to engage patients in Concurrent Disorder treatment at the time of their admission, considering the relapsing nature of the illness, and enhance all opportunities to motivate patients to contemplate change. Educational groups on Concurrent Disorders developed and implemented. Groups are co-facilitated by nurses, OT, OTA and SW. Groups focus on: mental health, addictions, concurrent disorders, stages of change, stigma, recovery thinking

28. Concurrent Disorder Clinician Revamped RN staffing model on adult inpatient unit by decreasing the number of nurses in PICU to 2. Created a Concurrent Disorder Clinician, Master prepared RN, who works with the interdisciplinary team on both adult and child/adolescent units. Detailed assessments (presenting situation, mental health history, medication, patterns of substance use, age at first use, family hx of mh/a, legal concerns, relationships, financial and medical consequences) and recommendations for outpatient treatment. Educates front line nursing staff i.e. safe management of alcohol withdrawal. Completes the Ministry required Assessment Tool for residential treatment.

29. Addiction Medicine Physician Specializes in both pain management and methadone treatment. Very well connected to CAMH for addiction beds. Works very closely with the 4 Psychiatrists who specialize in Concurrent Disorders, and the clinicians. Next Step: Recruiting more Addiction Medicine physicians to work across the inpatient units (medicine, Surg, CCC and Psychiatry)

30. Outcome of Results The Concurrent Disorder Program has provided the �safety net� that was needed for this high risk population. Better communication between the programs and documenting on-line has ensured that all teams are aware of each episode of care provided to the patient. Extensive education for staff has provided them with the level of comfort that they needed to work with Concurrent Disorders population.

31. Thank you�.. Any Questions?