‘CE to Go’ Building capacity through accredited distance education in Northern Ontario

1. ‘CE to Go’ Building capacity through accredited distance education in Northern Ontario Paula Ravitz MD FRCPC

2. Disclosure: No industry relations

3. With Appreciation • Our team: Robert Cooke, Barb Crawford , Annette Katajamaki, Therese Millette, Scott Mitchell, Paula Ravitz, Scott Reeves, Ana Rogers, Bhadra Sthankiya, Robert Swenson, John Teshima • Our partners: Northern Psychiatric Outreach Program – CAMH; Canadian Mental Health Association northern branch participants, executive directors & small group facilitators; Ontario Psychiatric Outreach Program; University of Toronto Faculty of Medicine CE Office; the U of Toronto and U of Ottawa department of psychiatry faculty; Mae Productions • Funding from: CAMH AFP The Innovation Fund & Ministry of Health and Long term Care

4. CE to Go: Goals • Improve access to professional development by mental health practitioners in underserviced settings • Facilitate dissemination of evidence supported clinical practices for clients with mental illness through the provision of expertise and evidence supported teaching with standardized materials • Foster collaboration between psychiatric outreach consultants & community mental health services through a coordinated knowledge transfer program

5. Desired Outcomes • Indirectly improve mental health of patients in under-serviced communities, by (ii) improving the knowledge and skills of front line mental health workers in areas identified through learning surveys, key informant interviews and consultation requests, via (iii) application of teaching, with (iv) comprehensive mixed evaluative methods

6. Psychiatric services in Northern Ontario • Average ratio of psychiatrists to patients 1:30,000 (Berntson et al, 2005) • Care delivered by inter-professional clinicians • Social workers, nurses, mental health clinicians, MDs – Family physicians and psychiatrists • OPOP – 60 consultants from 6 university-based programs whom provide a LOT of care • Telepsychiatry • Majority of time: direct care

7. Jill E. Sherman Raymond W. Pong J. Robert Swenson Margaret G. Delmege Abraham Rudnick Robert G. Cooke Paula Ravitz Phyllis Montgomery Mental Health services in smaller northern ontario communities: a survey of psychiatric outreach consultants (2010)

8. Capacity Building • An identified objective of outreach to underserviced areas: increase the capacity of local providers to provide appropriate assessment, care, and referrals. • Many consultants do not spend any time providing education and of those who do, 2/3rds provide informal educational activities (65%), and 1/3 provide some formal education (31%).

9. Opportunity to strengthen the education component of outreach • Identified gap and need for the OPOP model to go beyond the delivery of clinical care, to increase local capacity “I think an education/training component is important ... So that there is something in addition left in the community. So that it shouldn't perhaps all be patient‐focused. It should have an education, training focus.” “This survey helped me realize all the teaching I don’t do.”

10. RecommendationsMental Health Services in Smaller Northern Ontario Communities: A Survey of Psychiatric Outreach Consultants Recommendations Response Local capacity building in community mental health providers may result in strengthened support services • develop a tool to aid in prioritizing patients; • strengthen between‐visit support services; • increase the use of education as acapacity building tool; • develop multidisciplinary outreach; • create a sub-specialty support service for northern psychiatrists.

11. THE PROBLEM: • Front-line mental health clinicians who work in under-serviced remote settings, in Ontario and other places…such as Ethiopia, have minimal training yet see ++complex patients • Geographic barriers & time constrains learning of these mental health clinicians • Outreach consultants do little formal teaching yet recognize the potential benefit of building capacity in the communities where we provide outreach clinical services A POTENTIAL SOLUTION: • Increase the educational role of outreach consultants and experts through the creation of distance education materials to support these community agencies and build capacity

13. CE to Go – Methods I • Assembled team & advisory committee • Northern Psychiatric Outreach Program-CAMH CE Committee, CMHA KT Director, Northern Branch ED, Wilson Centre for research in education • Created preliminary “menu” of evidence supported educational offerings from learning needs surveys, informants and consultation requests • Recruited faculty experts

14. Methods IIEvidence based teaching of evidence based clinical practices • Learning needs verified and ranked with CMHA northern branch clinicians and executive directors • Formatted skills-based distance education modules based on CME best-practices : • Oral presentation with power point • SP demonstrations • Case-based, interactive learning guide • Practice reminders • ‘Commitment to Change’ exercise • Mentored local opinion-leader facilitators

15. Methods III • Invited nominations for & recruited opinion leaders • Following REB approval, recruited front-line mental health workers in 7 CMHA branches (north of Parry Sound) assigned to • self-directed v. facilitated small group learning

16. “Opinion Leaders” • A trusted professional colleague whom you would turn to for advice on a difficult clinical matter • Selected those with multiple nominations, verified with executive directors - Community Support Worker - Therapist - Director of Clinical Services - Social Worker/Psychotherapist

17. CONTEXT: Canadian Mental Health Association (CMHA) • CMHA : a national organization, with provincial divisions and local branches in 135 communities across Canada • Provides public education • Does applied research and policy analysis, • Advocates for healthy public policy and an effective and efficient health system

18. SETTING: CMHA Ontario Branches • Provide direct services to 33 communities • case management, supportive housing, social rehabilitation / recreation, employment support, assertive community treatment, crisis intervention, peer support, primary care, health promotion and public education and more... • Clients served include • Youth, adults, seniors with serious mental illness, concurrent disorders, dual diagnosis • Plus families

19. Learning Needs Survey Results (N = 102 from 7 Northern CMHA Branches) 1. What is your Role?

20. Learning Needs Survey Results 2. Please indicate your top 3 choices of topics listed.

21. Learning Needs Survey Results 3. Please indicate your level of interest for each topic.

22. The CE to Go: opening ‘Menu’ offerings

23. The Educational Intervention • Facilitated • All elements of Self-Directed Arm PLUS • Small Group Learning • with Local Champion, mentored by consultant/faculty expert • Self-Directed • Taped presentation with Power Point & captioned simulations • Focus: Skills-based • Learning Guide w/ Case Based Reflection and Practicing Exercises • Practice Reminders • Commitment to Change Exercise

24. A Mixed Methods Design • Pre-Course Measures • Readiness for Inter-professional Learning Scale (RIPLS; Parsell and Bligh) • This 19-item scale is used to explore differences in students' perception and attitudes towards multi-professional learning. • 2.Counselling Self-Estimate Inventory • (COSI; Larson 1992) • 42 self-assessment items measure the clinician’s ability to track, respond and work with difficult patients. • 3.Multiple-Choice Knowledge Questionnaires • (CE to Go faculty; 2010) • 25 MCQ items, some of which are case-based on each topic

25. A Mixed Methods Design • Post-Course Measures • 1.Counselling Self-Estimate Inventory (Larson 1992) • 2.Multiple-Choice Knowledge Questionnaires (CE to Go faculty; 2010) • 3.Commitment to Change Exercise – an intervention and a measure(Fox, Mazmanian & Putnam 1989) • shown to result in greater practice changes from continuing education research • 4.Interviews/Focus Groups with learners

26. Demographics of Learners (N=52)

27. CMHA’s 7 Northern Branches Facilitated Small-Group • Cochrane-Timiskaming (11) • Kenora (8) • Sault Ste Marie (4) • Sudbury-Manitoulin (8) • Self-Directed • Fort Frances (7) • North Bay (3) • Thunder Bay (15)

28. Ari Zaretsky & Mark Fefergrad; Series Editor: Paula Ravitz Ce to go:cbt for depression

29. The Learning Guide ‘Lessons’ 5 hours • Watch the 1-hour presentation • 30 minutes didactic • 3 x ~10 minute captioned simulations 2-4. Watch each of Role Plays #1-3 (one/session) • Questions for Reflection or Discussion • Role plays or exercises • Home work 5. Case-based consolidating session

30. CBT for Depression: Learning Guide example A. Questions for Discussion • Define “hot thought”? List 3 techniques to help a patient identify a hot thought. • What are ways to empathically respond to distress or tearfulness during a session? B. Experiential Tasks • Set an alarm to go off six minutes into the video. At that moment pay attention to and write down your feelings and thoughts. Be thorough. What do you notice? Connection between the thoughts and emotions? C. Homework • Complete the first three columns of the thought record on at least three different occasions when you notice a change in emotion. Attend to what you notice about patterns that may emerge between the three thought records.

31. Pocket Guide of Practice Reminders

32. Future Steps & Opportunities • Modules in various stages of progress • Translation of modules • +/- add modules on other topics or build upon current modules (part II) • Complete evaluation of 1st two modules • Focus Groups Adjust intervention/protocol in response to results • Use parts or whole modules with • differing groups of learners & facilitators including visiting consultants • in differing settings ( i.e. shared care, undergrad, post-grad, CME, inter professional education)

33. Thank you for your attention Paula.ravitz@utoronto.ca