SYMPOSIUM ON NEW APPROACHES
TO RESIDENTIAL TREATMENT
Strengthening Children’s Mental Health
Residential Treatment through Evidence and
Experience
Residential Symposium October 26, 2015
Why now?
Kinark’s long history and investment in residential treatment Commitment to continuous quality improvement and value
for money
Emerging research on efficacy of residential treatment MOMH and CYMH Transformation
A costly and intrusive service that has evolved over many years in the absence of a policy framework and a provincial or local service plan
Absence of global standards for clinical quality, performance measures and outcome measures
To what end?
Influence policy makers
Engage cross-sectoral providers and partners
Set new direction for residential treatment within the agency and contribute to setting a new direction across the service system
How we got there...
Extensive literature review
Internal and external consultation Client feedback/input
Integration of evidence and Kinark experience
What we learned…
Significant body of research relevant to the provision of residential treatment
Kinark’s experience of residential treatment over the last several decades is a microcosm of the sector’s experience System change required at both policy and service
framework levels
Program change required Critical Success Factors
Why we need critical success factors…
By definition are essential to the success of an initiative Provide a common reference point for everyone involved Articulate what’s important
How we identified the critical success factors Extensive review of best practice and research
Clinical alignment with the needs of children and youth with complex mental health issues
Consistent with Kinark’s mission and values
Consistent with Kinark’s staff’s experience of “what works”
Critical success factors 9 Critical Success Factors Clearly defined eligibility and suitability criteria Family-centered care Strong and cohesive inter-professional staff team Mimimizing physical interventions Cultural and linguistic competence Individualized and appropriate programming to match the needs of youth Seamless transition and integrated aftercare Connected residential and community partners in care Performance measurement
#1
Clearly defined eligibility and suitability criteria
• Treatment of children and youth should be first
attempted in the least restrictive and most natural setting possible. Residential treatment should be reserved for those who present with highly complex needs unable to be met in a less intensive and less intrusive setting.
• A tiered mix of residential treatment programs • Seamless step up and step down movement • Clearly defined program characteristics
• Clearly defined eligibility/suitability criteria • Standardized assessment framework
#2
Family-centered care
• The most effective treatments for children and youth
require some level of family involvement. Active family engagement in all aspects of the residential treatment program is paramount.
• Family contact maximized
• Families active participants in both treatment planning and intervention
• Strengthening transition and after-care preparation and support
#3
Strong and cohesive interprofessional staff team
• Evidence-based treatment should be carried out by
an interprofessional team that is knowledgeable,
collaborative, nurturing, skillful, and does not exhibit harmful conduct that may serve to re-traumatize
those who are most vulnerable.
• Appropriate training, supervision, and support is paramount for all front-line staff
• Clear roles and responsibilities
• Child and adolescent psychiatrists • Behaviour Therapists
• Nurses • Social Workers
• Psychologists • Educators • Child and youth workers
#4
Minimizing
physical interventions
• Residential treatment settings should create a safe
and nurturing environment where seclusion and restraint are only to be used in situations when
alternative, less restrictive interventions have been unsuccessful in promoting safety.
• Restraints should be the minimum required, applied for the minimum time possible
#5
Cultural and linguistic competence
• Residential settings need to be competent in serving
the diverse cultural and linguistic needs of the children and youth so they feel welcome,
understood, accepted, and safe.
• Practitioners must develop the necessary attitudes, skill, and knowledge base
• Policies and procedures must be developed • Investment in culturally diverse staff
#6
Individualized and appropriate
programming to match the needs of youth
• A standardized assessment framework is required to
identify the appropriate individualized treatment requirements unique to each child and youth,
aggressively targeting factors that will swiftly facilitate community reintegration, within a
treatment milieu that is structured, strengths-based, and youth-guided.
• Milieu-based interventions grounded in sound theory • Engage the child or youth in shared decision-making
#7
Seamless transition and integrated after-care
• Preparation for transition out of residential
treatment is an essential element of the individualized treatment plan and includes
integrated after-care that supports family/caregiver reunification and community re-integration.
• Transition planning to occur at onset of treatment • Commitment from community partners and the
care-giving system
• Funding required for transitional supports and integrated after-care needs
#8
Connected residential and community partners in care
• Residential treatment is a component within a
continuum of care that needs to integrate with
programming offered by community partners, with an identified primary care provider responsible for the coordination of services and the overall treatment plan.
• Residential treatment is ideally used as a targeted, short-term, and intensive intervention and support option
• Triage to less restrictive
• An integrated treatment plan requires the cooperation and coordination of various systems
#9
Performance measurement
• To ensure that services and interventions for
children and youth in residential treatment are effective, it is imperative that service providers develop and implement systems for defining and measuring organizational performance and client outcomes.
• Performance at both the organizational level and the person level should be measured
• A common set of performance indicators across the residential treatment sector
Where to from here…
Previous initiatives to strengthen the residential
treatment system have not resulted in significant change Significant public resources currently invested in a system
that has evolved in the absence of a comprehensive plan Identification of critical success factors provide a
roadmap for system review and change
Proposing two areas for action going forward
Where to from here…
20
Introduction of a multi-tiered system of residential services
Fifth
Fourth
Third
Second
First
Residential Treatment for
Mental Health Standard Residential Care
Secure treatment, child and adolescent hospital inpatient
Level 4 children and youth
Step up/step down treatment
Level 3 and 4 children and youth
Treatment: Interprofessional team
Level 3 children and youth
Treatment: Consultative services
Level 3 children and youth
Group Care
Level 1 and 2 children and youth
Second Third Fifth Fourth First Second Third Fourth Fifth
21
Expense and intrusiveness of residential treatment
Right service for the right kids at the right level
Range of evidence-informed alternatives to residential treatment
Kinark’s Durham experience
Alternatives to Residential Treatment MST Wrap-around FFT BSCT MTFC ACT
Alternatives to residential treatment
22 Critical Success Factors Clearly defined eligibility and suitability criteria Family-centered care Strong and cohesive inter-professional staff team Mimimizing physical interventions Cultural and linguistic competence Individualized and appropriate programming to match the needs of youth Seamless transition and integrated aftercare Connected residential and community partners in care Performance measurement Summary Fifth Fourth Third Second First Alternatives to Residential Treatment MST Wrap-around FFT BSCT MTFC ACT
Critical success factors
ENVISIONING a FUTURE SYSTEM of
RESIDENTIAL CARE
About CMHO
• CMHO works to develop solutions to important policy issues
affecting the child and youth mental health sector.
• We represent close to 100 accredited child and youth mental
health centres across the province that provide treatment and support to children, youth and families.
• We directly connect youth to our policy work via our New
Why Focus on Residential?
• Residential treatment a crucial component of the children’s mental health system
• Service providers identified the system is in some degree of crisis
• CMHO members have a shared commitment to build an effective and affordable system
Residential Policy Work
•
Steering Committee to guide the work:
– Cathy Paul, Chair (Kinark Child & Family Services)
– Josée Belanger (NEOFACS)
– Mary Broga (Hôtel-Dieu Grace Healthcare)
– Kathy Neff (Roberts/Smart Centre)
– Debbie Schatia (Turning Point Youth Services)
Design of the Environmental Scan
• Surveys, focus groups, in-person meetings
• Reached more than 130 participants:
– More than 80 Executive Directors of children’s
mental health centres.
– 16 strategic stakeholders and partners
– 11 frontline workers
– Numerous parents and families
External Partners / Stakeholders
• Canadian Mental Health Association
• Centre for Addictions and Mental Health
• Centralized Access to Residential Services
• Centre of Excellence for Child and Youth Mental Health
• Mental Health Commission of Canada
• Ontario Association of Child & Adolescent Inpatient Psychiatry
• Ontario Association of Children's Aid Societies
• Ontario Association of Child Rehabilitation Centres
• Ontario Association for Residences Treating Youth
• Ontario Residential Care Association
• Ontario Shores Centre for Mental Health Sciences
• Provincial Advocate for Children and Youth
• Provincial Council for Maternal and Child Health
• Pine River Institute
• The Family Navigation Project
Findings – General Themes
• Need for a system-wide plan
• Residential services should be part of a treatment
plan – not a ‘last resort’
• Treatment plans and placements must be matched
to needs
• System must align with other sectors and have
FUTURE MODEL OF COMMUNITY-BASED CARE FOR
Ability to Adapt
• Particular cohorts of children, youth and families:
– Comorbidity
– Transitional-aged youth
– Young parents and infants
– Families with exceptional needs
– Geographically disperse / remote
Key Enablers
• Ongoing case management
• Outcome measurement
• Inter-disciplinary teams and expanding scopes of practice
• Consistent and high-quality ongoing training
Next steps
• Obtain broad alignment from all parties on the
common goals and future direction of our residential treatment sector
• Work towards the development of policy
recommendations for government to guide system reform
SYMPOSIUM ON NEW APPROACHES
TO RESIDENTIAL TREATMENT
Elements of a future system of care
for youth with serious mental illness
Anthony Levitt, MD
Medical Director, Family Navigation Project; Chief, Brain Sciences Program,
Sunnybrook Health Sciences Centre. Professor, Department of Psychiatry, University of Toronto.
The Family
Na
>
igation Project
Living with mental illness or addiction is hard, getting help shouldn’t be
What the FNP does
• Phone and email based free service
• Families/caregivers of youth 13-26 in the GTA with mental illness and/or addiction.
• Clinically trained and experience Navigators with Medical (Psychiatric) involvement in all cases
• Resource matching, case-management, no time limit
Why families?
• Importantly,
– Families/caregivers are most often the drivers of health care seeking and behaviours.
– Families are the guardians of important medical and family history information.
– Families are often the only, or at least, the most valuable (if complicated) way of monitoring for progress of treatment.
• However,
– Families are often left out of treatment planning because
• Privacy issues
• It takes extra clinician time, or time away from care of the identified client
• Families/caregivers can add to the complexity of care
– They are not fully objective and may have their own mental health or addiction issues
Why do families seek our services?
Don’t understand mental illness/addictions, not sure if their youth needs help (15%)
Know their child needs help, but cant figure out a way into the system (15%)
In the system (70%),
• but cant figure out how to advocate for their loved one
• know how to advocate, but not getting the help they need
• getting the help, but multiple resources not coordinated
• help available, but cant get their youth to attend or follow up
• youth willing, but exhausted all possible local resources
Who we serve
• 850 families navigated in past 18 months
• Youth aged 13-26; median age 19
• 48% mental illness only, 50% concurrent
• To do this we have:
– 7 full time navigators, Medical Director, Program Manager, Intake Worker/Admin assistant
• Wait time from first contact to Intake screen = 1 business day
• Wait time from screen to contact with Navigator = 2 business days
• 95% of clients we find local resources
• 85% of these resources are publically funded
Family perspective
“
Residential services became the
only solution; we ended up
sending our child there because we
had no other solution.”
System Issues for complex cases
Entry
• Lack of easy identification of where specialized care exists
• Insufficient programing for certain conditions
– E.g. Concurrent disorders, Borderline PD, OCD, Dual disorders
with acute mental health issues
Transition
• Inconsistent assessments leads to communication and continuity issues
• Lack of coordinated case management
• Criteria for movement between levels are not clear
After care
• Comprehensive or “wrap around”/co-ordinated after-care programs rare or non-existent
The Continuum of Mental Health
Services
Taking the Next Step Forward:Building a Responsive Mental Health and Addictions System for Emerging Adults.
(2015) Mental Health Commission of Canada.
$
V o l u m e sLooking towards a future state:
• Residential treatment is a key part of the continuum of
care
• Residential treatment needs to be rational and
intentionally targeted at youth with complex needs
– Accommodation (with various levels of supervision and
outside programming)
– Care (support, group programming etc)
– Treatment (intensive psychotherapy, with or without
medical care)
• Standardized Assessment with clear entry, “course correction”, and exit criteria
Looking towards a future state:
Examples of innovation
– Mayo’s CAAMP – families & youth in residence
together
– Victoria, Australia – inpatient facility where
families are “admitted” together with youth
SAMHSA Consensus IOP for Adults:
“We had no idea what
was available and what
to expect. We didn’t
even know what
SYMPOSIUM ON NEW APPROACHES
TO RESIDENTIAL TREATMENT
Kathy Neff
Roberts/Smart Centre
youturn Youth Support Services
Developing a System-Wide Residential
Approach: the Ottawa Experience
Building on a History of
Collaboration
• System of Care Practice Review (SOCPR)
• High Risk Youth Initiative
• Ottawa Mental Health Service Collaborative IPC
• Child Adolescent Needs Strengths(CANS)
Current System Challenges
• Child Protection challenges
• No latency aged residential beds
• Secure Referrals that “almost” fit – Step Up
• Lack of transition out of secure treatment –Step Down
• Lack of Psychiatric consultation
• Waitlists
• OPR’s taking out of province youth
• Difficulty in accessing specialized services in French
Impetus for change?
• Children’s Hospital of Eastern Ontario
• Residential Crisis Unit
Current Residential System
• Roberts/Smart Centre: Secure Treatment 8 beds;
Long Term Treatment 5 beds; Long Term Treatment Fee for Service 10 beds
• Youth Services Bureau: Residential Crisis 8 beds
• Royal Ottawa Health Care Group: 8 inpatient
beds for youth 16 and over
• CHEO: 19 inpatient beds for short term treatment
and stabilization
Ottawa Service Continuum for
High Risk Youth
• 4-6 beds (3CIC+2TP) • 30-90 days • Transitional Support • Family Counselling • 6-8 beds (4CIC+2TP) • 90 days (3-4 months) • Transitional Support • Family Counselling
• Residential Crisis Beds (4)
• Residential Treatment beds (3CIC+5TP) RSC
• Secure Treatment beds (8) RSC • Transitional Support RSC • Crisis Line (YSB) (access to
crisis beds)
• Mobile Crisis Team (YSB)
• Case Mgt and Transitional Support (YSB) Crisis Services Residential Services Step Up Services Step Down Services
Crisis Services
Regional Crisis line Mobile Crisis Team Case management Transitional support
Residential Services
• Crisis beds both sort term 3-5 days and long term 30 days stabilization-
• Long Term residential treatment 6 months
• Secure treatment- goal is stabilization in 180 days
• Transitional support
Step Up
• New program
• Specifically to respond to youth in crisis who do not meet all the criteria admission into secure
• Will allow youth to come out of the hospital
• Focus on stabilization
• Family involvement is crucial
• Family nights held weekly to increase peer support and reduce isolation of families
Step Down
• Crucial to move youth as soon as possible out of the secure environment
• Goal to consolidate gains and move to a more normalizing environment
Protocols to Support Transition
• Pathway Protocols essential amoung both core and allied partners
• Build on the high levels of collaboration that exist between current partners – IPC
• Increasing need for more integration and perhaps some shift in service to respond effectively
SYMPOSIUM ON NEW APPROACHES
TO RESIDENTIAL TREATMENT
Mary Broga
Hotel Dieu Grace Healthcare
Regional Children’s Centre
Former Model of Residential
Treatment
• Treatment of choice in late 70s and early 80s
• RCC – pre-adolescent – 14 Beds
• Maryvale – 7-17 – 54 Beds
• Child focused – goals for child not family
• Discharge dependent of resolution of all
child’s issues – not unusual for 2-3 years in program
Impetus for change
?
• Progress on goals occurred most in first 6 months then declined
• Gains made in program did not transfer when child returned home
Impetus for change?
New learning
• Attachment theory
• Family preservation models
Where residential treatment fits
• Part of the continuum of intensive services which include in-home, day treatment, 8-8 program, and overnight care
• Question: Why the child is sleeping overnight- what goal is it trying to achieve?
• Residential treatment – Intensive Care Unit (ICU)
New Model of Care
• 6-17 years with significant emotional & behavioral
needs
• Needs cannot be met through other forms of
treatment
• Temporary removal from community school, and for
some, their home for an intensive treatment program
New Model of Care
• Distinctions clearly drawn between residential treatment versus care
• Less disruptive approaches to treatment must have already been implemented
• Most children/youth return home every evening
• Move to less intensive treatment at earliest possible time with transitions well planned
New Model of Care
• Educate and work with the families to strengthen the
family environment in treatment programs designed for them (in-home, outpatient)
• Resulted in increased family participation
New Model of Care:
Family Learning Place
• 16 bedrooms – one for every child with a maximum of 6-8 children staying overnight
• Day treatment
– 8am – 8pm
– School hours
• Family nights held regularly to increase peer support and reduce isolation of families
New Model of Care: Maryvale
• Acute inpatient psychiatric admission for (7 to 17)
• 2 residential beds
• Day treatment
– half day school and half day treatment
– full time - after school mental health respite
Family Assertive Community
Treatment (FACT)
• ACT developed for patients with the most challenging and persistent mental health issues
Family Assertive Community
Treatment (FACT)
• For situations where there is insufficient grounds for apprehension by CAS but they continue to
monitor and provide support.
• Mental health staff and child welfare staff
become FACT team to provide home and
SYMPOSIUM ON NEW APPROACHES
TO RESIDENTIAL TREATMENT
Roundtable Discussion Part 1
Critical Success Factors in Residential Treatment
(10 Minutes)
Developing a Future Model of Care for Children & Youth With Complex Mental Health Needs
Roundtable Discussion Part 2
Intensive Non-Residential Treatment
(20 Minutes)
A Multi-Level or Tiered Approach to Residential Treatment
(20 Minutes)
After-Care Supports for Children & Youth Leaving Residential Treatment
(20 Minutes)
SYMPOSIUM ON NEW APPROACHES
TO RESIDENTIAL TREATMENT
