Champlain LHIN Inpatient Mental Health & Addictions Capacity Plan

Current State Report

21 August 2017

CHAMPLAIN LHIN INPATIENT MENTAL HEALTH & ADDICTIONS CAPACITY PLAN CURRENT STATE REPORT

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...... 4

EXECUTIVE SUMMARY...... 6

1. CONTEXT ...... 15 1.1 Project Overview ...... 15 1.2 Project Scope...... 15 1.3 Project Approach & Methodology ...... 16 1.4 Key Definitions ...... 18 1.5 Data Limitations ...... 19

2. CURRENT STATE ASSESSMENT ...... 21 2.1 Description of the Champlain LHIN ...... 21 2.2 Inpatient MH&A Capacity ...... 22 2.3 Related MH&A Programs and Services ...... 31 2.4 Leadership, Governance, and Culture ...... 32 2.5 Regional Need for Service ...... 35 2.5.1 Prevalence of Mental Health ...... 35 2.5.2 Projected Future Need ...... 36 2.6 Service Delivery ...... 37 2.6.1 Service Volumes ...... 38 2.6.2 Patient Profile ...... 40 2.6.3 Reason for Admission...... 48 2.6.4 Occupancy Rates ...... 54 2.6.5 Service and Operations ...... 58 2.6.6 Use of Technology ...... 60 2.7 Patient Flow ...... 62 2.7.1 Entry and Admission ...... 62 2.7.2 Patient Flow ...... 72 2.7.3 Discharge ...... 74 2.7.4 Conditions Best Managed Elsewhere...... 77 2.7.5 Community Capacity Impact ...... 81 2.8 Access and Equity ...... 82 2.8.1 How equitable is access to inpatient MH&A Services? ...... 83 2.9 Quality ...... 85 2.9.1 Readmission Rate ...... 85 2.9.2 Incidents and Restraints ...... 91

2.9.3 Patient Outcomes ...... 92 2.10 Efficiency ...... 94 2.10.1 Service Costs ...... 94 2.10.2 Service Efficiency ...... 98 2.11 Health Human Resources Utilization ...... 100 2.11.1 HHR Capacity and Resource Mix ...... 100 2.11.2 Scope of Practice ...... 104

3. JURISDICTIONAL SCAN AND BEST PRACTICE SUMMARY ...... 105

4. APPENDIX ...... 116 4.1 LHIN Demographic Profile ...... 116 4.2 Champlain Inpatient Mental Health and Addiction Programs and Services ...... 119 4.3 Patient Acuity Measures ...... 130 4.4 Admission Diagnosis ...... 135 4.5 ALC Destination Waiting for by Hospital, Last FY ...... 140

Acknowledgements

This report has been prepared on behalf of the Champlain Inpatient MH&A Service Capacity Plan Steering Committee. The committee is acknowledged for its dedication and thoughtful direction of the process. The Steering Committee members are listed below.

Steering Committee Membership:  George Weber, The Royal Ottawa Health Care Group, Co-Chair  Bernard Leduc, Hôpital Montfort, Co-Chair  Raj Bhatla, Chair Champlain Inter-Hospital Committee  Barbara Casey, Children's Hospital of Eastern Ontario  Jacinthe Desaulniers, Réseau des services de santé en français de l’Est de l’Ontario  Jeanette Despatie, Cornwall Community Hospital, Interim CEO Brockville General Hospital  Heather Garnett, The Ottawa Hospital  Kathy Gillis, Chair Department of Psychiatry  Marc LeBoutillier, Hawkesbury & District General Hospital  Alex Munter, Children's Hospital of Eastern Ontario  Pierre Noel, Pembroke Regional Hospital  Tom Schonberg, Queensway Carleton Hospital  Frank Vassallo, Kemptville District Hospital  Kevin Barclay, Champlain LHIN, Senior Health System Integration Specialist

The OPTIMUS | SBR Project Team:  Terri Lohnes  Andrea Spencer  Rachel Steger  David Lynch  Glenna Raymond  Janice Dusek  Jacquie Dale  Guy Théroux  Nathan Duyck  Lindsay Martin

The following individuals, organizations, and groups are acknowledged for their participation in the stakeholder consultation process.  People with lived experience  Psychiatric Survivors of Ottawa  Parents' Lifelines of Eastern Ontario

 Ottawa Police  Ottawa Paramedic Service  Indigenous Health Circle Forum  Champlain Inter-Hospital Committee  ACTT/FACTT-DD  Champlain Crisis Teams  Champlain Primary Care Working Group  Addiction and Mental Health Network Champlain  Member hospitals of the Champlain Association of Small Hospitals  CMHA Ottawa and other Community MH&A Providers  Montfort Renaissance  Salus Ottawa  THRIVE

The contributions from the participating organization’s administrative, clinical, and decision support teams at each hospital and the Champlain LHIN are also appreciated, in particular to:  Andrew Bonner, The Ottawa Hospital  Mitsi Cardinal, The Royal Ottawa Health Care Group  Sonia Dicaire, Hôpital Montfort  Barb Fisher, Children's Hospital of Eastern Ontario  Robyn Griff, The Royal Ottawa Health Care Group  David Hesidence, The Royal Ottawa Health Care Group  Henna Hussain, The Royal Ottawa Health Care Group  Heather Mallon, The Royal Ottawa Health Care Group  El Mostafa Bouattane, Hôpital Montfort  Coralee Purdy, Queensway Carleton Hospital  Brian Schnarch, Champlain LHIN  Gamil Shahein, Pembroke Regional Hospital  Rhiannon St. Pierre, Cornwall Community Hospital  Ellen Whittingham, Queensway Carleton Hospital

Executive Summary

Context

In response to the objectives outlined in the Champlain LHIN’s Integrated Health Services Plan 2016-19, and in recognition of the need to continue to improve access to inpatient mental health and addiction services, the Champlain LHIN convened a Steering Committee to develop an Inpatient MH&A Capacity Plan. The Steering Committee was led by Co-Chairs, George Weber, CEO of The Royal Ottawa Healthcare Group, and Bernard Leduc, CEO of Hôpital Montfort and membership included:  Representation from each hospital with inpatient MH&A beds  Representations from small, rural, and community hospitals that refer into the inpatient MH&A system;  Representation from the University of Ottawa Department of Psychiatry;  Representation from the Réseau des services de santé en français; and,  Representation from the Champlain Mental Health Inter-hospital Committee.

The focus of this Steering Committee was to develop a Capacity Plan for inpatient mental health and addiction services being provided across the Champlain LHIN by schedule 1, schedule 2/3, and specialty facilities. The specific goals of the project were to increase efficiency, effectiveness (e.g. patient and family experience), and flow across identified hospitals and inpatient programs with limited additional financial investment.

Success for the Capacity Planning project was defined as:  A deeper understanding of the capacity of the current inpatient mental health and addictions system to meet demand, both now and into the future.  A clear path forward for how the Champlain LHIN can better integrate mental health and addictions services for better outcomes and value, informed by local needs, including other LHIN-wide initiatives and the needs of priority populations.  Ownership by key staff, medical leadership, hospital leadership, and the LHIN for the recommendations to improve the capacity of the local inpatient mental health and addictions system.

Purpose and Scope of this Document

This document presents the Current State Assessment of Inpatient MH&A service in Champlain LHIN. While a comprehensive view of the MH&A system in Champlain LHIN and Ontario can be construed broadly (and appropriately) to include elements of outpatient, community and primary care as well as social services and even justice services, the scope of this review is designated hospital inpatient MH&A services. However, the resulting Capacity Plan must be situated within

the context of the larger MH&A system to be effective and recognize the entire MH&A continuum of care, especially how other parts of the system impact the use of and need for inpatient services. Therefore, the capacity of services delivered in the community (primary care, outpatient services, community providers, emergency department) were not measured but were considered as they relate to inpatient system inflows and outflows. This limited scope is the starting point for MH&A system planning, as mandated by the Steering Committee, with the intent on applying insights gained to future MH&A planning initiatives.

Process Undertaken

The Steering Committee and OPTIMUS | SBR completed the Capacity State Assessment between February and June 2017. The approach included extensive stakeholder consultations with over 200 MH&A system stakeholders, including those with lived experience; secondary data analysis and a jurisdictional scan and best practices review.

Current State Summary

Inpatient MH&A Programs

Inpatient MH&A services in Champlain LHIN are delivered by seven (7) hospitals across eight (8) sites. There is a mix of general acute adult MH&A beds, pediatric MH beds, as well as specialty programs focused on certain patient populations and diagnoses (both adult and pediatric).

Each hospital with inpatient MH&A services offers various inpatient mental health and addiction programs. The region has a number of programs including:  General Acute Psychiatry: Psychiatric intensive care/observation, stabilization, psychiatric assessment, diagnosis, treatment and discharge planning for those with acute mental illness (including crisis).  Crisis: Provides short-term specialized diagnostic clarification, assessment, treatment, and stabilization of persons experiencing an acute mental health crisis episode.  Mood: Inpatient assessment and treatment for patients with recurrent, chronic treatment resistant and co-morbid mood disorders.  Forensics: Provides specialized assessment, treatment, and rehabilitation for adults with severe psychiatric illness who have come into conflict with the criminal justice system.  Geriatric: Provides care for patients over the age of 65 (or younger patients living with Alzheimer’s or Frontotemporal Dementia) with severe multiple and/or complex psychiatric illnesses.  Schizophrenia: Specialized treatment and care to individuals with diagnoses of treatment resistant schizophrenic related illness with comorbidities or psychosis.  Children and Youth: Serving children and youth who are experiencing an acute mental health crisis.

 Recovery: Serves those with severe mental illness (SMI) in developing recovery goals and skills to meet them using the Illness Management and Recovery (IMR) Model, an evidence-based psychiatric rehabilitation practice (© 2011 by Dartmouth and Hazelden Foundation).  Eating Disorder: Inpatient eating disorder programs for pediatric and adult populations.  Substance Use: Medical detoxification (alcohol) and/or stabilization on opioid agonist therapy for patients with severe substance use disorder who cannot be stabilized as an outpatient.  Concurrent Disorder: Provides integrated and specialized stabilization, assessment, diagnostic clarification, and treatment services to clients with co-morbid severe, complex, active and symptomatic substance use and mental health disorders.

Inpatient MH&A Bed Capacity:

There are 423 inpatient MH&A funded beds in operation in the Champlain region including pediatric and specialty beds. Overall, the greatest capacity exists at the Royal (210) followed by The Ottawa Hospital (87) and Montfort (46). Of the beds used for general acute care specifically, the greatest capacity of funded mental health and addictions beds is at The Ottawa Hospital (81), followed by Montfort (38), and Queensway Carleton (24). There are a number of specialized program-specific beds located at The Royal, CHEO, The Ottawa Hospital and Montfort.

Table 1: Champlain LHIN Inpatient Mental Health and Addictions Beds by Type and Facility1

Source: Reported by Individual Hospitals

1 Please note that the 6 eating disorder beds at the Ottawa Hospital are not fully funded. The 12 bed concurrent disorder unit at The Royal only operates 5 days a week with patients going home on weekends and are hospital-based residential beds. These beds are funded from the Community MH&A stream (the same envelope as other residential addictions beds offered by addictions treatment centres in the LHIN), not from Global funding. Additionally, bed totals do not include unfunded MH&A beds that may be periodically used to address urgent bed pressures or funded beds for which there is physical space but are not operational. The Royal’s 210 beds mentioned in the IP Capacity report encompass only approximately half of the inpatient services the Royal offers. Additional beds are used to provide services at The Royal Ottawa Place LTC facility (64 beds). The Royal operates a unique partnership with the Provincial Ministry of Community Safety and Correctional Services through the St. Lawrence Valley Correctional and Treatment Centre (Secure

Overarching Findings Themes: The detailed Current State Report below outlines the overall capacity of the inpatient MH&A system. It also outlines how that current capacity is used and the resulting experience and outcomes for patients, families and providers. Throughout the Current State assessment, a number of key themes emerged which are categorized in the graphic below. Observations in these areas have a number of implications for how the inpatient MH&A system operates and have significant impact on patient experience, providers, and overall value to the system.

Figure 1Current State Themes and Opportunities

Leadership, Governance & Culture

Equity & Access Flow Service Delivery

Health Human Resources

Treatment Unit) which includes 100 Schedule 1 beds and a 59 bed Forensic Treatment Unit at Brockville Mental Health Center. The Royal also operates 183 beds in Homes for Special Care across the region.

Leadership, Governance & Culture: Leadership, governance and culture includes the structure of the system, accountability structures and mechanisms, focus and direction of leadership, and the behaviours and attitudes exhibited by system stakeholders. The key observations in this category have broad and significant implications on the entire system, including many of the other key theme areas identified above. As a result, addressing the key findings and observations in this area will also have broad impact on the entire system including equity and access, flow, service delivery and health human resources.

Observations Implications  No regional governing or oversight body that  Regional variation in the capacity and use of holds the MH&A system accountable for Health Human Resources and inpatient MH&A delivering coordinated and effective services service delivery. across the continuum of care.  Limited awareness and communication across  Variability in the level of trust between inpatient the continuum of care (inpatient, outpatient, care providers and community care providers. community, and primary care) lead to challenges  Forums exist for collaboration and relationship managing patient flow as well as the provision of building among the inpatient system; however, coordination of person-centered care across the there are limited formal partnerships or continuum. oversight.  Political dynamics and territorial behaviours  Lack of clarity of roles and responsibilities across (clubs of patients) by organizations impact hospitals and the continuum of care, especially patient access and flow and impede trust and clear definitions of which providers should be communication between different system providing what levels/types of care (specialty vs providers and result in sub-optimal use of acute vs primary). inpatient resources.  Organizational silos, both within and between  Leadership focus on the advancement of sites, due in part to funding, capacity challenges individual sites and programs and the specific and differences in operating mechanisms and part of the care pathway they provide rather system. than a holistic view of the patient.  Successful implementation of Regional Programs  Perceptions that there is an imbalance of in other disease areas as well as specific influence and equity in system planning initiatives in MH&A. discussions with a focus and emphasis on the Urban-Ottawa region with less influence and understanding of the needs and barriers of smaller and more rural communities.

Equity & Access: Equity and Access includes whether people in Champlain are able to receive high-quality, appropriate and timely inpatient MH&A service and care that is fair and appropriate to them and their needs, no matter where they live, what they have, or who they are.

Observations Implications  Patients and those with lived experience indicated  Challenges for specialized clinical populations to that the MH&A services they received varied access appropriate care environments can depending on where care was accessed across the contribute to ALC, suboptimal outcomes, poor Champlain region. experiences, and unsafe work environments.  Perceptions by patients, families and providers  Francophone – Montfort is the only facility that that the only/easiest way to get MH&A support is offers full Francophone service and milieu. Most through a MH crisis and entering the system Francophone patients access services at Montfort; through the ED. The ED is the primary entry point however, a large number access care at other into the inpatient MH&A system, in 2016/17 there hospitals with varying levels of French language were approximately 5560 ED visits that resulted in services and lack of a francophone milieu. direct admission to a site with inpatient MH&A  Indigenous – Providers identified that there are beds representing 79% of the region’s MH&A opportunities to enhance the relationships admissions. between Indigenous communities and hospitals to  Populations with limited/no service options due ensure effective transitions for Indigenous to program inclusion/exclusion criteria: patients as well as the provision of culturally o Neuropsychiatric disorders appropriate care. Challenges with transitions o Acquired brain injury between inpatient and outpatient/community are o Autism without intellectual disability compounded by lack of culturally-appropriate o Concurrent disorders programs and supports. o Dementia  Rural Communities – Most specialized inpatient o Involvement in criminal justice system programs and some acute programs must be o Other medical comorbidities accessed far from home. This is compounded by o Lack of housing support lack of community programs and supports to treat  Populations with limited access to appropriate inpatients in the community resulting in increased patient service programs/environments: used of inpatient resources. o Dual diagnosis  Pediatrics and Youth – Capacity gaps were o Neuropsychiatric disorders identified for specialized treatment programs for o Medically complex geriatric psychiatry pediatric populations (e.g., addictions) as the only  Socioeconomic, demographic and cultural factors treatment program is for eating disorders. impact access to care options Transitional aged youth were also identified as a o Financial barriers for therapy high needs population who require support as o Transportation barriers for acute and they transition to the adult system. The strategic specialized services partnership between CHEO and The Royal is o Gaps in culturally appropriate care for currently making progress to support better Indigenous populations transitions, but there are further opportunities to o Variable access to French language services ensure effective supports and transitions. and care milieu  Specialized clinical populations have access challenges and cause ALC rates due to capacity gaps and/or eligibility.

Flow: Patient flow includes entry into the system, as well as movement within the system and finally discharge and transition out of the system. These all represent significant pain points and can impact outcomes, patient experience and system efficiency.

Observations Implications  Patient, providers and the data suggest that the  Patients are not entering the inpatient system ED is the primary entry point into the inpatient through the most efficient and patient-centered MH&A system because access through other entry path (coordinated direct referral) and are often points is too challenging. entering in crisis.  Inpatient units are facing different levels of flow  Hospitals are not managing capacity and flow at a and capacity challenges across the region, system level and are developing local although there are high levels of variability within workarounds and quality improvement initiatives sites, especially during surges. Unit occupancy to address capacity pressures that are not scaled levels range from 71% at Pembroke to 108% at broadly. Ottawa General. When ED holds and off-service  Patients are experiencing long wait-times to are included, occupancy ranges from 72% at access community/specialty programs resulting in Pembroke to 114% at Ottawa General. longer stays in inpatient setting and poor  Patients are not effectively transferred throughout transitions between inpatient and the community the system to use available capacity and ensure because patients often are not able to access patients are accessing the right level of service. resources. ALC rates are better than the provincial average,  Hospitals are faced with ALC challenges in however there is a lot of variability between sites inpatient units which act as a barrier to patient with quarterly rates ranging from close to 0% up flow and prevent patients from accessing the most to a maximum of 24.4% since 2012. Additionally, appropriate level of care based on their needs. providers qualitatively identified that patients often wait in designated MH&A beds for a different level of care (acute waiting for specialty).  Capacity of outpatient and community-based services and supports for MH&A patients are limited resulting in increased demand for inpatient services: o Lack of integration and coordination of services between many inpatient and community programs o Long wait times for community programs and transitional supports o Lack of community supports for some specialized populations  Many hospitals have lower length of stay than peers but are challenged to connect patients to the appropriate supports in the community.  Significant capacity is used by ALC patients waiting for supportive housing and long-term care, although there is significant variability between sites.

Service Delivery: Service delivery includes how much service is delivered across the system, why that service is being accessed and how it is delivered.

Observations Implications  Lack of common standards across the system:  Patients experience differences in baseline care at o Standards of care different sites across Champlain. o Admission and discharge criteria  There are likely opportunities for standardization to o Models of care improve effectiveness and quality. o Defined care pathways  Information is not transferred effectively between o Standard scope of services different providers treating the same patient at o Common admission, assessment and discharge different points in the continuum. tools  The services being delivered are not aligned with o Health Human Resource resourcing recovery focused philosophy and do not meet  Providers and those with lived experience lack expectations of patients receiving the services or awareness / knowledge of the various components the providers delivering them. of the MH&A system.  There are poor transitions between care settings.  Service focus on stabilization with a lack of access to treatment, beyond pharmacological therapy, was raised as a concern by both patients and providers.  Circle of care and information sharing often excludes families and community providers. Interpretation and application of existing privacy legislation often creates challenges with respect to privacy and disclosure.  Patients and families feel there are opportunities to improve level of compassion and empathy while reducing stigma while accessing services.  Outcome measures at the patient level are not well integrated into clinical services.  There are differences in philosophies of care between inpatient and community settings and there are still challenges with communication and coordination of services even when the programs are part of the same larger organization.  There is significant variability in different quality outcomes, cost per inpatient day and the use of tools such as restraints across hospitals.

Health Human Resources: Health Human Resources include all types of people engaged in actions whose primary intent is to enhance health (e.g., psychiatry, nursing, allied health, peer supports).

Observations Implications  Committed, engaged, and expert staff who go  Patients use inpatient MH&A system to gain access above and beyond for their clients. to psychiatry resources.  Champlain LHIN appears to be well resourced with  Rural bed capacity is constrained by psychiatry Psychiatrists, as compared to the provincial coverage limiting admissions and patient flow. average; however, there are still a number of  Health human resources are not being optimally challenges with psychiatry capacity, including: used to support patient care. o Regional distribution of psychiatrists with  Patients and families often do not have access to higher concentrations in urban-centers and peers supports which can impact outcomes as well challenges recruiting and retaining as the quality and experience of transitions. psychiatrists in rural areas o Age distribution, with a large proportion close to retirement o Gaps in specialty-psychiatry (e.g., geriatric psychiatry) o Limited community-based access (e.g., limited referrals to community-based psychiatry, roster size, etc.).  There is no consistency (or standard) for a staffing model across Champlain.  Many MH&A care providers identified that they are not working to full scope of practice due to health human resource capacity constraints. For example, mental health nurses and social workers do not have capacity to complete Cognitive Behaviour Therapy (CBT) and Dialectical Behavior Therapy (DBT) and there was a lack of Psychologist resources at many of the sites.  Family and peer support programs have been especially valuable and well received, where they are available.

1. Context

1.1 Project Overview

1.2 Project Scope

The scope of the Capacity Plan project was designated inpatient mental health and addictions services in Champlain LHIN provided by schedule 1, schedule 2/3, and specialty facilities. However, the Inpatient MH&A Capacity Plan must be situated within the larger MH&A system and recognize the entire MH&A continuum of care, especially how other parts of the system

impact the use of and need for inpatient services. Given the limits in scope, the capacity of outpatient and community-based services delivered were not measured but were considered as they relate to inpatient system inflows and outflows.

1.3 Project Approach & Methodology

The Capacity Plan consists of:  A Current State Assessment of Inpatient MH&A care in Champlain; including extensive consultations, secondary data analysis, and a jurisdictional scan and best practices review;  Recommended future state changes to increase efficiency, effectiveness, and flow across the identified hospitals and inpatient programs to meet the mental health and addictions needs of the Champlain population with limited additional financial investment; and,  Implementation plan and considerations to support the implementation of an integrated Regional Inpatient MH&A Program.

This report includes the first phase of that work, the Current State Assessment of Inpatient MH&A care in Champlain LHIN. In particular, it will provide direction regarding current capacity and demand for different MH&A services; types of services and level of acuity; patient flow through the system; identification of service duplication and gaps; patient experience, quality and clinical outcomes; as well as financial performance and efficiency.

Based on the findings outlined in this report, OPTIMUS | SBR and the steering committee will prepare recommendations and build out select future state elements.

The Steering Committee and OPTIMUS | SBR completed the current state assessment work from February through June, and will be developing recommendations through the end of July 2017. The approach included and/or is expected to include the following steps:

Current State Description Assessment

Guiding Questions 1. What is the current operational capacity of inpatient mental health and addictions services in the Champlain LHIN? 2. What is the current and projected future demand for inpatient mental health and addiction services in the Champlain LHIN? 3. How effective (quality) and efficient is the current delivery of inpatient mental health and addiction services in Champlain LHIN? 4. What are the issues and pressure points for inpatient mental health and addiction services? Methodology Description

Stakeholder Gather the perspectives of internal and external stakeholders on the Consultations current state of service and program delivery and identify potential gaps, duplication and opportunities for improvement. Stakeholder engagement consisted of:  Discovery interviews with steering committee members  Focus groups with people with lived experience  Group interviews and focus groups with Inpatient MH&A staff and administrators  Group interviews and focus groups with hospital and community partners

Secondary Data Document review and data analysis to understand the current state of Analysis inpatient mental health and addictions services in terms of service delivery and use patterns to understand gaps, barriers and the main drivers for future system design.

Jurisdictional Scan Best Practice/Jurisdictional Scan to identify and understand leading and Best Practices practices in other jurisdictions to inform future system design and capacity Review planning.

Accordingly, a brief literature scan was conducted with a focus on:  Integrated Shared Governance Structures  Team Based Care Models  Patient Flow and Access to Services  Use of Technology and Innovation

1.4 Key Definitions

Facilities, Hospital Abbreviations and Types

Inpatient MH&A care is currently delivered by 7 hospitals and 8 sites in the LHIN. Hospitals are classified as:

Hospital names, abbreviations and classifications are included below: Abbr. Hospital Note

Pembroke Pembroke Regional Hospital Schedule 22

Cornwall Cornwall Community Hospital Schedule 1

Queensway Carleton Queensway-Carleton Hospital Schedule 1

Ottawa Civic3 The Ottawa Hospital, Civic Campus Schedule 1

Ottawa General The Ottawa Hospital, General Campus Schedule 1

Montfort Hôpital Montfort Schedule 1

CHEO Children’s Hospital of Eastern Ontario Schedule 1

The Royal4 The Royal Ottawa Mental Health Centre Specialty

2 Schedule 2 facilities are exempted (but not restricted) from having to provide inpatient services and may not accept involuntary admissions 3 Note: If referred to as “The Ottawa Hospital” throughout the document, this indicates that the analysis considered both the Civic and General sites. If site specific data analysis was completed, we have identified that associated site, Civic or General. 4 Note: Brockville was not included in any analyses for The Royal.

Peer groups are often used to benchmark data, OMHRS uses the following categories of peer groups:

Term OMHRS Peer Group Definition

Pembroke Peer Group General <25 beds

Cornwall Peer Group General <25 beds

Queensway Carleton Peer Group General < 25 beds

Ottawa Civic Peer Group General / Teaching

Ottawa General Peer Group General / Teaching

Montfort Peer Group General >= 25 beds

The Royal Peer Group 1&2 – Psychiatric (Teaching and non- Teaching)

The LHIN recently created sub-regions to support system planning. However, translating hospital data to sub-regions requires full postal codes which were not provided due to confidentiality reasons. As a proxy the following regions were used to do the geographical analysis:

Region FSA Code

Western k8a, k8b, k8h, k7s, k7v, k0j Champlain

Ottawa k1a, k2a, k1b, k2b, k4b, k1c, k2c, k4c, k1e, k2e, k1g, k2g, k1h, k2k, k1j, k2j, k1k, k2k, k1l, k2l, k1m, k2m, k4m, k1n, k1p, k2p, k4p, k1r, k2r, k1s, k2s, k1t, k2t, k1v, k2v, k1w, k2w, k1x, k1y, k1z

Ottawa Rural k0a, k0e, k0g, k7a

Eastern K4a, k6a, k6h, k6j, k4k, k6k, k4r, k0b, k0c, k7c

1.5 Data Limitations

Through various analyses, OPTIMUS | SBR identified multiple data quality issues due to inconsistent collection and reporting across the Champlain region, especially as it relates to OMHRS, community mental health and addictions, and some institution specific indicators. As a result, a number of reported measures were not included in the analysis. However, many of these indicators would be useful to inform future planning discussions if the data is collected and reported consistently to allow accurate comparisons between sites. An additional identified limitation is the time lag that has occurred since the publication of many articles, reviews and

identified best practices. There is a risk with the continually and rapidly changing MH&A sector landscape and needs that publically available documentation may be outdated.

Ontario Mental Health Reporting System (OMHRS): General quality concerns were identified with data collected and analyzed from OMHRS. It is believed that there are different reporting practices among hospitals in Champlain leading to inconsistencies in reported data.

Paid Hours per Patient Day: There were significant differences in reporting practices between hospitals for Paid Hours per Patient Day. One identified inconsistency includes the types of clinical care included in the calculation, such as nursing versus social work. These differences make meaningful comparisons between hospitals a challenge and therefore this indicator was not included in the analysis.

Admission Source: Admission Source to inpatient MH&A sites, as reported in OMHRS, is not uniformly reported across sites. Of main concern, is the appropriate classification of patients who are admitted through the ED. There is no classification for admissions via the emergency department in OMHRS, and some organizations are reporting these patients as being admitted from a private home/apartment/rented room and other are reporting these patients as being admitted from an acute unit/hospital. These reporting methods skew the analysis and as a result, only discharge destination was analyzed per site.

Wait-time Data: Wait-times tracked for internal purposes and are not publically reported for all MH&A programs. They are also not collected in a consistent manner across the MH&A continuum making comparisons between different organizations difficult. This was true both in specialty MH&A, acute MH&A (wait-times for transfer to higher MH&A bed), and in the community. As a result, quantitative measures of wait-times were not included in the analysis and only qualitative feedback was reported.

Seclusion Rooms: Multiple sites indicated that there were discrepancies between data reported on seclusion rooms in OMHRS and reality at hospitals. For example, OMHRS reports the use of seclusion rooms at The Ottawa Hospital and the Royal, however both hospitals do not have seclusion rooms indicating limited quality of the data gathered from OMHRS. As a result, this analysis has been removed from this report.

Language Identity: All site’s as part of the admission process confirm a patients preferred language of service (English or French), although not all sites make an active offer for services in French. Additionally, many sites recently started to collect information about languages beyond English and French and so regional data is not yet available. A recent initiative in Champlain is working to address this issue and will eventually result in an improved data set, however, currently there is not enough data collected to make meaningful comparisons.

Bilingual Capacity: Many sites across the region can identify that they have bilingual staff working on MH&A units, however, at many sites language proficiency has only recently begun to be tracked and is not available for all staff.

2. Current State Assessment

This section provides an overview of the Champlain LHIN’s system, together with analyses that ask and answer key questions about the populations’ current and future needs for inpatient MH&A services, as well as trends in the current use of resources and system performance. This section also includes commonly identified themes based on discussions with various stakeholder groups including patients, their families and care providers.

2.1 Description of the Champlain LHIN

Key Questions for this Section:  What is the demographic profile of Champlain LHIN?

Demographic Profile

Champlain LHIN has a large, diverse population and geography. The LHIN is bordered by Quebec, North East LHIN, South East LHIN, and Lake Ontario along the southern border. The LHIN is divided into five sub-regions: Western Champlain, Western Ottawa, Central Ottawa, Eastern Ottawa, and Eastern Champlain. Champlain’s sub-regions have very different demographic and sociocultural profiles with a mix of both urban and rural areas. Socio-economic indicators, including income, unemployment, and education are better in Champlain than the Ontario average; however, there are pockets with significant socio-economic challenges.  As of 2015, approximately 9.5% of Ontarians reside in the Champlain region, representing 1,315,975 persons. In the Champlain LHIN, those age 65 and older comprise 15.9% of the population and those aged 19 and younger are 27.7%, slightly lower than Ontario for both. The population is forecasted to grow, on average, by 1.1% per year over the next 10 years (2017-2026).  About one third of the population in the Champlain LHIN lives within Central Ottawa (34.1%), the dense urban core. Among sub-regions, Western Champlain has the lowest proportion of children (% age 19 and Younger) at 20.7% based on 2015 population projections.  Champlain region has a number of special language and cultural groups including Francophone and Indigenous peoples. The region has the largest Francophone population in Ontario, particularly centered in the Eastern side of region. The region also has a slightly higher proportion of Indigenous peoples because of two First Nation communities located within the region. Ottawa specifically has the largest population of Inuit outside the North and the LHIN has a substantial population of Metis. Overall, Champlain has fewer visible minorities and immigrants as a proportion of its population than the Ontario average.

2.2 Inpatient MH&A Capacity

Key Questions for this Section:  What is the mandate, mission and focus of each facility that has inpatient mental health and addiction beds?  What inpatient mental health and addiction programs and services are offered at each organization, including:  Descriptions/definition of each program?  Admission/inclusion criteria?  Discharge criteria?  Age ranges served?

 What are the bed numbers, types, and service levels at each centre?

Organizations

Although many of the hospitals have different focus areas, all hospitals providing inpatient MH&A services in Champlain are striving to achieve similar missions and visions. The focus is on providing exceptional, patient-centered care based on collaboration, innovation, and leading best practices in mental health. Many of the hospitals with inpatient MH&A beds are general acute hospitals (The Ottawa Hospital, Queensway Carleton, Pembroke and Cornwall) and some have distinct focuses such as Montfort, which provides francophone services, CHEO, which treats pediatric populations, and The Royal, which is a specialty psychiatric hospital.

Bed Capacity

There are 423 funded inpatient MH&A beds in Champlain LHIN including pediatric and specialty beds. Overall, the greatest bed capacity exists at the Royal (210) followed by The Ottawa Hospital (87) and Montfort (46). In past years Cornwall and Pembroke have both decreased the number of MH&A beds in operation, Montfort continues to have unfunded capacity for 12 MH&A beds and some sites including Pembroke and The Ottawa Hospital open unfunded MH&A beds to manage surges in bed pressures.5

Approximately 40% of funded inpatient mental health and addiction beds are used to provide general acute care. It is assumed that the remaining 60% of funded beds are used for the provision of specialized care. Champlain’s MH&A beds are geographically concentrated in the Ottawa area, with only 4% of the bed capacity located in Western Champlain and only 4% of the bed capacity in Eastern Champlain.

There are also a number of planned upcoming changes to bed capacity including: opening a 12- bed inpatient unit at Hawkesbury hospital in 2019/20 and increasing the number of inpatient beds at Queensway Carleton from 24 to 28 in 2019/20.

5 The Royal has other beds which are used and reserved for partnership with the Government of Yukon and Government of Nunavut.

Figure 2 Number of Funded MH&A Beds in Champlain

Number of Funded Mental Health Beds in Champlain Region 250 200 150 100 50 0 Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort Royal Ottawa CHEO Carleton General Source: Reported by Individual Hospitals

Table 2: Number of Funded and Operational Inpatient Mental Health and Addiction Beds in Champlain by Type and Facility6

Source: Reported by Individual Hospitals

Champlain LHIN’s number of inpatient beds per capita are similar to the provincial average. However, it is important to note that per capita comparisons are imperfect because they do not account for cross-regional care, especially from specialized psychiatric hospitals which are concentrated in a few LHINs (Central East, Champlain, North Simcoe Muskoka and Toronto Central) but provide care to individuals across Ontario. There is also variability in the number of beds per capita in each LHIN due to historical investment decisions.

6 Please note that the 6 eating disorder beds at the Ottawa Hospital are not fully funded. The 12 bed concurrent disorder unit at The Royal only operates 5 days a week with patients going home on weekends and are hospital-based residential beds. These beds are funded from the Community MH&A stream (the same envelope as other residential addictions beds offered by addictions treatment centres in the LHIN), not from Global funding. Additionally, bed totals do not include unfunded MH&A beds that may be periodically used to address urgent bed pressures or funded beds for which there is physical space but are not operational. The Royal’s 210 beds mentioned in the IP Capacity report encompass only approximately half of the inpatient services the Royal offers. Additional beds are used to provide services at The Royal Ottawa Place LTC facility (64 beds). The Royal operates a unique partnership with the Provincial Ministry of Community Safety and Correctional Services through the St. Lawrence Valley Correctional and Treatment Centre (Secure Treatment Unit) which includes 100 Schedule 1 beds and a 59 bed Forensic Treatment Unit at Brockville Mental Health Center. The Royal also operates 183 beds in Homes for Special Care across the region.

Figure 3: Total Number of Funded MH&A Beds by LHIN7

Total Number of Funded MH&A Beds By LHIN 800 700 600 500 400 300 200 100 0

Total Number of Mental Health Beds Ontario Aberage

Source: OMHRS

Figure 4: Number of Funded MH&A Beds Per Capita by LHIN8 Number of Funded MH&A Beds Per Capita By LHIN (per 1000s) 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00

Number of Beds Per Capita (per 1000s) Ontario Average

Source: OMHRS

7 Note: Pediatric beds and Concurrent beds are not accounted for in OMHRS. Data for Champlain was gathered from site reported data and includes Youth beds (8 at The Royal and 25 at CHEO) and Concurrent beds (12 at The Royal). 8 Note: Pediatric beds and Concurrent Disorder beds are not accounted for in OMHRS.

Programs and Services

Each hospital with Inpatient MH&A services offers various inpatient mental health and addiction programs. The region has a number of programs including:

 General Acute Psychiatry: Psychiatric intensive care/observation, stabilization, psychiatric assessment, diagnosis, treatment and discharge planning for those with acute mental illness (including crisis).

 Crisis: Provides short-term specialized diagnostic clarification, assessment, treatment, and stabilization of persons experiencing an acute mental health crisis episode.  Mood: Inpatient assessment and treatment for patients with recurrent, chronic treatment resistant and co-morbid mood disorders.

 Forensics: Provides specialized assessment, treatment, and rehabilitation for adults with severe psychiatric illness who have come into conflict with the criminal justice system.

 Geriatric: Provides care for patients over the age of 65 (or younger patients living with Alzheimer’s or Frontotemporal Dementia) with severe multiple and/or complex psychiatric illnesses.

 Schizophrenia: Specialized treatment and care to individuals with diagnoses of treatment resistant schizophrenic related illness with comorbidities or psychosis.

 Children and Youth: Serving children and youth who are experiencing an acute mental health crisis.

 Eating Disorder: Inpatient eating disorder programs for pediatric and adult populations.  Substance Use: Medical detoxification (alcohol) and/or stabilization on opioid agonist therapy for patients with severe substance use disorder who cannot be stabilized as an outpatient.  Concurrent Disorder: Provides integrated and specialized stabilization, assessment, diagnostic clarification, and treatment services to clients with co-morbid severe, complex, active and symptomatic substance use and mental health disorders.

Both the general acute MH&A beds and specialty programs have unique sets of admission and discharge criteria. There is currently no universal system of utilization assessment in place, however, trials of such a system known as Level of Care Utilization System (LOCUS) have been undertaken at select locations in the region. Based on current criteria, most voluntary admissions

to inpatient programs require a patient to have severe, active and symptomatic mental health disorders; significant impairment in functioning; and, identified treatment goals. Consistently, across sites, there is not a shared understanding of the admission criteria among patients and care providers leading to inappropriate referrals.

Discharge criteria, however, are not as prescriptive. Discharge is determined on a case-by-case basis but commonly occurs when there is no further requirement for inpatient services. This can occur when: a patient can safely receive treatment as an outpatient or from an alternative organization; when patients have made progress towards their identified treatment goals; when patients’ symptoms and medication are felt to be in good control; and, when patients are ready to integrate back into the community at the highest level possible.

Age ranges served for each inpatient mental health and addiction program across Champlain also vary. The majority of programs are offered from age 16 or 18 until the end of a patient’s life. Programs that specifically target geriatric patients are available from age 65 onwards, whereas programs specific to youth are available from age 0 through to 16 or 18 years of age, depending on the program. Unless otherwise indicated, bars showing age range of patients continue infinitely.

Figure 5: Age Ranges Services by Inpatient Mental Health Programs in Champlain Region

Source: Site Reported Data

Please refer to Appendix 4.2 for detailed summary tables outlining the specific mandates and missions of each facility offering inpatient mental health and addiction beds as well as a more detailed list of inpatient mental health and addiction programs and services and their admission and discharge criteria.

Identified program and service gaps include:  pediatric treatment programs9

9 Pediatric treatment gaps include patients with dual diagnosis, eating disorder beds for children under the age of 16, and specialized pediatric addictions treatment

 dual diagnosis, specifically focused on developmental disability;  medically complex psychogeriatric  full inpatient concurrent disorders (24/7 capacity)  urgent care and short term stabilization.

Overall, it is difficult for patients and care providers to differentiate between similar programs at different hospitals in Champlain. Many of the above identified program and service gaps may be incorporated as part of the various acute and specialty programs defined above, however, without the specific identification of programming it is difficult for patients and care providers to understand and access the most appropriate level of care.

French Language Capacity

Given the large Francophone population in Champlain and the importance of language to MH&A care and treatment, French language capacity is an important consideration for the region’s capacity plan. Montfort is the only hospital that offers all inpatient mental health and addiction services in French and creates a Francophone treatment milieu.10 There is a mix of French language capacity at the other hospitals within Champlain, ranging from bilingual staff to programs designated as FLS, although since most of their service delivery is Anglophones. As such, the other hospitals are not able to create the same supportive environment and usually lack connections with francophone community MH&A providers to support transitions and discharge. The Royal and the Ottawa Hospital indicate that many of their programs are also available in French and many of The Royal’s program are designated French language services. Queensway Carleton, Pembroke, and CHEO do not offer any core inpatient services in French but CHEO and Pembroke do have bilingual staff available. The below table shows in detail which programs and services are offered in French on inpatient mental health and addiction units.

Table 3: French Capacity at The Royal to Provide Inpatient MH&A Services in French Language

The Royal Mental Health French Capacity Inpatient Programs Yes No Crisis  Currently not FLSA designated but working towards achieving requirement Champlain Forensic  Geriatric  Mood & Anxiety  Currently not FLSA designated but working towards achieving requirement

10 Francophone milieu is not the same as services in French language

The Royal Mental Health French Capacity Inpatient Programs Yes No Recovery  Currently not FLSA designated but working towards achieving requirement Schizophrenia  Currently not FLSA designated but working towards achieving requirement SUCD-ASU  Youth  Concurrent Disorders Unit  Source: Site Reported Data

Table 4: French Capacity at Hospitals in Champlain Region to Provide Inpatient MH&A Services in French Language

French Capacity Hospital Yes No Bilingual Resources11 Montfort  All inpatient mental  All staff are bilingual. health services and  Nurse practitioner, interventions are occupational therapist and developed and social workers link up with offered in French to community services during meet the needs of the patient hospitalization to the francophone ensure transition to patients. francophone community services upon discharge. Cornwall  Two part-time  40% of staff are bilingual. psychiatrists speak  Do refer to CMHA (bilingual French services) and Centre de le  Recreation therapist Santé Communautaire de and program clerk L’Estrie are Francophone. QCH  Core programs are offered in English Pembroke  AMH Orientation  No specific  Bilingual staff is available on Regional booklet, and Patient services request. MH education offered in pamphlets are French on the available in French unit CHEO  Neither unit  Both psychiatric inpatient and offers eating disorder inpatient comprehensive units have clinicians who

11 Staff bilingualism is not consistently collected across the region and as such total rates for all staff are not available.

French Capacity Hospital Yes No Bilingual Resources11 assessment have the capacity to offer and treatment bilingual services. services in  Psychiatric Inpatient unit has French 2 bilingual Social Workers.  Eating Disorder Inpatients has a bilingual Psychologist. The Ottawa  Programs offered in  Bilingual staff available at all Hospital French campuses.  Some referral to francophone services via Montfort. Source: Site Reported Data

2.3 Related MH&A Programs and Services

Other MH&A services and functions beyond inpatient services are not in-scope for this project but impact the need for and utilization of inpatient MH&A services. These services and functions are delivered by many organizations across Champlain region with the largest provision of services by The Royal. These services include:  Outpatient programs and services  Day hospital programs  Case management services  Community-based MH&A services  Community/Supportive housing  Consultations and telepsychiatry services  Psychiatry emergency services  Long-term care programs and services  Research and education,  Regional leadership, planning and capacity building  Services/capacity reserved for other jurisdictions (federal, other LHINs, other provinces)12

Additionally, within Champlain, three organizations have specialized mandates with respect to certain patient populations or regional leadership for MH&A  Regional MH&A Leadership: The Royal is the primary provider of specialized levels of MH&A care within Eastern Ontario and provides a wide range of intensive level services. The Royal operates the largest Community Mental Health program in the LHIN including seven community treatment teams. It also offers, through many of its programs,

12 Other jurisdictions include: Provincial Ministry of Community Safety and Correctional Services, forensic inpatient beds located in South East LHIN at the Brockville Mental Health Centre, Veterans Canada, Canadian Forces, RCMP, and Nunavut and Yukon.

outreach, consultation and clinical capacity building services through partnerships. The Royal operates the Pathways to Better Care Program which provides administrative capacity building and system transformation services across the LHIN. The Royal offers a diverse set of education and training activities which are accessed by many professionals, individuals with lived experience and the public. The Royal acts as an expert resource for the region/province and the LHIN and is often tasked with developing innovative solutions to tackle complex emerging MH&A issues within the community.13  Francophone MH&A Services: Montfort is Ontario’s Francophone Academic Hospital and has a provincial mandate to improve access to health care in Ontario, with a specific focus on francophone communities. This includes participating in planning and supporting French language health services, helping the Government of Ontario to meet its obligations under the French Language Service Act, serving as a Centre of Excellence and hub for French language health care professional education, and demonstrating research and academic programming consistent with an AHSC.  Child and Youth Mental Health: CHEO is the largest provider of child and youth mental health services in Eastern Ontario, and houses several provincial and regional programs, including the Provincial Centre of Excellence for Child and Youth Mental Health which works with agencies to strengthen mental health services and build an accessible system of care for children, youth and their families and caregivers; and The Young Minds Partnership strategy (in partnership with The Royal).

These broader MH&A services and regional/provincial leadership mandates will be important considerations in future state planning and implementation as they can have impact on the need for and delivery of inpatient MH&A services and may be important resources to build upon and leverage as part of system-wide MH&A improvements.

2.4 Leadership, Governance, and Culture

Key Questions for this Section:  What are the governance, leadership, and accountability structures for inpatient MH&A and how do they impact system operations?  Are there clear and distinct roles and responsibilities for entities in the inpatient MH&A system?  How does the culture of inpatient MH&A services impact care delivery and system effectiveness?

13 The development of the FACT team, the Regional Complex Schizophrenic Project (Co-Lead in partnership with TOH and other schedule 1 Hospitals in the Ottawa region), the development of a new community CBT program and lastly, bringing CAPA to the youth system are a few examples of The Royals regional leadership.

Across Champlain, there is strong commitment from leadership to provide exceptional care at all levels of the inpatient MH&A system. However, there is an opportunity for improvement around system-level thinking and leadership. Broadly, leaders’ main priority and focus appears to be on improving their own organization and programs, as this is what previous accountability mechanisms, quality assurance, funding and structures were geared to, rather than thinking in terms of system wide change and improvement. There is a general consensus of support among leaders for change and transformation of the MH&A system and its players’ interactions. There was support and enthusiasm for a regionally coordinated and integrated inpatient MH program that follows the same standards to deliver consistent outcomes and experiences, as opposed to multiple programs being offered at multiple sites across Champlain, delivering services in unique ways. There are pockets of excellence and examples of enhanced collaboration and coordination between different programs (e.g., facilitating transfers between The Ottawa Hospital and Montfort to manage surge) however, at a broad system level this collaboration and coordination is not as prevalent.

In order to improve coordination and care in the Champlain MH&A system, a number of identified challenges need to be addressed.

 The current structure of the inpatient MH&A system does not have a common governing body that sets coordinated system level direction and that holds the system accountable for delivering coordinated and effective services across the continuum of care. There is no overarching responsibility for all parties – including acute, specialty and community care providers – to work together and optimize the performance of the overall system. With this fragmented system structure and funding models that incentivize such a system, it is difficult to manage patient flow across the Champlain region, along all parts of the continuum of care.

 System players have a lack of clarity of roles and responsibilities across sites and the continuum of care, especially considering which providers should be providing what levels/types of care (specialty vs acute vs primary care) as well as language based services. There are perceptions that the region’s specialty resources are being used to provide primary and/or maintenance mental health care inappropriately, resulting in barriers for new patients to access resources as specialty beds are taken up by patients with lower need. In addition, there is uncertainty on which services should be considered specialty, including Electroconvulsive Therapy (ECT), and in what situations patients should be accessing different types/levels of service.

 Limited awareness and communication across the continuum of care, especially between inpatient care providers and the community-based providers, has led to challenges with communication among a patient’s circle of care and has impeded effective discharge planning to support patients during transitions. Champlain LHIN does not have a common

discharge tool or integrated system that allows information to be effectively shared between providers at different organizations. Additionally, those that work in inpatient settings, including providers who are responsible for discharge planning, often have low awareness and understanding of resources and programs that exist in the community and vice-versa for community providers’ awareness and understanding of inpatient services.

 In addition, there is variability in the level of trust between and among inpatient care providers and community care providers. This lack of trust can result in providers deciding not to refer a patient that may be more appropriately serviced by another provider or program. Sites that share a common governance structure – those that have both community and inpatient programs – often have better awareness of programs that are available across the continuum of care. However, there are often still differences in philosophies of care between inpatient and community settings and there are still challenges with communication and coordination of services even when the programs are part of the same larger organization.

There has been a significant amount of work done to enhance relationships between hospitals including the establishment of the Inter-Hospital Committee, various planning tables, and daily meetings between MH managers at the Ottawa-based hospitals. These tools and techniques have had a positive impact on relationships as well as patient flow and care, however many of these mechanisms are informal and there are still challenges in the working relationships between sites that impact the overall culture of the system. For example:

 Political dynamics and territorial behaviours across organizations that impact flow, demonstrated by perceptions among service providers, patients, families and partners, that suggest that there are “clubs,” or groups, of patients that are better supported and have easier access to care. Although providers recognized the value of continuity of care, many gave examples of lower acuity patients being transferred rather than higher acuity patients because they had an existing relationship with a specialty program.

 Challenges between referring and receiving hospitals, with respect to responsiveness, admission criteria and intake when patients need access to resources or hospitals need support to manage bed capacity. In some cases, lower acuity patients were transferred prior to higher acuity patients, or referrals/transfers are turned away after the transfer has occurred, for a variety of reasons (e.g., lack of clarity on admission criteria, inappropriate referrals/transfers, involuntary admissions being reversed). These challenges were identified during transfers between community hospitals to hospitals with acute inpatient MH&A capacity as well as acute to specialty care.

 Organizational silos, both within and between sites, due in part to funding patterns, capacity challenges and different operating mechanisms and systems impede transitions

and flow of patients to the most appropriate level and destination of care. A result of these silos is a system culture that focuses on the advancement of individual sites and programs rather than a holistic view of the patient across their care continuum.

 Perceptions exist that there is an imbalance of influence in system planning discussions with a focus and emphasis on the Urban-Ottawa region without understanding the needs and barriers of smaller and more rural communities. It is crucial to consider available resourcing and programs across the region in its entirety to ensure that all patients have equal access to appropriate levels of care and the decisions are made considering all relevant perspectives.

2.5 Regional Need for Service

Key Questions for this Section:  What is the need for inpatient MH&A services and how is it geographically distributed across Champlain?  How is that need expected to change in the future?

2.5.1 Prevalence of Mental Health

The estimated number of people with MH&A conditions in Champlain is 231,659. The highest percentages of the population with MH&A conditions are in Eastern Ottawa (21%) and Central Figure 6: Estimated Number of Persons with MH&A across Champlain Sub-Regions in 2014/15

Prevalence of MH&A in Champlain Sub-Regions 250000 21.5% 21.0% 200000 20.5% 20.0% 150000 19.5% 19.0% 100000 18.5% 50000 18.0% 17.5% 0 17.0% Western Western Central Eastern Eastern Champlain Ontario Champlain Ottawa Ottawa Ottawa Champlain

Est. # persons with a mental health/addictions condition 2014/15 Est. % persons with a mental health/addictions condition 2014/15 Source: LHIN Sub-Region Profiles

Ottawa (21%), the highest absolute number of people with MH&A conditions reside in Central Ottawa. 14, 15

Figure 7: Population Living With Mental Health / Addictions Condition in Champlain LHIN in 2014-15

Source: LHIN Sub-Region Profiles

2.5.2 Projected Future Need

Assuming that prevalence rates remain constant over time, the number of people diagnosed with MH&A conditions in Champlain is expected to rise to almost 350,000 by 2040 due to expected population growth. Certain specialized populations are expected to grow in the future, specifically pediatric and geriatric groups. Since these groups are more likely to experience MH&A challenges,

14 Even within sub-regions there is variability in the levels of MH&A, of note is that within Central Ottawa there is a further concentration of those with mental health and addictions issues in one forward sortation area (“FSA”) within the “Mission District”. 15 Note: Bar not included for Est. # of persons in Ontario with mental health/addictions due to large scale. Ontario has an estimated 2,322,417 persons with mental health/addiction in 2014/15.

the need for inpatient MH&A services may actually be higher over time and resources rebalanced to support changing demographics:  Young people aged 15 to 24 are more likely to experience mental illness and/or substance use disorders than any other age group and have higher suicidality.16  Rates of mental illness for adults between the ages of 70 and 89, including but not limited to dementia, are projected to be higher than any other group by 2041. One in four seniors already lives with a mental health problem or mental illness, and as this population grows so too will the need for mental health services.17

Figure 8: Forecasted Prevalence of MH&A in Champlain LHIN 2016 to 2014 Projected MH&A Population In Champlain LHIN 2016 to 2041 400 350 300 250 200 150 100

Number People of (1000s) 50 0 2010 2015 2020 2025 2030 2035 2040 2045 Year

Source: Ontario Ministry of Finance projections (Spring 2016), LHIN Sub-Region Profiles

2.6 Service Delivery

Key Questions for this Section:  What volumes of inpatient MH&A care are delivered in Champlain?  Who are the current users of inpatient MH&A care in Champlain, including:  demographics?  language identity and preferences?  acuity/complexity level?  Why are patients accessing inpatient MH&A services?  Where are patients accessing inpatient MH&A services relative to their homes?  What is the patient’s preferred language to be served in?

16http://www.camh.ca/en/hospital/about_camh/newsroom/for_reporters/Pages/addictionmentalhealthstatistics.aspx 17 http://www.mentalhealthcommission.ca/English/focus-areas/seniors

2.6.1 Service Volumes

Across Champlain Region there were 7,002 admissions reported in 2016/17 at all the hospitals. Total admissions at Pembroke, Cornwall, Queensway Carleton, CHEO and The Royal were relatively stable over the past 3-year period. The number of admissions to The Ottawa Hospital and Montfort have increased over the past 3-year years. Figure 9 Total MH&A Admissions to Inpatient MH&A Hospitals in Champlain18

Total MH&A Admissions

2500 2000 1500 1000 500 0 Pembroke Cornwall Queensway The Ottawa Montfort CHEO The Royal Carleton Hospital (Combined)

2014/15 2015/16 2016/17

Source: Site Reported Data

The number of unique patients admitted to hospitals in Champlain was 5,523 in 2016/17; however, one patient may have experienced hospital admissions at multiple sites and so is not reflective of the number of unique patients at a regional level. A similar upward trend, to total MH&A admission, is shown by The Ottawa Hospital and Montfort, both hospitals have been admitting an increasing number of unique patients over the past 3 years. The relative proportions of total admissions and unique MH&A patients appears to be similar across all hospitals.

18 Note: Admission numbers for The Royal does not include admissions to the Forensic Inpatient Program at Brockville or the Secure Treatment Unit. Number of Discharges was used as a proxy measure for number of admissions to CHEO.

Figure 10 Number of Unique Patients in Inpatient MH&A Hospitals in Champlain19

Unique MH&A Patients 2000 1500 1000 500 0 Pembroke Cornwall Queensway The Ottawa Montfort CHEO The Royal Carleton Hospital (Combined)

2014/15 2015/16 2016/17

Source: Site Reported Data

As of FY 2013/14 Champlain LHIN’s admission rate (per 100,000 population age 15+) is the mid- range among LHINs and is lower than the provincial average of 483.220 In terms of volumes of admissions and length of stay, Champlain also performed close to the mid-range and was the fifth highest LHIN in terms of volumes of admissions (5175) and the eighth in length of stay (26.2).

Figure 11 Adult Designated Mental Health and Addiction Unit Utilization by LHIN in 2013/14 Adult Designated Mental Health Unit Utilization by LHIN, 2013/14 800 700 600 500 400 300 200 100 0

Rates per 100,000 Population Age 15+ Active Cases Rates per 100,000 Population Age 15+ Admissions Rates per 100,000 Population Age 15+ Discharges

Source: LHIN Network 2016-19 Integrated Health Services Plan Environmental Scan

19 Note: Number of Unique Patients for The Royal does not include patients in the Forensic Inpatient Program at Brockville or the Secure Treatment Unit. Assuming patients at The Royal are not being admitted to more than one program. 20 LHIN Network 2016-19 Integrated Health Services Plan Environmental Scan

Table 5 Adult Designated Mental Health and Addiction Unit Utilization in Volume by LHIN, 2013/14

Volumes LHIN of patient Active Cases Admissions Discharges Total Days Average LOS Erie St. Clair 2,997 2,798 2,779 63,086 22.7 South West 4,975 4,582 4,590 136,810 29.8

Waterloo 3,168 2,926 2,940 82,550 28.1 Wellington HNHB 5,924 5,496 5,467 136,244 24.9 Central West 2,674 2,517 2,542 52,917 20.8 Mississauga 3,284 3,074 3,045 56,323 18.5 Halton Toronto Central 6,611 6,177 6,156 184,172 29.9 Central 5,966 5,669 5,672 116,471 20.5 Central East 6,196 5,640 5,643 134,166 23.8 South East 1,973 1,670 1,752 106,071 60.5 Champlain 5,523 5,157 5,118 135,883 26.6 North Simcoe 2,876 2,621 2,628 83,430 31.8 Muskoka North East 3,971 3,650 3,655 98,576 27 North West 1,324 1,206 1,211 39,932 33 Unknown LHIN 1,882 1,629 1,646 98,093 59.6 Out‐of-Province 2,028 1,824 1,785 59,775 33.5 Ontario 59,344 54,812 54,844 1,524,724 27.8 Residents† Source: LHIN Network 2016-19 Integrated Health Services Plan Environmental Scan

2.6.2 Patient Profile

Age, Gender, Socio-Economic Indicators

There is variability between sites in the gender, age, and socioeconomic distribution of patients.  There is a larger proportion of females at Pembroke, Queensway Carleton, The Ottawa Hospital General Campus, as well as CHEO. There is a larger proportion of males at The Ottawa Hospital Civic Campus, Montfort and the Royal.  Two-thirds of patients admitted to adult inpatient mental health are between the ages of 25 and 64. Most of the patients admitted to pediatric inpatient MH&A beds are above the age of 13. Some hospital’s patient age distribution is impacted by the types of programs

and services. For example, The Royal has a geriatric program and a youth program and so admits more seniors and youths.  Much of the average patient population who access inpatient MH&A services are persons who are unemployed and have achieved lower levels of education.21 With the exception of the Royal, between 25% and 30% of patients are employed. Cornwall (58.5%), Montfort (47%), Ottawa Civic (64%), Ottawa General (59%) and the Royal (62%) report similar levels of patients having completed high school. Queensway Carleton reports significantly higher rates of high school completion at 80%, while Pembroke reports lower levels at 25%.

Figure 12 Gender of Current Patients in Inpatient MH&A Hospitals in Champlain

Gender of Current Patients in Inpatient MH&A Hospitals in Champlain 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort The Royal CHEO Carleton General

Male Female

Source: OMHRS for all sites except CHEO, which is based on site reported data

21 This is consistent with reports from the Centre for Addictions and Mental Health (CAMH) reporting that Canadians in the lowest income group are 3 to 4 times more likely than those in the highest income group to report poor to fair mental health. Studies in various Canadian cities also indicate that between 23% and 67% of homeless people report having a mental illness.

Figure 13 Age at Admission of Current Patients in Inpatient MH&A Hospitals in Champlain22

Age Distribution of Inpatient MH&A Patients in Adult Facilities 40%

35%

30%

25%

20%

15%

10%

0% 0 - 17 18 - 24 25 - 44 45 - 64 65+

Source: OMHRS

Figure 14 Age Distribution of Inpatient MH&A Patients at CHEO

Age Distribution of Inpatient MH&A Patients at CHEO 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0-12 13-17 18+

Source: Site Reported Data

22 Note: Does not include patients at CHEO or The Royal’s youth and concurrent disorder program as these are not reported in OMHRS data.

Figure 15 Current Percentage of Patients per Age Group in MH&A Inpatient Hospitals in Champlain23

Current Percentage of Patients per Age Group in MH&A Inpatient Hospitals in Champlain 120%

100%

80%

60%

40%

20%

0% Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort CHEO The Royal Carleton General

0 - 17 18 - 24 25 - 44 45 - 64 65+

Source: OMHRS and CHEO self-reported data

Figure 16 Socioeconomic Indicators of Adult Inpatient MH&A Patients in Champlain Region (Q1-3 2016/17)24

Socioeconomic Indicators of Adult Inpatient MH&A Patients 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Carleton

Married/partner/significant other High school completed Employed

Source: OMHRS

23 Note: Includes both Admission Assessment and Short-Stay. The Royals youth program and concurrent disorders are not included as they are not reported in OMHRS. 24 Note: Pembroke Regional did not report Marital Status or Completion of High-School in Short-Stay Assessment Data, lowering the overall average. Analysis includes both Admission Assessment and Short-Stay. The Royals youth program and concurrent disorders are not included.

Location of Residence

Over half of Champlain LHIN’s regional inpatient admissions for MH&A are from residents of Central Ottawa. Each hospital is generally serving their local community.  Cornwall and Pembroke are the most focused on serving their local regions with 88% and 94% of patients coming from their surrounding geography.  The Royal and CHEO serve the broadest geography, which is expected given the specialized nature of these hospitals’ services and patient population, with 58% of The Royal’s and CHEO’s patients from the Central Ottawa area.

Figure 17 Location of Residence for MH&A Inpatients in Champlain25 Location of Residence of Inpatients

Eastern Ottawa Ottawa - Rural Western Champlain Other

13% 14%

11%

56%

Pembroke Cornwall Queensway Carleton 0% 1% 0% 0% 3% 5% 5% 1% 6% 6% 11%

88% 72% 94%

25 Note: Numbers reported as less than 5 assumed to be 2, additionally for planning purposes it would be beneficial to look at location of residence according to Champlain LHIN Sub-Regions, however, these are new regional structures and have not yet been implemented across the hospital’s decision support teams making this analysis not feasible within the timelines of this project.

The Ottawa Hospital

Eastern Ottawa Ottawa - Rural Western Champlain Other

5% 12% 6% 5%

72%

Montfort The Royal CHEO 4% 1% 9% 6% 18% 16% 24% 12% 10% 10% 5% 7% 58% 62% 58%

Language

Language is a critical component of MH&A care, and Champlain LHIN has the largest number of Francophone individuals in the province. The region has a number of French language services including formal (FLSA designated) Francophone inpatient MH&A services, a francophone treatment milieu at Montfort, some FLSA designated specialized services at The Royal, and informally at sites with bilingual staff (although a full francophone milieu is not created).  The table below shows where Francophone patients (identified French as language of preference) are being admitted for inpatient MH&A care. Montfort serves the greatest number of patients whose preferred language of service is French; however, one third of people who prefer services in French are accessing care at a hospital that does not primarily provide service in French, but do have bilingual resources available.26  There may be factors other than language that influence where a patient accesses care such as location, familiarity with the site, as well as dispatch protocols for ambulatory and police services when selecting where to bring a patient.27  As detailed in Section 2.6.1, all facilities, except for Queensway Carleton Hospital, have the ability to use bilingual staff; however, Montfort is the only facility that offers all inpatient mental health and addiction services in French and creates a Francophone milieu. The Royal and the Ottawa Hospital indicate that many of their programs are also available in French. It is important for Champlain to investigate ways to develop a critical mass of accessible Francophone MH&A services. The Ottawa Hospital and the Royal both have bilingual staff; however, inpatient programs and services are provided primarily by Anglophone staff and do not create the ideal environments for Francophone patients.

26 It is important to note that if an “active offer” was consistently provided to patients, we would expect to see a higher number of individuals indicating a preference to receive services in French. In general, a proportion of Francophones will default to English when they are not offered a choice of language, thus not indicating French as their preference. 27 Police and ambulatory services often attempt to bring patients to EDs that they are familiar; language preferences are not explicitly part of the dispatch protocols that dictate which ED patients are brought to. The proportion of patients brought by police and ambulatory services was not available as part of the data analysis.

Table 6 Proportion of Total Admissions Indicating French as Preferred Language Over 3 Years2829

Region Grand Proportion of Hospital Ottawa – Western Eastern Other Ottawa Total Total Admissions Rural Champlain

Pembroke 10 10 <1%

Cornwall 74 11 4 3 92 6% Queensway Carleton 1 3 11 3 1 19 Hospital 1%

The Ottawa Hospital 44 50 264 20 4 382 5%

Montfort 236 631 138 4 1009 36%

The Royal 24 23 109 21 4 181 4% Source: Site Reported Data

2.6.3 Reason for Admission

Reason for Admission

Patients can be admitted to inpatient MH&A units for a number of reasons and a single admission may be due to multiple reasons. As shown below, most patients are admitted to inpatient MH&A units for specific psychiatric symptoms, threat or danger to self, or inability to care for self.

28 Note: Numbers reported as less than 5 assumed to be 2. Do not have data on what language patients are receiving care in. 29 Note: There is a risk that this data is not reliably collected across the Champlain region. Literature also indicates that language preference is an under-representation of the need for FLS services. Despite these risks, FLS data is scarce and the measure of proportion of total admissions indicating French as preferred language will be used as the measure in this report.

Figure 18 Reason for Admission per Hospital in Champlain3031

Proportion of Adult Inpatient MH&A Admissions Reason for Admission for 2016 Fiscal Year 80%

70%

60%

50%

40%

30%

20%

10%

0% Forensic Other Criminal Threat of Problems with Inability to Threat or Specific Assessment justice danger to addiction care for self danger to self psychiatric involvement others symptoms

Source: OMHRS

With respect to specific diagnoses, approximately two thirds of patients are admitted for either a Depressive disorder, Schizophrenia spectrum and other psychotic disorder, or substance-related and addictive disorders. There is significant variability between sites:  The diagnosis of Schizophrenia spectrum and other psychotic disorders represents the largest proportion of admissions, although a smaller overall percentage (24-46%), at most other hospitals, except Pembroke which does not accept involuntary admissions and transfers many of these higher acuity patients to Ottawa-based hospitals. The percentage of patients diagnosed with this disorder is particularly high at the Ottawa General Site (46%), which is 12% higher than the Champlain LHIN-wider average. Please refer to Appendix 4.4 for an analysis of admission diagnosis per hospital.

30 Note: Admission Assessment and Short-Stay included. 31 Note: Due to data quality, it is important to note that some issues causing inpatient admission (e.g., dual diagnosis, aggressive behavior) are not consistently coded in ED data collection.

Figure 19 Admission Diagnosis32

Champlain LHIN-wide Admissions by Diagnosis

Depressive disorders

3% 7% Schizophrenia spectrum and other psychotic disorders 22% 6% Substance-related and addictive disorders Neurocognitive disorders 10% Anxiety disorders

3% Bipolar and related disorders 4% Personality disorders 11% 34% Trauma- and stressor-related disorders Unreported

Source: OMHRS

Patient Acuity Measures

When a patient is admitted to an inpatient MH&A unit (both short-stays and long-stay admissions), there are a number of assessments conducted to determine baseline acuity along a number of measures33. Generally, patient acuity levels (proportion of medium to high acuity scores) appear to be relatively similar to provincial peer hospitals. An analysis of each measure, based on reported data in OMHRS over the past 3-years shows there is significant annual variation between the sites with no clear trends; however, the Ottawa General consistently ranks as having the highest proportion of medium to high acuity patients, except for the Cognitive Performance Scale which showed the highest acuity mix was at The Royal. Lower acuity measures may signal an opportunity to transition care from an inpatient setting to the home or community in order to ensure acute and specialized resources are used by higher acuity patients.  The proportion of patients with a score of 3 or greater on the Aggressive Behaviour Scale Assessment is reported for 15 to 21% of patients across sites in Champlain. Pembroke reports significantly lower scores indicating that only 2.6% of patients are scoring greater than 3.  The proportion of patients with a score of 3 or greater on the Cognitive Performance Scale is generally low across all sites in Champlain, ranging between 0.7 and 6.7%. The Royal

32 Note: Admission Assessment and Short Stay both included. 33 Measures include: Aggressive Behaviour Scale Assessment, Cognitive Performance Scale, Depressive Severity Index, Risk of Harm to Others Scale, Self-Care Index, Severity of Self Harm Scale, and Positive Symptoms Scale.

reports a significantly higher percentage (16%) of patients measuring a score greater than 3.  The proportion of patients with a score of 7 or higher on the Depressive Severity Index varies across sites with approximately 4% of patients at Cornwall scoring 7 or higher. Sites most commonly report roughly 15% of patients scoring 7 or higher. Ottawa General however reports almost 34% of patients measuring a depressive severity index greater than 7 in 2016.  The proportion of patients with a risk of harm to others scale score of 3 or greater ranges between 25% and 30% of patients at inpatient MH&A sites in Champlain, except for Pembroke which reports a much lower percentage (9%) of patients with a score greater than 3.  The proportion of patients with a self-care index score greater than 3 varies greatly across sites. The lower percentage of patients scoring greater than 3 is seen at Cornwall (6.6%), while the highest percentage is seen at the Royal (24%) and Ottawa General (36%).  The proportion of patients with a severity of self-harm scale greater than 3 is particularly low at the Royal (21%) and Montfort (27%), while Ottawa General (45.5%), Cornwall (46%) and Queensway Carleton (53%) report much higher percentages of patients scoring greater than 3.  The proportion of patients with a positive symptoms scale score greater than 7 is greatest at Ottawa General (14%) and the lowest at Cornwall (1.3%) and Pembroke Regional (2.4%).

Figure 20 Hospital Score per Acuity Measure34

Hospital Score for Acuity Measures 60% 50% 40% 30% 20% 10% 0% ABS CPS DSI Risk Harm Self Care Self Harm Positive Symptoms

Pembroke Regional Cornwall Queensway Carleton Ottawa Civic Ottawa General Montfort The Royal

Source: OMHRS

The below figures summarize acuity measures across each hospital for 2016/17. Green indicates that the hospital’s score for acuity is at least 10% lower than their peer comparison. Red indicates that the hospital’s score for acuity is at least 10% greater than their peer comparison. Detailed hospital and peer comparison figures can be found in Appendix 4.3.  Pembroke is serving lower acuity patients than its peers with respect to aggressive behavior, risk of harm, and self-harm.  Cornwall is serving lower acuity patients than its peers with respect to depressive scale and self-care.  Overall the below table suggests that severity of self-harm is very high among sites. Queensway Carleton appears to be serving higher acuity patients when compared to their peers for the measure of self-harm.  The Ottawa General appears to be serving higher acuity patients with respect to depressive scale.  The Ottawa Civic and Montfort are serving lower acuity patients when compared to their peers for both self-care and self-harm.  Acuity measures at the Royal may be affected by the fact that they do not have an Emergency Department and receive patients from lower levels of care, were they are stabilized in order to then receive specialty services.

34 Note: Admission Assessment and Short-Stay included.

Figure 21 Summary of Patients Acuity Measure per Scale / Index Compared to Peer Measures

LEGEND >10% Lower than Peer Within 10% of Peer Average >10% Higher than Peer Average Average

Site Percentage of Patients Measure per Scale / Index Compared to Peer Measures (2016 Q1-Q3) Positive Risk Harm Self Care Self Harm ABS >3 CPS >3 DSI >7 Symptoms >3 >3 >3 >7 Pembroke 2.60% 0.70% 10.46% 9.27% 9.52% 30.63% 2.37% Regional

Cornwall 8.69% 4.59% 4.37% 26.20% 6.61% 46.30% 1.26%

Queensway 14.60% 1.62% 13.40% 26.00% 17.10% 53.60% 8.33% Carleton

Ottawa 15.41% 2.61% 17.06% 26.44% 19.70% 36.41% 12.00% Civic

Ottawa 20.82% 6.71% 33.94% 31.47% 36.77% 45.53% 14.23% General

Montfort 17.78% 2.52% 12.99% 29.44% 11.75% 27.38% 7.99%

The Royal 16.09% 16.31% 16.31% 23.34% 24.44% 21.03% 7.21% Source: OMHRS

Patient Complexity

Patients using inpatient MH&A services may be experiencing multiple co-morbidities in addition to their MH&A challenges. This may add additional complexity to their assessment and treatment in an inpatient setting. The hospitals with the highest proportion of patients with co-morbidities are The Royal, Montfort and the Ottawa General.

Percentage of Patients with Comorbidities (2016) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort The Royal Carleton General

No comorbid medical diagnoses 1 - 2 comorbid medical diagnoses 3 or more comorbid medical diagnoses

2.6.4 Occupancy Rates

There were significant differences between sites’ perceived ability to manage patient volumes. Pembroke felt the most comfortable with managing patient volumes (but currently transfers many of their higher acuity and all non-voluntary patients to Ottawa). The Ottawa Hospital, particularly the Ottawa General site, had the most significant challenges managing patient volumes and often operates over capacity.

Occupancy (Patient Days/Funded Patient Days)

MH&A patient days can be spent in a number of locations including on an inpatient MH&A unit, in the Emergency Department waiting to be admitted to a designated MH&A bed, or in a medical/surgical bed as an off-service patient. The graph below shows total patient days over the past three fiscal years. The two sites that have the most inpatient days in non-designated beds are Queensway Carleton (off-service) and The Ottawa Hospital (ED holds).

Figure 22 Total MH&A Patient Days Including Inpatient Unit, Emergency Department, and Off-Service35

Total MH&A Patient Days Including Inpatient Unit, Emergency Department, and Off-Service 20000

18000

16000

14000

12000

10000

8000

6000

4000

2000

0 2014 2015 2016 2014 2015 2016 2014 2015 2016 2014 2015 2016 2014 2015 2016 2014 2015 2016 2014 2015 2016 Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort CHEO Carleton General

Patient Days Off-Service ED Hold MH Inpatient

Source: Site Reported Data

In Champlain the average annual occupancy rate of funded and operational MH&A beds ranges from 71% at Pembroke to 108% at Ottawa General. Occupancy greater than 100% (such as that experienced at Ottawa General) is due to sites opening unfunded MH&A beds to deal with bed pressures by converting 2-bed rooms into 3-bed rooms with the same staffing mix. Compared to the 90% funding target at the LHIN level, there are unused beds in operation at some Champlain hospitals. Most notably Pembroke, CHEO and Cornwall have unused beds in operation.

35 Note: CHEO is a sum of Mental Health and Eating Disorder Patient Days.

Figure 23 Total Occupancy Rate for Funded and Operational Inpatient MH&A Beds3637

Total Occupancy Rate For Funded and Operational MH&A Beds 120%

100%

80%

60%

40%

20%

0% Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort CHEO The Royal LHIN Funded Carleton General

2014/15 2015/16 2016/17

Source: Site Reported Data

When off-service and ED patient days are taken into consideration, occupancy levels range from 72% at Pembroke to 114% at Ottawa General, with the Ottawa Civic also experiencing occupancy levels of over 100% (106%). All of the hospitals except Pembroke and CHEO, are operating at over 90% on average and many sites experience significant variations in occupancy rates depending on surge demand.

36 The Ottawa Hospital had to open up 2 unfunded beds in the inpatient unit to deal with bed pressures. 37 Note: Sites reported target capacities of 90% so that both acute and specialty programs could be responsive to surge pressures in the ED as well as lack of community capacity resulting in ALC. It is difficult to justify having any part of the system underutilized, and holding 10% unoccupied. In the future, with better system level bed management, it may be possible to match demand and capacity and funding on a total MH system basis, and fund services and programs.

Figure 24 Total MH&A Inpatient Occupancy Including Inpatient Unity, ED and Off-Service

Total MH&A Occupancy Including Inpatient Unit, Emergency Department, and Off-Service 120%

100%

80%

60%

40%

20%

0% Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort CHEO The Royal Carleton General

2014/15 2015/16 2016/17

Source: Site Reported Data

Recognizing that 100% occupancy is not the target of hospitals operating in Champlain, an analysis assuming funded capacity of 90% was completed. There appears to be unused inpatient capacity in the Region, particularly at Pembroke. There are also unused bed days at CHEO, however these are pediatric programs. The Ottawa Hospital (both sites) and the Royal appear to be the most capacity constrained. Queensway Carleton and Montfort are also operating over a 90% occupancy target. It is important to note that even though the majority of sites in Champlain are operating over 90% does not mean they are operating at 100% capacity.

Figure 25 Unused Inpatient Funded Beds per Day in Champlain38

Unused Bed Days Per Day in Champlain LHIN 10.00

5.00

0.00 Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort CHEO The Royal Carleton General -5.00

-10.00

-15.00

-20.00

-25.00

2014/15 2015/16 2016/17

Source: Site Reported Occupancy Data

2.6.5 Service and Operations

Patients, families, and care providers identified a number of opportunities to enhance the care received in inpatient MH&A settings across Champlain.  System Focus on Stabilization: Patients, families, and care providers identified that inpatient MH&A care is commonly focused on patient stabilization rather than treatment. This can result in limited and delayed access to professionals including psychiatrists and psychologists; individuals with lived experience indicated that they had to wait days to be seen by a psychiatrist in an inpatient unit. There is also misalignment between the expectations of patients and their families and the care they receive during inpatient stays. This includes receiving higher doses of medication than expected and having less access to therapy and counselling.  Communication Across Circles of Care: Families, providers, and partners identified that it was often challenging to define and implement a connected and coordinated circle of care which can negatively impact care planning, particularly as patients transit the system. Families and non-hospital partners, including primary care providers, community agencies, police and ambulatory services often report feeling disengaged in the

38 Note: Based on site reports, have assumed 90% funded rate. Assumed CHEO has 25 funded beds and the Royal has 210 funded beds (12 of which discharge on weekends).

coordination of a patient’s care. In some instances, the above mentioned groups are excluded from the circle of care and are therefore not getting the information they need to ensure safe and appropriate care and support care planning and transitions. It is important to explore ways to involve and disseminate information appropriately, while at the same time, respecting the privacy and autonomy of patients.  Integration of Mental Health and Addictions Services: Mental health and addictions services need to be a part of a common system given the interdependencies in care. Studies indicate that individuals with a mental illness are twice as likely to have a substance use problem compared to the general population. At least 20% of these individuals with a mental illness have a co-occurring substance use problem.39 However, in the current system, addictions is often a contraindication for many mental health inpatient programs, preventing access. MH&A services also need to be integrated and aligned with broader physical health to ensure holistic patient care.  Need for Consistency and Standards: Unclear processes and procedures result in inconsistent patient experience and expectations depending on a patient’s health service provider. Unclear standards of care, care pathways, as well as minimum standards or scope of services contribute to differences in baseline care received at different sites across Champlain. Health Quality Ontario (HQO) has developed quality standards for Behavioural Symptoms of Dementia, Schizophrenia, and is currently in the process of developing quality standards for Opioid Use Disorder and Schizophrenia care in the community. Implementing these tools will require changes to clinical pathways, decision supports for clinicians, changes to clinical systems, greater collaboration with community providers and increased education and training. The noted differentiation in standards of care is also affected by a lack of common tools across sites to support admission, assessment, and discharge. This is consistent with the recent Auditor General’s Report which stated that the “Ministry [of Health and Long Term Care] has not created mental health standards to ensure that specialty psychiatric hospitals are consistent regarding which patients they admit, how they treat those patients and how those patients are discharged.”  Need to Enhance Compassion and Respect: Patients indicate that they desire to be treated with compassion and empathy throughout their inpatient stay as well as at transition points from inpatient care to community. Those with lived experience explained that there is stigma associated with entering a MH&A care program, especially in the emergency department.  Integration of Outcomes: Clinicians and individuals with lived experience indicated that there is a need to embed patient outcome and service measures (e.g., ED wait times, timely discharge, connection to community) into clinical services to ensure that the

39 Centre for Addiction and Mental Health. Mental Illness and Addictions: Facts and Statistics. Retrieved from: http://www.camh.ca/en/hospital/about_camh/newsroom/for_reporters/Pages/addictionmentalhealthstatistics.aspx

highest quality of care is provided to inpatients and so hospitals can be held accountable for the care they provide.

2.6.6 Use of Technology

There is a strong desire for the use of technology in today’s healthcare system. Technology has the ability to improve efficiency for those providing care as well as overall patient satisfaction. Telemedicine, including Ontario Telemedicine Network (OTN), is used across a number of facilities in the Champlain LHIN to improve access to mental health care. For example, The Royal completed approximately 3,600 OTN encounters in that last fiscal year. Currently, OTN capabilities are most commonly used to support appointments and/or screening for admission if travel is difficult. However, there are many opportunities to expand the use of OTN in Champlain including for the provision of treatments and therapy sessions.  There are some examples in Champlain of innovative ways to use OTN. This includes a Pilot between CHEO and Cornwall using OTN to complete an assessment with patients to determine if it is appropriate for the patient to be transferred to a higher acuity site.  There is an increasing use of OTN and tele-psychiatry at The Royal for Indigenous clients in order to reduce waitlist times and get patients access to the psychiatry services they require. There is still a reported lack of virtual and tele-psychiatry supports for Primary Care Providers.  Community Mental Health Program (CMHP) uses OTN to support inpatient teams and other services across the region.

Engagement with stakeholders indicated interest in OTN and working to include technology in the standard of care for patients. It is important to note that there was also resistance expressed by many providers and patients in Champlain regarding the use of OTN as there is a large cultural shift that would need to occur in order to efficiently use OTN to provide MH&A services. Table 7 Technology Capabilities per Inpatient MH&A Program at The Royal

Telemedicine The Royal Program Capability Details (Including OTN) Crisis  No dedicated capability for inpatient unit  services Champlain Forensic  OTN used for court connections and video remands  OTN used for inpatient medical clinics  example to cardiology  OTN transfer of care meetings between Forensic programs Geriatric  Aspects of care during admission can be  completed via OTN, including discharge planning and family meetings

Telemedicine The Royal Program Capability Details (Including OTN) Mood & Anxiety  No dedicated capability for inpatient unit  services Recovery  Inpatient services cannot be provided via OTN however OTN is available for family  appointments and/or screenings for admission (e.g. Nunavut) Schizophrenia  Inpatient services cannot be provided via OTN however OTN is available for family  appointments and/or screenings for admission (e.g. Nunavut) SUCD-ASU  Inpatient services cannot be provided via  OTN however OTN is available for outpatient consultations, assessments and follow visits Youth  Inpatient services cannot be provided via OTN however OTN is available for family  appointments and/or screenings for admission (if travel is difficult) Concurrent Disorders  Unit Source: Site Reported Data

Table 8 Technology Capabilities at Inpatient MH&A Sites in Champlain

Telemedicine Hospital (Including Capability Details OTN) Montfort   Currently exploring the use of OTN technology with HGH partners to provide timely psychiatry consultations.  OTN is presently offered to Hearst and Hamilton for perinatal psychiatry. Cornwall   Cerner  CRMS Queensway Carleton   ARRP and CT Pembroke Regional  OTN Consults with The Royal supporting area client and their respective family physicians, in Pembroke, Renfrew, Deep River, Barry’s Bay CHEO   Tele-psychiatry consultations within the Champlain LHIN. CHEO MH has pilot program (with Cornwall Community Hospital) called Virtual-ED, which provides psychiatric assessments to emergency

Telemedicine Hospital (Including Capability Details OTN) departments in hospitals, which lack access to a child psychiatrist (completed via OTN). The Ottawa Hospital   TOH has 3 telemed clinics  Overall increase in levels of telemedicine use Source: Site Reported Data

2.7 Patient Flow

Key Questions for this Section:  What is the typical patient flow through the inpatient MH&A system?  How does data move through the inpatient mental health and addiction system?  Are their challenges with equity in inpatient MH&A care?  Urban and rural  Language  Indigenous  Addictions and mental health  Special high-needs populations  Are conditions being treated with inpatient services that are best managed elsewhere?  How is the flow of patients from community to hospital and back to community working?  Do community agencies have the capacity they need to adequately support patients discharged from hospital (or is lack of capacity creating backlogs in hospital)?

2.7.1 Entry and Admission

Admission into Inpatient MH&A

Patients can enter the inpatient MH&A system through a variety of mechanisms including the Emergency Department, transfer from another hospital, referrals from community providers (e.g., ACTT, crisis teams), direct referrals from physicians, and the court system (for forensic patients).

Stakeholders identified challenges getting patients access to the appropriate level of care within the system. This is partially a result of a lack of coordinated access and management among inpatient mental health and addiction sites. In Champlain, there is a decentralized responsibility for securing access to care for patients as well as inconsistent discharge practices at sites. This leads to the perception that patients may be receiving services at the wrong level of care and/or at an incorrect facility.

 Available definitions to clinicians are unclear and inconsistent and do not support them to determine the most appropriate level of care and support patients to access it. The Royal has started to use the Level of Care Utilization System (LOCUS) model; however, this model is not used broadly across the region to help determine the most appropriate place for the patient to receive treatment. This challenge is further compounded by limited accountability in Champlain for one individual or a governing body to prioritize patients based on acuity and preferred language and get them access to appropriate care.  Coordinated and central intake at hospitals has been helpful to facilitate entry into the system. Centralized intake at The Royal (including the partnership with CHEO for the youth MH program) was viewed positively by system stakeholders.

Among patients and clinicians, there is a lack of understanding of what criteria allow for patients to be admitted into inpatient MH&A programs and services. This stems from various factors:  Unclear admission criteria and processes – This is especially apparent for specialty programs. Referring sites commonly do not know what the admission criteria are for each inpatient program and feel that the criteria change often. This may be due to lack of communication between referring and treating sites.  Lack of transparency and follow-up – It is not clear to referring clinicians why some patients are rejected from entering inpatient programs while other patients are accepted and there is lack of communication and follow-up between referring and receiving hospitals.  Perceived biases for existing patients – There is a perception among sites that there are “clubs,” or groups of patients that are seen by facilities and that access for these patients is much easier. Although providers recognized the value of continuity of care, many gave examples of lower acuity patients being transferred rather than higher acuity patients because they had an existing relationship with a specialty program. The transfer data suggest some support for this perception with low levels of admissions to specialty programs from acute hospitals. Table 10 indicates that a small proportion of admissions at each hospital are a result of transfers from other sites. For example, 13% of the Royal’s admissions come from transfers from other sites, most commonly from Ottawa Civic, Ottawa General and Queensway Carleton.

Emergency Department

A patient experiencing MH&A conditions can go to any ED across the region for service; however, entry into the inpatient MH&A system happens through schedule 1 or 3 facilities – Pembroke (only voluntary), Cornwall, Queensway Carleton, The Ottawa Hospital (2 sites), Montfort and CHEO. The Royal no longer has an emergency department.

In Champlain, the ED is the primary entry point into the inpatient MH&A system, in 2016/17 there were approximately 5560 ED visits that resulted in direct admission to a site with inpatient MH&A beds representing 79% of the region’s admissions. Overall, ED visits for MH&A-related conditions has increased, especially at the acute centres in Ottawa including The Ottawa Hospital, Montfort and Queensway Carleton. Figure 26 Total MH&A ED Visits per Hospital in Champlain40

Total MH&A ED Visits 14000

12000

10000

8000

6000

4000

2000

2013 2014 2015 2016 (Projected)

Source: NACRS

Champlain LHIN has much higher ED rates for certain MH&A-related conditions. The rate of ED visits and hospitalizations for Intentional Self-Harm per 100, 000 is almost double the Ontario average and is especially challenging in Western (81.6) and Eastern Champlain (89.2). ED visits for

40 Note: Assumed 2016 straight line projection based on Q1-Q2 data. MH&A ED visit are visits with ICD-10 Chapter 5 Mental and Behavioural Disorders (F00-F99 for Main Problem) OR Intentional Self-harm (X60-X84, Y87.0 for Any Diagnosis) OR Poisoning & Toxic Effect of drugs, medicaments, biological & non-medicinal substances (selected T codes for Main Problem) OR Factors influencing health status and contact with health services (selected Z codes for Main Problem; eg.: psychiatric exam, psychotherapy, alcohol/drug rehabilitation).

Opioid Related Harm are also problematic, especially in Western (80.3) and Eastern Champlain (82.9).

Figure 27 ED Visits for Intentional Self Harm41

ED Visits - Intentional Self-Harm 100 90 80 70 60 50 40 30 20 10 0 Western Western Ottawa Central Ottawa Eastern Ottawa Eastern Champlain Ontario Champlain Champlain

Emergency Department Visits for Intentional Self-Harm per 100, 000 per fiscal year quarter (2014/15-2015/16) Hospitalizations for Intentional Self-Harm per 100,000 per fiscal year quarter (2012/13-2015/16)

Source: LHIN Sub-Region Profiles

41 Note: Average rated per fiscal year quarter, calculated over several fiscal years. Akwesasne and out of LHIN postal codes not included.

Figure 28 ED Visits for Opioid Related Harm

Emergency department Visits for Opioid Related Harm per 100,000 ) per fiscal year quarter (2012/13-2015/16) 90 80 70 60 50 40 30 20 10 0 Western Western Ottawa Central Ottawa Eastern Ottawa Eastern Champlain Champlain Champlain

Source: LHIN Sub-Region Profiles

Most providers, patients and families recognized that entry through the ED is not the most efficient use of resources nor the most person-centered approach. However, direct referral or facilitated entry into the inpatient system was perceived to be too challenging with the current infrastructure and processes in Champlain.  Many clinicians, administrative teams and those with lived experience identified that the ED department was the easiest way to enter into the inpatient MH&A system and access necessary resources. Perception exists that the only way to get access to treatment in the MH&A system is to go through the ED.  There are limited emergent psychiatric ED resources in the region. Unlike TC LHIN, Champlain does not have a psychiatric ED (like the one at CAMH). There are also gaps in resources and entry points for patients that need services but may not require an inpatient stay (e.g., mid-level, rapid, urgent access).  There are a number of programs and initiatives underway that focus on providing alternative options for patients needing to access care rather than waiting in the ED including: o CRISIS teams that link patients with resources in the community. Queensway Carleton recently added a MH crisis intervention team in the ED. The first year of the program has shown success with referrals to psychiatry having decreased 20% and patients who are referred are more likely to be admitted. At Cornwall, 90% of the patients in the ED with a mental health diagnosis are see by their mobile crisis team.

o The Ottawa Hospital’s Psychiatric Emergency Service (PES) where patients receive immediate access to a MH specialist through the ED. o The Targeted Engagement and Diversion (TED) program in Ottawa is designed to divert the homeless population to Ottawa Inner City Health where they are observed and then receive appropriate care, such as addictions services. The Psychiatric Outreach Team of CMHP at the Royal provides psychiatric support to the TED program. o Crisis beds at The Royal for patients followed in the hospital’s outpatient programs. o Geriatric Psychiatry Program Services operating across the LHIN in a collaborative care model. o The Alcohol Medical Intervention Clinic (AMIC) provides rapid access to safe outpatient alcohol medical withdrawal management services direct from The Ottawa Hospital ED. o Familiar Faces program at Queensway Carleton, the Ottawa Hospital and Montfort to connect those with severe mental illness and have had repeat admission or repeat unscheduled ED visits to appropriate community resources through system navigation, transitional case managers and referrals to community MH&A support services.

Providers and patients also identified a number of challenges related to ED care with respect to admission, specifically the use of involuntary admissions as well as MH&A patients being admitted off-service to medical or surgical beds.  In 2016 there were projected to be 256 admissions to hospitals that did not have any inpatient MH&A capacity. Referring hospitals often reported having to hold patients in the ED for long periods or admit them off-service while they wait for a transfer to a hospital with designated MH beds.  Patients can enter the inpatient MH&A voluntary or involuntary (under the Mental Health Act). However, stakeholder engagement identified many instances of this tool being used inappropriately to support access to MH&A services. o Both referring and receiving hospitals reported that a large number of involuntary admissions must be reversed after assessment. Providers and patients described examples of clinicians using involuntary admissions as a tool to try and get their patients access to inpatient mental health and addiction programs and services, even though they knew that they were inappropriately using this tool.

CritiCall

CritiCall is a provincial system dedicated to supporting access to and delivery of urgent and emergent care in Ontario. CritiCall provides on-call coverage for inpatient MH&A beds. CritiCall

ensures that a psychiatrist is always available for consult and that there is an inpatient bed registry for Schedule 1 facilities.  The current mental Health CritiCall assignment is a 5-week repetitive rotation whereby the Ottawa Hospital is assigned 4 weeks and Queensway Carleton Hospital is assigned one week. Transfers from Winchester District Memorial Hospital and Glengarry Memorial Hospital are supposed to refer to Cornwall; however, due to coverage challenges at the site Cornwall has not been able to accept CritiCall transfers. Since May 2017, transfers from Hawkesbury to Montfort have been coordinated through the CritiCall system, prior to May 2017, the transfers took place through an Assurance of Access Agreement between Montfort and Hawkesbury.  The current schedule appears to place a burden on the Ottawa Hospital, which is already struggling with capacity challenges due to its own volumes.  There is no surge plan in place for when there are no beds available at the site on-call.  Since Pembroke is not a schedule 1 facilities, all of the non-voluntary admissions must be transferred to a hospital in Ottawa (either the Ottawa Hospital or Queensway Carleton).

Figure 29 Total CritiCall Referrals by Referring Hospital (2016)42

Total Criticall Referrals by Referring Hospital (2016) 90 80 70 60 50 40 30 20 10 0

Referring Hospital

Source: CritiCall Ontario. Mental Health and Addictions. Jan 01 - Dec 31 2016

Between January and December of 2016, there were 266 CritiCall cases, of those, most (47%) were for suicidal/suicidal ideation. This total does not include the transfers currently taking place between Hawkesbury and Montfort through the Assurance of Access Agreement between Montfort and Hawkesbury which add another 76 similar transfers to the total regional volume.

42 Most of Hawkesbury’s emergent transfers go to Montfort outside of the CritiCall system due to the large proportion of Francophone residents in the local area. Last year (FY 2016/17) Hawkesbury transferred 76 patients to the ED at Montfort.

Figure 30 CritiCall Cases by Diagnosis

CritiCall Cases by Diagnosis 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

Source: CritiCall – Mental Health Summary Report, 2016

In total, 80% of the cases resulted in a transfer of patients, while a combined 20% included a consult being completed or no transfer required. The Ottawa Hospital (combined sites) received 77% of the transferred cases.

Figure 31 Final Outcome for CritiCall Cases

Final Outcome for CritiCall Cases

Patient Listed Patient To Remain

Send To Clinic Transfer Accepted HLOC Source: CritiCall – Mental Health Summary Report, 2016

Table 9 Total Number of CritiCall Cases Received Per Hospital in Champlain43

Total Number of Cases Received by Each Hospital Jan 2016 – Dec 2016

% Cases Median Total of Cases Median Receiving Hospital Received Response Accepted 2016 Accept MTH 2016 MTH

Cornwall 7 3.40% CHEO 6 2.90% 3.6 14 Montfort 1 0.50% Queensway Carleton 33 16.20% 7.2 23 Ottawa Civic 83 40.70% 4.1 20.6 Ottawa General 74 36.30% 4 22.8 LHIN Total 204 1 18.9 80.4 Source: CritiCall – Mental Health Summary Report, 2016

43 Most of Hawkesbury’s emergent transfers go to Montfort outside of the CritiCall system due to the large proportion of Francophone residents in the local area. Last year (FY 2016/17) Hawkesbury transferred 76 patients to the ED at Montfort.

2.7.2 Patient Flow

Hospital Transfers and Repatriation

There are significant levels of patient flow within the inpatient MH&A system. Transfers occur from community, to acute, to specialty programs and then eventual repatriation back to non- tertiary care or community. These transfers are where a significant number of challenges exist, especially when trying to manage capacity at a system level. Transfers are challenging for both hospitals as well as patients and their families for a number of reasons.  Lack of integration and strong relationships between referring community hospitals and acute care sites and between acute care and specialty MH&A programs making transfers difficult.  Transitions or transfers from the youth inpatient MH&A system to the adult system are difficult to navigate for patients.  Challenges for patients in acute MH&A beds to gain access to specialty programs as evidenced by the proportion of admissions to The Royal’s specialty programs from acute inpatient MH&A facilities.  Limited admissions to specialty programs on weekends makes managing bed flow challenging as acute hospitals with EDs may experience surges over the weekend.  Specialty hospitals have limited options available to discharge ALC patients and free up inpatient beds. Acute and community hospitals indicated a similar situation in terms of ALC. It is important to note the possibility of stigma attached to mental health patients, especially patients with a prior history of responsive behaviours who may, as a result, be repatriated in a less timely manner.

Although challenges still exist, there have been advancements in the right direction including forums for collaboration and relationship building. These include: The Inter-hospital committee; daily meetings between MH managers at Queensway Carleton, the Royal, Montfort and The Ottawa Hospital; and, the implementation of central intake and Director of Flow at the Royal.

Table 10 Number of Admissions Transferred to Other Hospital in Champlain44

Source: OMHRS Note: The ‘transfer to’ location can be an inpatient mental health bed or another service. Additional hospitals, nursing homes/homes for the aged and internally used classifications are all included under “Other” in the table.

44 Ottawa Civic Note: Other includes Min of health Internally used classification, nursing home, home for the aged, Kingston General Hospital, Mackenzie Health, and transfers within Ottawa Civic Site. The Royal Note: Other includes nursing home, home for the aged, Brockville General Hospital – Elmgrove Site, Hawkesbury and District General Hospital, Ottawa Civic Hospital Familiy Medicine, CAMH, Renfrew Victoria Hospital, Baycrest Hospital, ROHCG – Brockville, Homewood Health Centre, Almonte General Hospital, and Anson General Hospital, as well as transfers within the Royal. Ottawa General Note: Other includes Min of health Internally used classification, nursing home, home for the aged, Ottawa Hospital Rehab Hospital, Ontario Shores Centre for Mental Health Sciences, and transfers within the Ottawa General Site. Montfort Note: Other includes Min of health Internally used classification, nursing home, home for the aged, Ottawa Hospital Rehab Hospital, Hawkesbury and District General Hospital, Saint Francis Memorial Hospital, Home Care Program, and transfers within Montfort. Queensway Carleton Note: Other includes Min of health Internally used classification, CHEO, and within Queensway Carleton. Pembroke Note: Others include nursing home, Renfrew Victoria Hospital, Deep River and District Hospital, Supportive Housing, and within Pembroke Regional.

Figure 32 Percentage of Total MH&A Admissions Due To Inpatient Transfers

Percentage of Total MH&A Admissions Due to Inpatient Transfers 14%

12%

10%

0% Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort The Royal Carleton General

Source: OMHRS

2.7.3 Discharge

Discharge Disposition

The transition out of inpatient MH&A care can be difficult for both patients and families. Reported data indicates that most inpatients are being discharged to a private home, apartment or rented room. Across all sites, between 55 and 90% of patients are being discharged home. This is highest for Pembroke (92%), Cornwall (86%), and Queensway Carleton (87%). The Royal shows more variation and commonly discharges patients to long-term care homes (10.8%)45.

Housing still remains a major issue in Champlain LHIN. Almost all sites have a small percentage of patients categorized as homeless upon discharge (with or without shelter support). Most notably, Montfort has 5.99% of patients discharged to homelessness (with or without shelter support). Hospitalized and homeless is a challenge both in urban areas where there is pressure to move long-term shelter clients into newly available capacity and in rural areas where shelter capacity does not exist. There are partnerships in place in order to address these issues including the Psychiatric Outreach Team at the Royal who provides a social worker who works in partnership

45 This increased discharge to LTC may be due to Geriatric Psychiatry Outreach services serving all LTC homes across Champlain and providing equitable access to the specialized Inpatient beds.

with the Ottawa Hospital inpatient MH units to support those being discharged to shelters or housing partners to provide a bridge in care and work to prevent readmissions.

Figure 33 Inpatient Discharge Destination

Inpatient MH&A Discharge Destination (2016) 120

100

0 Pembroke Cornwall Queensway Ottawa General Ottawa Civic Montfort The Royal Carleton

Private home/apartment/rented room Board and care/assisted/semi-independent living Psychiatric hospital or unit Homeless (with or without shelter) Long-term care home (nursing home) Acute unit/hospital Unreported

Source: OMHRS, 2016 Q1-Q3

Discharge Planning and Care Coordination

As described in the figure above, the majority of patients across all sites are discharged home following an MH&A inpatient stay. This means that most patients will require some extent of after-care and ongoing treatment in the community. A number of challenges were identified by clinicians and patients.  Inconsistent discharge planning across MH&A inpatient sites. This is partially due to constrained capacity in the hospitals. Discharge planning is to be completed by social workers and care coordinators, however, there are limited number of FTE per funded bed for these specific roles. Queensway Carleton recently completed a number of quality improvement projects to improve throughput in inpatient MH&A units, one of which included implementing rounds, earlier discharge discussions and discharge planning.  Limited transition supports in the current system. Often there is not direct flow from inpatient to community programs (e.g., ACTT) and community services receive referrals

after a patient has left the inpatient unit and has already re-entered the community. Alternatively, hospitals may be keeping patients until ACTT teams can complete their assessment, which contributes to inpatient beds being used for inappropriate level of care. When looking at ACTT specifically, it is important to note that often times, provincial criteria set for eligibility to ACTT are not met within an admission. There are also long waiting lists for ACTT in the Champlain Region due to limited available resources for high demand. For example, CMHA Ottawa has transition teams in place to assist patients transitioning from hospital to community, however stakeholders indicated that they are difficult, if not impossible, to access.  Care coordination and case management is not standard or consistent across multiple sites and services, ultimately leading to patients and their families acting as coordinators. This leads to unclear oversight of a patient’s comorbidities and drugs, as well as overall disease management. Some improvement has occurred in the system, for example, Forensics at the Royal has introduced Transitional Rehabilitation Housing Programs (THRPs) which provide intensive case management services to forensic clients, promoting recovery and helping them to successfully navigate the transition into community life.  Lack of standardized information flow leading to the inconsistent availability of information when a patient goes into or is discharged from the hospital. As mentioned previously, there is a disconnect between community programs and hospitals. A tool, such as common health records or services care plans, is needed to allow for consistent sharing of information. This challenge can also be mitigated by improved relationship building between providers in the community and hospital.

Relationships and Communication with Community Providers

There are various groups of providers that deliver care and service to patients in a community setting. These providers take over care upon discharge and provide ongoing support and treatment to patients with MH&A issues. Connections to the inpatient MH&A system is critical to support patients across the continuum of care and to effectively manage transitions. A number of opportunities for improvement were identified.  Need for increased communication and inclusion of community providers in the circle of care. Community providers (including some hospital-based community programs) identified that it is often a challenge to be included in their patient’s circle of care when they are in an inpatient setting. This impacts their ability to inform care decisions, contribute to discharge planning and help manage transitions. o Community providers (including many hospital-based community programs) do not have access to patient records. In this respect, programs such as the Royal community health passport program have been beneficial. Another good initiative is that of the Ottawa Hospital and the ACT teams who recently collaborated on a common referral form for their patients attending Emergency

Departments to ensure consistent and relevant clinical and contact information. Overall there is a need for increased information transfer both between hospital and community as well as community to hospital.  There is currently a lack of awareness about what community programs exist and what their specific admission criteria are. This can be improved by increased communication and stronger relationships between community and inpatient service providers, and general transparency and consistency in criteria application. o A positive example, showing strong partnerships includes the geriatric program at The Royal. The program provides both urgent back-up services and outreach services for seniors in LTC settings (Rural Outreach services across Champlain and a section of the SE LHIN and Geriatric Psychiatry Community Services in Ottawa) and Long-Term Care residents, thereby reducing the number of visits made in acute care settings, as well as providing preventative services through outreach and Ambulatory care, thereby avoiding acute episodes altogether. o The Familiar Faces program, which supports clients who are not directly supported for 2-3 months while they wait to transition to community services (either case management or ACTT) was seen as a positive example of improving relationships and transitions for patients. Ultimately that goal of the program is to ensure patients are appropriately connected to community supports, to decrease repeat admission within 30 days of last visit and to increase overall patient satisfaction and well-being. The program has experienced minor issues with overall greater demand than supply.  Need for increased supports for community providers dealing with high acuity patients. Many individuals have no access to primary care further compromising the care of those with a mental health diagnosis. Where individuals do have access, Primary Care Providers currently have a difficult time managing medications for patients with severe MH&A and often need support from the patient’s psychiatrist.

2.7.4 Conditions Best Managed Elsewhere

In order to best use the resources and capacity in the system, it is important to treat patients in the most appropriate setting. Inpatient MH&A care that can be best managed elsewhere includes:  Patients that are in designated to inpatient MH&A beds that would be best managed elsewhere (traditional ALC).  Patients that are in an off-service bed (medical or surgical unit or Emergency Department) waiting for a designated bed to come available. This could happen both at sites with inpatient MH&A beds if there are capacity challenges on the unit as well as hospitals without inpatient MH&A beds if they are unable to transfer patients to a site with a designated bed.

 Patients that are in a designated MH&A bed but are waiting for a bed in a different acuity setting (e.g. patient in an acute MH bed waiting to be transferred to a specialty inpatient program at another hospital).

Overall, hospitals in Champlain LHIN are struggling with all three types. In addition, the Royal provides Electroconvulsive Therapy (ECT), with limited resources both for inpatient and outpatient ECT. Outpatient ECT is primarily maintenance ECT, leading to very limited capacity for providing a full course of outpatient ECT, leading to many patients being admitted to the hospital. The Ottawa Hospital also provides ECT on both an inpatient and outpatient basis. The Ottawa Hospital should limit the provision of ECT to patients with complex medical needs. If processes and protocols were to be improved, patients could receive ECT as an outpatient. Research shows that there are neurostimulation tools being used elsewhere, including at the Centre for Addiction and Mental Health. CAMH is currently using Transcranial Magnetic Stimulation (TMS) and ECT on an outpatient basis.

ALC Rates

Overall, Champlain region has a better MH&A ALC rate than the provincial average, however there is a lot of variability between sites with quarterly rates ranging from close to 0% up to a maximum of 24.4% since 2012. The most variability is seen in ALC rates at Ottawa General and Pembroke.  Champlain LHIN’s MH&A ALC rate (8.2%) is slightly below the provincial average, however, 8 out of every 100 patient days are still taken by waiting for another care setting.  The lowest average ALC rate for MH&A is Queensway Carleton which has ranged between 1% and 7.9% with an average of 3.5% since 2011.  The highest average ALC rate for MH&A is Pembroke which has ranged between 1% and 24.4% with an average of 11.5% since 2011. The most significant variation is seen at Pembroke, with peaks generally happening in November through to January, potentially suggesting a structural issue.  The ALC rate at The Ottawa Hospital is increasing, especially at the General Campus which has ranged between 12.8% and 19.7% since 2015.  The Royal’s ALC rate has remained quite stable over the past number of years, while many sites ALC rates have decreased and stabilized.  CHEO’s ALC rate is low ranging between 3% and 4.8% since 2014.

Figure 34 Quarterly Mental Health ALC Rates46

Quarterly Mental Health ALC Rate 30%

25%

20%

15%

10%

0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 13/14 13/14 13/14 13/14 14/15 14/15 14/15 14/15 15/16 15/16 15/16 15/16 16/17 16/17 16/17 16/17

Ontario Champlain Royal Ottawa Montfort Pembroke Queensway Carleton Ottawa Civic Ottawa General Cornwall

Source: Access to Care, Cancer Care Ontario

The MH&A ALC rate is primarily driven by two factors: waiting for Supervised/Assisted Living (3.2% of 8.2%) or Long Term Care (3.4% of 8.2%). These two factors being the largest contributors to a region’s overall ALC rate are similar to other LHINs across the province. This is consistent with the recent Auditor General’s Report on Specialized Psychiatric Hospitals which found that “specialty psychiatric hospitals are now more and more playing the role of long-term-care homes for patients with dementia, brain injury or intellectual disability, or the role of supportive housing” and that many “more people could have been treated if patients were not staying in the hospitals longer than necessary as a result of a shortage of beds in supportive housing and long-term-care homes”. Within the pediatric system the largest contributors to ALC are patients waiting for transfer to the Children’s Aid Society, resident treatment centres, other specialty programs, and waiting for discharge home. Hospitals across the region are not consistently tracking the diagnosis of ALC patients and so a quantitative breakdown of ALC by diagnosis was not included in the analysis. Qualitatively, sites reported that dual diagnosis and neuropsychiatric disorders accounted for the largest proportion of ALC patients.

46 Note: Some ALC rates are missing in recent years.

Figure 35 Percent Contribution to Mental Health ALC Rate by LHIN and Discharge Destination

Percent Contribution to FY 15/16 Mental Health ALC Rate by LHIN and Discharge Destination 30%

25%

20%

15%

10%

0% Central Provincial South East North East Champlain South West North West Erie-St.Clair Central East Central Central WestCentral Toronto Central Mississauga Halton Mississauga Waterloo Wellington North Simcoe Muskoka North Simcoe Hamilton Niagara Haldimand Brant Haldimand Niagara Hamilton

Complex Continuing Care Convalescent Care Home with CCAC Home with Community Services Home without Support Long Term Care Mental Health Palliative Care Rehab Supervised or Assisted Living Unknown TBD

Source: Access to Care, Cancer Care Ontario

This trend is also evident at the site level, Supervised/Assisted Living and Long Term Care are the biggest contributors to ALC at every hospital. Waiting for Supervised or Assisted Living looks to be an increasing problem and is the largest contributor to ALC at Ottawa General (11.2% in 15/16), Ottawa Civic (4.9% in 15/16), Pembroke (15.6% in 15/16), Montfort (4.0% in 15/16), and Queensway Carleton (4.0% in 15/16). While Supervise/Assisted Living is still an issue at The Royal and Cornwall, the largest contributor at these sites was Long Term Care (The Royal was 4.8% and Cornwall was 8.7% in 15/16). Refer to Appendix 4.5 for detailed graphs.

Other Instances of Care not being delivered in the right place

There are other instances of care not being delivered in the right place that are not captured by traditional ALC Rates. These include MH&A patients being off-service (medical or surgical bed), being held in the ED while waiting for a MH&A bed and patients waiting in a MH&A bed for a higher or lower acuity bed to come available. Many of the inpatient MH&A units in Champlain are struggling with all three challenges.  Many community hospitals that have patients present to the ED with MH&A conditions often have to hold a patient in the ED or admit them to a non-MH&A bed while waiting for a transfer which can sometimes take multiple days.  Many of the acute care hospitals identified that it can be very challenging to get new patients admitted into specialty programs. This challenge is echoed when discussing the identified lack of dual diagnosis inpatient beds in Champlain LHIN.  In addition, once a patient no longer needs specialized MH&A care, repatriation can be a significant challenge resulting in patients remaining in inpatient beds.

2.7.5 Community Capacity Impact

The scope of this review was limited to inpatient MH&A capacity; however, to understand flow into and out of the inpatient system qualitative input was gathered on how community capacity is impacting flow through and demand for inpatient capacity. Champlain LHIN spends approximately the same as the provincial average ($72 versus $71, respectively) on community MH&A and addictions services (excludes care provided by community psychiatry). Stakeholders indicated that community capacity is constrained by multiple factors.  Many community programs have long wait-lists, some of which have a wait time of multiple months to years in extreme cases. This was also true for higher acuity patients being treated in the community through ACTT programs.  Challenges with capacity for outpatient services such as ECT treatment, especially for maintenance. Outpatient ECT helps to support people staying in and receiving treatment in the community.  Lack of support for Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) in the community.  Lack of community supports for specialized populations, including supportive housing for Dual Diagnosis. Dual Diagnosis refers to individuals with a developmental disability or disorder who also develop a mental health problem. The KPMG Provincial Review of Dual Diagnosis Programs reports that limited access to supportive housing with adequate staffing levels and skills is a key barrier to patient flow and a contributing factor to high number of ALC clients that exist in hospitals.

 Lack of PTSD/specialized trauma supports for patients including refugees, women, as well as youth populations. It was reported that these individuals will often present to EDs and will impact waitlists for general psychiatry programs.  Lack of comfort for Primary Care Providers to manage MH&A. Collaborative care models such as the Family Health Team model to support interdisciplinary teams are not common in Champlain LHIN. Figure 36 Community MH&A LHIN Funding Per Capita47

Community MH&A LHIN Funding Per Capita $250

$200

$150

$100

$50

Source: MLAA Sector Funding by LHIN, 2015

2.8 Access and Equity

Key Questions for this Section:  How accessible and equitable are inpatient MH&A services across Champlain, specifically for:  Urban and rural populations  Francophone populations  Indigenous communities  Specialized clinical populations

47 Note: Straight per capita measures, not adjusted for population characteristics, other (non-LHIN funded) programs or cross-LHIN care seeking patterns.

2.8.1 How equitable is access to inpatient MH&A Services?

Patients and those with lived experience indicated that the MH&A services they received varied depending on where care was accessed across the Champlain region. This indicates that standards of care may be unclear and not uniform across sites and providers. Select populations of patients also indicated variance in the care that is available to them and ultimately received.  Francophone: Language is a critical component of MH&A care, and Champlain LHIN has the largest number of Francophones in the province creating a need for French Language Services MH&A services in the region. Montfort is the only facility where all acute and specialized MH&A services are available in French. All other facilities, except for Queensway Carleton Hospital, have the ability to use bilingual staff and some have designated French language services. When determining which location to bring a patient, language preference is not currently part of dispatch procedures for police or ambulance, making it difficult to triage patients to the most appropriate location of care. In addition, there is currently limited Francophone housing providers in the Champlain region to support transition out of inpatient care. Individuals requiring Francophone services do however get more rapid access to many community services as they have lower wait-lists. Stakeholders indicated that wait times for community services varied from 1 month for Francophone patients to 18 months for Anglophone patients.  Indigenous: Current relationships between communities and hospitals need to be enhanced in order to ensure effective transitions for Indigenous patients as well as the provision of culturally appropriate care. This could include the involvement of Indigenous community groups from admission through to discharge to ensure continuum of care and care transition. Partnerships at some site are flourishing, including current work between Health Services Pikwakanagan and the Royal to develop partnerships to better work with community and build additional community programming. Upon discharge, many patients end up on the street as the wait lists for Housing First programs are very long. There is therefore a need for enhanced aftercare. Overall, there is a need for more willingness among providers and support staff to reach out and engage with Indigenous communities in order to provide services that are specific to the unique needs of Indigenous patients. Some progress has been made including the Royal recently approving a comprehensive strategy to improve services for indigenous people including cultural safety and sensitivity training for staff, efforts to recruit and hire more indigenous staff, physical changes to the building to include more Indigenous art and space and continuing to evolve cooperative programs with Indigenous service agencies to improve care pathways and service delivery for Indigenous clients.  Urban versus Rural: Specialized inpatient programs (other than the geriatric psychiatry program) require travel to Ottawa limiting access for patients from rural communities. This is compounded by lack of community program and supports to treat patients in the community and keep them out of inpatient settings.

 Geriatrics: Geriatric in-patient programs are the only programs that allow for patients with dementia leading to high demand. These beds are also located in the Urban-Ottawa region leading to challenges with rural areas where there are high proportions of seniors. Additionally, there are many seniors with MH&A challenges that are occupying acute beds which creates challenges for discharge planning and results in waitlists for geriatric programs.  Pediatrics and Youth: CHEO is the primary facility that serves the youth population in Champlain. A Youth program offered at the Royal also specifically serves children between the ages of 15.5 and 18. CHEO also offers the only dedicated eating disorder program with 6 beds serving stable youth up to the age of 16, which was described by stakeholders as being focused on stabilization rather than treatment. Overall, capacity for youth services is constrained, especially for transitional aged youth who are needing to move from the youth to adult inpatient programs and services.  Access to Treatments and Therapies: There is limited access to Electroconvulsive (ECT) and CBT and DBT therapy in Champlain. ECT services are centralized in the Urban-Ottawa area, available at The Royal, Montfort and the Ottawa Hospital. These services have the potential to keep patients out of MH&A inpatient beds, including individuals with borderline personality disorder.  Special Clinical Populations: This includes patients that are do not have access due to admission criteria, o Admission criteria of many programs limits care for those that have both mental health and addictions issues, otherwise referred to as concurrent disorders. Recent restructuring of certain programs has resulted in better access to medical detox beds and improved community care pathways. However, the Royal is the only facility that has a dedicated 12-bed inpatient program for concurrent disorders48. Care providers indicated that there is a need for a treatment facility for patients with concurrent disorders, which is accessible to all, including indigenous individuals and French speaking individuals. o Addictions specific programs are limited in the Champlain region. The addictions program at The Royal includes various outpatient and inpatient services that are harm reduction based, including an inpatient medically supervised withdrawal management unit as well as an inpatient concurrent disorders unit. The Ottawa Hospital also does not have an addictions program available. In general, there is a disconnect between mental health and addictions programs across the Province. There is a need for increased integration between mental health and additions due to the interdependencies in care.

48 Note: The program for concurrent disorders at the Royal is only a 5-day/week inpatient stay, patients are required to go home on weekends.

o There are limited services designed specifically for patients with Dual Diagnosis and similarly limited services for individuals with Neuropsychiatric disorders. Dual Diagnosis refers to individuals with a developmental disability or disorder who also develop a mental health problem. Neuropsychiatric disorders referrers to individuals with neurological disorder complicated by a mental health diagnosis. There is currently limited specialized inpatient or community capacity for this population. The KPMG Provincial Review of Dual Diagnosis Programs reports noted that there is a complete lack of specialized inpatients beds in Champlain LHIN for Dual Diagnosis patients. For example, patients with Dual Diagnosis are often left at the Emergency Department when their family or community housing agency is no longer able to meet their needs, leaving these patients without a discharge destination. Dual diagnosis and neuropsychiatric patients require appropriate community supports, tertiary services, and staffing skill mix. Current care settings are not appropriate for this patient population and put both patient and care providers at an increased risk.49

2.9 Quality

Key Questions for this Section:  Are there any current clinical/quality outcomes that need to be addressed?  What family outcomes considered in the current service delivery model?

2.9.1 Readmission Rate

30-Day Readmission Rates

Readmission to inpatient care may be an indicator of relapse or complications after an inpatient stay. Readmission rates may be influenced by a variety of factors, including poor discharge planning and lack of timely follow-up care. Readmission rate can be analyzed at the hospital level and at the regional level. The first occurs when a patient is readmitted to the same site that they had an inpatient stay at within 30 days. Note some readmissions within 30 days are driven by the need to discharge patient within 60 days back to LTC home to avoid losing the bed. When a bed is lost, repatriation back to the LTC home is usually very lengthy and impacts ALC and flow. The second is a patient being readmitted to any site within 30 days after being released from an inpatient hospital stay.  Site readmission rates across Champlain region show significant variability with Pembroke and Cornwall experiencing higher rates than the Ottawa-based acute and specialty

49 Some support is available to help inpatient units with Dual Diagnosis patients; the Regional Dual Diagnosis Consultation Team goes onto inpatient units within 2 days of request to support admission of a client with dual diagnosis.

hospitals; however, this may be due to these sites being the only option for care within their region with patients more likely to admit to the same hospital in rural regions where there is less choice.

Figure 37 30-Day Hospital Readmission Rate50

30-Day Hospital Readmission Rate 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Carelton

Fiscal Year 2014 Fiscal Year 2015 Fiscal Year 2016

Source: OMHRS

Regional Readmission Rates

Regional readmission rate is a more reliable measure of quality of care than 30-day readmission rates per individual hospital because patients may access care from multiple hospitals (especially in Ottawa where they have many choices). Regional readmission rates shown are higher than the site specific readmission rates and are also more similar between rural and urban hospitals suggesting that patients in urban Ottawa are accessing care from a number of different facilities. Most of the readmissions happen within 10 days of discharge from inpatient MH&A care.

50 Note: This is readmission to the same site. Admission Assessment and Short Stay included. The Royal does not have an ED and therefore their site readmission rates may be lower.

Figure 38 Regional Readmission Rates by Hospital51

30-Day Regional Readmission Rates By Hospital 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Pembroke Cornwall Queensway Montfort Ottawa Civic Ottawa The Royal LHIN Carleton General

FY2014/15 FY2015/16

Source: OMHRS

Repeat ED Visits

Across all LHINs, there is a similar percentage of patients needing repeat visits to the Emergency Department within 30 days or less from discharge. Regional repeat ED performance indicates that Champlain has the fourth highest (17.8%) percentage of repeat visits to the ED.

51 Note: Excludes D/C Reason = TRANSFERRED, DECEASED, DECEASED – SUICIDE where Index D/C date = Admit Date. Additionally, the Royal does not have an ED and can actively control readmissions. The Royal was included in this analysis as it will capture if a patient of the Royal was admitted to another site within 30 days.

Figure 39 Percentage of MH&A Patient Readmitted Within 30 Days by LHIN

Percentage of MH&A Patient Readmitted Within 30 Days by LHIN Q4 14/15 30%

25%

20%

15%

10%

0% ESC SW WW HNHB CW MH TC C CE SE Ch NSM NE NW

Source: Champlain LHIN

Site specific repeat ED performance shows variability across hospitals. At inpatient MH&A facilities in Champlain, 7-day readmission ranges from 7% at CHEO to 13% at Pembroke. This range is similar to other regional hospitals. This rate may indicate that if patients are needing to return to the ED within seven days of discharge that they may have been inappropriately discharged. Alternatively, this could be a function of lack of community services or of primary care follow-up. Patient needing to revisit the ED within 30 days of discharge are slightly higher and range from 14% at CHEO to 23% at Pembroke. Of all Champlain hospitals, Arnprior and Carleton Place have the highest rates in these two categories.

Revisits to the ED within 365 days were also similar across sites with the highest being at The Ottawa Hospital Civic Campus (46%) and Pembroke (44%). Overall, of the hospitals involved in the current capacity planning, Pembroke appears to have the highest rates of patients needing to revisit the ED.

Rates for patients revisiting the ED due to substance abuse are similar to those of patients with mental health, however 365-day revisit rates are typically higher ranging from 43% to 96%. 365 day revisits for substance abuse compared to mental health are significantly higher at The Ottawa Hospital, Civic and General Campus, and Montfort.

Figure 40 Percentage of Regional Repeat Visits for Mental Health

Percent of Mental Health Revisits within Given Time Frame for Champlain Hospitals

QCH TOH Civic TOH Gen. CHEO Hopital Montfort Pembroke RVH St.Francis Deep River Arnprior Cornwall Hawkesbury Winchester Glengarry Almonte CPDMH Kemptville Other 0% 10% 20% 30% 40% 50% 60%

7 day 30 Day 365 Day

Source: Champlain LHIN A Profile of Mental Health and Addictions Repeat Visits of Champlain Residents, 2013

Figure 41 Percentage of Regional Repeat Visits for Addictions

Percent of Substance Abuse Revisits within Given Time Frame for Champlain Hospitals

QCH TOH Civic TOH Gen. CHEO Hopital Montfort Pembroke RVH St.Francis Deep River Arnprior Cornwall Hawkesbury Winchester Glengarry Almonte CPDMH Kemptville Other 0% 20% 40% 60% 80% 100% 120%

7 day 30 Day 365 Day

Source: Champlain LHIN A Profile of Mental Health and Addictions Repeat Visits of Champlain Residents, 2013

At a LHIN level, Central Ottawa (18.5%) and Western Champlain (18.4%) have the highest rates of repeat ED visits for mental health. For substance abuse, repeat visits to the ED occur most often at hospitals in Central Ottawa (25.5%) and Western Ottawa (20.4%).

Figure 42 30-day Repeat ED Visits per Champlain Sub-Region

30-Day Repeat Emergency Department Visits 30

0 Western Western Ottawa Central Ottawa Eastern Ottawa Eastern Champlain Champlain Champlain

30-Day Repeat Emergency Department Visits for Mental Health (%) 30-Day Repeat Emergency Department Visits for Substance Abuse (%)

Source: LHIN Sub-Region Profiles

2.9.2 Incidents and Restraints

Critical Incidents

Reported data indicates that the number of critical incidents has decreased significantly over the past three fiscal years. In 2014 there were approximately 23 critical incidents and in 2015, 27 incidents were reported. In 2016, there were fewer than 15 critical incidents in Champlain’s MH inpatient units, which is about a 45% decrease from the previous fiscal year. Table 11 Number of Critical Incidents Per Hospital in Champlain

The Ottawa Pembroke Queensway Cornwall Hospital Montfort The Royal CHEO Regional Carleton (Both) 0 2014 0 0 <5 <5 0 13 0 2015 0 <5 <5 <5 <5 7 0 2016 0 0 0 <5 <5 <5

Source: Site Reported Data

Restraint Use/Control Interventions

Restraint use, either physical or chemical, varies significantly between sites. Rates will depend on programs offered, populations served, as well as policies and procedures in place.  The Ottawa Hospital, both General and Civic sites, have the highest reported use of restraints, physical and chemical. It is important to note that The Ottawa Hospital has the highest proportion of medium to high acuity patients, explaining why they tend to use more restraints when compared to other hospitals in the region.  At most hospitals, the use of restraints has remained the same over the past 3 fiscal years, however, Pembroke has decreased the overall use of restraints, reporting that they do not use restraints on roughly 93% of patients. This report is consistent with the fact that no involuntary admissions occur at Pembroke. There is opportunity overall to address these practices, for example almost 40% of patients at Ottawa Hospital experience some form of restraints. Figure 43 Percentage of Patients Where No Restraints or Acute Control Medication is Used

No Restraint or Acute Control Medication Used 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carelton

Fiscal Year 2014 Fiscal Year 2015 Fiscal Year 2016

Source: OMHRS

2.9.3 Patient Outcomes

There is significant variability in patients’ overall change in care needs at discharge between sites. Pembroke and Queensway Carleton have the highest rates of improvement. 93.9% of patients at Pembroke and 98% of patients at Queensway Carleton indicate that they experienced

improvement or marked improvement. It is important to consider that Pembroke has a large number of short-stay admissions, which may influence the level of improvement seen among patients. Cornwall has the highest rates of patients’ deteriorating, with approximately 27% of patients indicating their care needs were worse upon discharge. Figure 44 Overall Change in Care Needs at Discharge

Overall Change in Care Needs At Discharge 120 100 80 60 40 20 0 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 Percent Percent Discharge of Assessments 2016 (Q1-Q3) 2016 (Q1-Q3) 2016 (Q1-Q3) 2016 (Q1-Q3) (Q1-Q3) 2016 2016 (Q1-Q3) 2016 (Q1-Q3) 2016 (Q1-Q3) 2016 (Q1-Q3) Pembroke Cornwall Queensway Ottawa Ottawa Montfort The Royal LHIN Province Carleton Civic General Average

Deteriorated No change Improvement Marked improvement

Source: OMHRS

Overall, hospitals did not use a common measure of patient satisfaction making comparisons between sites difficult. Cornwall does not survey inpatient MH&A patients and therefore there were no results to include in this analysis. Overall, patients were most satisfied with care at Pembroke, Queensway Carleton and The Ottawa Hospital. The lowest scores were experienced at The Royal, however these scores have been improving over the last 3 years. CHEO uses overall experience of care score on the OPOC tool to measure patient satisfaction. For their inpatient psychiatry unit, the 2016/17 reported score was 3.13 out of a possible score of 4, while their score for the eating disorder inpatient unit was 3.21 out of 4.

Figure 45 Overall Satisfaction per Hospital5253

Overall Satisfaction 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pembroke Cornwall Queensway The Ottawa The Royal Montfort Regional Carleton Hospital

2014 2015 2016 (Q1-Q3)

Source: Site Reported Data

2.10 Efficiency

Key Questions for this Section:  How efficient are sites at providing inpatient MH&A Care?  What are the costs to deliver services?

2.10.1 Service Costs

Total Spending

Champlain LHIN spends approximately $222 per capita on inpatient MH&A. This spending is slightly below that of the provincial average.

52 Cornwall uses the CIHI tool to measure patient satisfaction. This tool excludes patients that are discharged from mental health units. 53 Note: The Royal switched to using Ontario Perception of Care (OPOC) one year ago to measure perception of care making year over year comparisons of patient satisfaction difficult.

Figure 46 Inpatient MH&A Spending ($) Per Capita54

Inpatient MH&A Spending Per Capita 700

600

500

400

300

200

100

Source: Champlain LHIN

Cost per Inpatient Day

There is significant variability both between sites in the Total Cost per Inpatient Day as well as site annual costs. Reported data suggests that CHEO has a significantly higher total cost per inpatient day – over double the total cost per inpatient day when compared to Queensway Carleton, The Ottawa Hospital, and Montfort. Pembroke and Cornwall also have higher costs relative to the other adult acute hospitals, although this may be due to lower occupancy rates and splitting fixed costs between a smaller number of beds.

54 Total spending for inpatient MH functional centres

Figure 47 Total Cost per Inpatient Day Per Hospital in Champlain

Total Cost ($) per Inpatient Day 800

700

600

500

400

300

200

100

0 Pembroke Cornwall Queensway Ottawa Montfort CHEO The Royal Champlain Regional Carleton Hospital LHIN

Average of 2014/2015YE Average of 2015/2016YE Average of 2016/2017Q2

Source: HIT

Overtime

Reported data shows variability across sites and fiscal years. The Ottawa Hospital and Montfort have a significantly higher amount of relative overtime compared to other sites.

Figure 48 Over-time / Total Work Hours per Hospital in Champlain55

Over-time / Total Work Hours 6% 5% 4% 3% 2% 1% 0% Pembroke Cornwall Queensway Ottawa Montfort CHEO The Royal Champlain Regional Carleton Hospital LHIN

Average of 2014/2015YE Average of 2015/2016YE Average of 2016/2017Q2

Source: Site Reported Data

Sick Time

Reported data shows variability across sites and fiscal years. Pembroke has a significantly lower relative amount of sick time. The Ottawa Hospital, Montfort and CHEO are over 1% higher than the Champlain LHIN average in 2016/17Q2.

55 Note: High overtime rate at Montfort is reportedly due to a high number of vacant RN positions reflected by the difficulties in recruiting bilingual nurses.

Figure 49 Sick-time / Total Work Hours per Hospital in Champlain

Sick Time / Total Work Hours 8% 7% 6% 5% 4% 3% 2% 1% 0% Pembroke Cornwall Queensway Ottawa Montfort CHEO The Royal Champlain Regional Carleton Hospital LHIN

Average of 2014/2015YE Average of 2015/2016YE Average of 2016/2017Q2

Source: Site Reported Data

2.10.2 Service Efficiency

Length of Stay

Patients who are admitted to inpatient MH&A in Champlain generally stay for 2 weeks. The average length of stay (ALOS) ranges from 10-20 days at the acute inpatient MH&A hospitals and is much higher at The Royal, which is expected given specialty tertiary care and specialized programs require more service.  Pembroke has the lowest ALOS at greater than 50% less than other hospitals in the region. It is important to note that the site also has a lower acuity mix and does not accept involuntary patients.  ALOS for CHEO in the mental health inpatient program has ranged between 8.7 and 9.8 days over the last 3 fiscal years and between 27.5 and 32 days in the eating disorder programs. These ranges are similar to other hospitals in the region and any variation is reflected in the type of program offered.  Concerns were raised by staff that there is significant pressure within Champlain to discharge patients in order to deal with bed pressures, ultimately influencing the reported average length of stay.

Figure 50 Average Length of Stay Inpatient MH&A Hospital Admissions56

Average Length of Stay Inpatient MH&A Hospital Admissions 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Pembroke Cornwall Queensway Ottawa Civic Ottawa Montfort The Royal LHIN Ontario Carleton General

2014-15 (Actual) 2015-16 (Actual) 2016-17 Q1 to Q3 (Actual)

Source: OMHRS

Relative to peers, most hospitals in the region have shorter average length of stays, except for Cornwall, which has had longer ALOS relative to peer hospitals over the past 3-years.

Figure 51 ALOS / Peer ALOS Inpatient MH&A Admissions57

ALOS/Peer ALOS Inpatient MH&A Admissions 140% 120% 100% 80% 60% 40% 20% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Carleton

2014-15 (Actual) 2015-16 (Actual) 2016-17 Q1 to Q3 (Actual)

Source: OMHRS

56 Note: Short-Stay Admission is not included. 57 Note: Short-Stay Admission is not included.

In addition to having a shorter overall length of stay for long-stay admissions, Pembroke also has the highest percentage of short-stay admits (<3 days). Cornwall also has a high proportion of short-stay admissions when compared to other hospitals in the region.  Stakeholders indicated that sites, such as Pembroke, are using admissions as a mechanism to support lack of psychiatry coverage so that patient are able to be seen by a psychiatrist after an initial assessment in the ED. This is an area of opportunity to provide this care in different way and reduce the need for short stay admissions. Figure 52 Percentage of Admissions Being Short Stay

Percent of Admissions with Short Stay (<3 days) 60% 50% 40% 30% 20% 10% 0% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Carleton

2014-15 (Actual) 2015-16 (Actual) 2016-17 Q1 to Q3 (Actual)

Source: OMHRS

2.11 Health Human Resources Utilization

Key Questions for this Section:  What are the current human resources levels/patterns at each centre?  What is the role/coverage of various healthcare professionals?  Is there the correct mix and number of staff?

2.11.1 HHR Capacity and Resource Mix

Full Time Employees (FTE) per funded bed were calculated for each inpatient program at each facility. For the Royal, red indicates the programs with the highest FTE per funded bed for a specific role type. Incomplete information for Queensway Carleton and Pembroke was provided and as a result have not been included in this analysis in full.  On average, at the Royal, across all inpatient programs, there is an average of 0.5 RN per funded bed, with higher FTE assigned to mood and anxiety, SUCD-ASU, and Youth programming. On average there are 0.10 Social Workers per funded bed, with higher FTE assigned to mood and anxiety, youth and patients with concurrent disorders. These

findings align with average FTE per bed at all other hospitals in Champlain, which report 0.64 RN on average (range is 0.13 – 1.47) and 0.06 social worker on average (range 0.02- 0.14).  At the LHIN level, there are a reported 251 psychiatrists in Champlain, 15 psychiatrists specifically focus on children and youth, 8 focus on forensics, and 13 focus on geriatrics. On average, at the Royal, there is 0.42 psychiatrist per funded bed. Psychiatrist per bed is especially high (0.80) for mood and anxiety programs58. Based on reported FTE data from all other hospitals, there is an average of 0.07 psychiatrist per funded bed. Psychiatry per bed is particularly low at Cornwall and Pembroke. This aligns with stakeholder findings which report that these sites have been recruiting for many years without much success to recruit/retrain staff and that the resources are at critical levels for both the inpatient program and for outpatient services. Rural communities, especially Cornwall and Pembroke, struggle to get psychiatry coverage. Psychiatry FTE have also been reported to be low for youth and geriatrics. In terms of geriatrics, at the Royal there is approximately 0.37 psychiatrist per funded bed. The youth program has 0.59 psychiatry per funded bed at the Royal. Stakeholders also identified challenges with community psychiatry practices as well as the pending retirement of many psychiatrists resulting in resources taking on limited new patients.  Psychology FTE across all hospitals in Champlain is low on average. The Royal reports 0.02 FTE per bed and all other hospitals have an average of 0.01 FTE per funded bed.  Peer supports were identified as being very beneficial to both patients and their families, however, are only available at some sites. The Royal reports an average of 0.04 FTE per bed. This is due to the ongoing skills mix adjustment resulting in the transition in Orderly positions to PSW. All other hospitals have an average 0.01 peer support per bed, with the highest at Montfort (0.07) and Pembroke (0.05) although a number of sites do not have Peer supports available.

58 Note: Psychiatrists at The Royal also cover a very extensive regional and community mental health mandate and includes research chairs.

Figure 53 FTE per Funded MH&A Bed at The Royal5960

Source: Site Reported Data

59 Note: Staffing for Crisis Inpatient program is accounted for in Mood & Anxiety. Number of total funded beds, used to calculate average at the Royal, does not include 59 beds in BMHC Forensic Treatment Unit and 64 long term care beds at Royal Ottawa Place, or beds at St. Lawrence Valley Correctional and Treatment Centre. 60 Note: The Royal does employ 3 Peer support workers in the Schizophrenia and Community Programs. However, through a partnership with Psychiatric Survivors of Ottawa (PSO), peer support workers employed by that organization work with Royal patients in Schizophrenia and Mood as they near discharge to connect them to peer supports in the community. The Royal is considering expansion of this program to other Programs.

Figure 54 FTE per Funded MH&A Bed in Champlain61

Source: Site Reported data

CPA guideline cited in Kurdyak et al. (2014)62 indicates that there should be approximately 15 psychiatrists for every 100,000 people. Given the estimate of 287 psychiatrists in Champlain63 and a population of approximately 1.3 million people, this ratio stands at roughly 22 FTE psychiatrists per 100,000 which would place Champlain in the high-supply level indicated in Kurdyak’s analysis. Although Champlain LHIN appears to be well resourced with Psychiatrists, as compared to the provincial average, there are still a number of challenges with psychiatry capacity:  The distribution of psychiatrists is concentrated in the urban Ottawa area, while both Cornwall and Pembroke have had significant challenges recruiting and retaining Psychiatrists which has impacted inpatient capacity and their ability to be responsive to transfers from referring partners.  A large proportion of the Psychiatrists in Champlain are nearing the age of retirement (46% over the age of 60) and so succession planning and long-term capacity is at risk.  Many psychiatrists are community-based practices and are not affiliated with hospital services. Accessing private practice psychiatry in the community was a challenge (both for patients and for referring primary care physicians), often resulting in patients attempting to get support through the hospital system.

61 Note: Montfort reported data as Individuals rather than FTE. Peer support and Psychiatry FTE at Pembroke are not paid for by the hospital. 62 Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario. Kurdyak et al. (2014). Retrieved online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4242254/pdf/OpenMed-08-87.pdf 63OPHRDC Physician Reports. Retrieved online: http://www.ophrdc.org/wp-content/uploads/2016/08/2015-Summary-Physicians-in- ONTARIO-by-Specialty-and-LHIN.pdf

Figure 55 Number of Psychiatry Specialists by LHIN

Number of Psychiatry Specialists By LHIN 800 700 600 500 400 300 200 100 0

Psychiatry Psychiatry ‐ Child & Adolescent Psychiatry ‐ Forensic Psychiatry ‐ Geriatric

Source: Ontario Physician Human Resources Data Centre

Figure 56 Number of Psychiatrists Per 100,000 Population (2016)

Number of Psychiatrists Per 100,000 Population 70 60 50 40 30 20 10 0

Source: Ontario Physician Human Resources Data Centre

2.11.2 Scope of Practice

Many MH&A care providers identified that they are not working to full scope of practice due to clinician resource capacity constraints. For example, mental health nurses and social workers do not have capacity to complete CBT and DBT and there was a lack of Nurse Practitioner and Psychologist resources at many of the sites.

3. Jurisdictional Scan and Best Practice Summary

Key Research Question: What are the best practices in system integration that could support inpatient mental health and addiction services in Champlain LHIN?  Best practices may be related to:  Strategies  Services  Patient and family involvement in terms of care offered and treatment plan on discharge  Use of other resources  Integration lessons learned  Online connectivity with patients

An examination of ten (10) Canadian and international jurisdictions including South Essex, Intermountain Healthcare in the United States, Netherlands, Vancouver, Nova Scotia Health Authority, Toronto Region Hospitals, Central East LHIN, South East LHIN, and the Champlain LHIN led to the identification of five areas of best practice that can assist in improving inpatient mental health care delivery.

Based on these findings, Champlain LHIN needs to consider five areas in order to provide better care and better community support, ultimately leading to prevention of hospitalization due to mental health and addictions. 1. Must setup strong governance structure in order to integrate and plan MH&A services. 2. Patients need reliable access to interdisciplinary MH&A services through primary care to avoid hospitalization and improve care over the continuum. 3. Implementation of a range of MH&A community support services will help to avoid hospitalization and improve transition and care for patients. 4. Need to develop and adopt standard MH&A clinical practices across Champlain region. 5. Technology needs to be fully utilized, which will enable better care and allow for a more efficient use of resources.

A description of each key takeaway is detailed below.

1. Integrated Shared Governance Structure

The Champlain LHIN has a number of integrated service models64 currently in place with the ultimate goal of coordination, access, standardization and sustainability. Governance is a shared,

64 Champlain LHIN Regional Programs. Retrieved online: http://www.champlainlhin.on.ca/GoalsandAchievements/ PopularTopics/ReglProgs.aspx

collaborative model between health service providers, partner organizations, and other stakeholders.

Identified benefits of a regional approach to service delivery include:  equal, quicker and “closer to home” access,  enhanced coordination of care,  seamless transition for individuals between service providers and sectors, and  a forum to focus on region-wide standards for quality and safety.

The previous successful implementation of regional models in the Champlain LHIN in the areas of maternal newborn health, cancer, hospice palliative care, rehabilitation, and orthopedics can be leveraged and applied to that of mental health care. Programs considering integration in the Champlain LHIN could follow the same integration principles that have been applied to other integrations in the region: 1. Combined clinical-administrative leadership; 2. Models built on trust, collaboration and partnerships, (rather than formalized merged organizational structures); 3. All require a coordinating body to create and sustain changes – a hub and spoke model, where one facility (the hub) provides leadership to various satellite programs; 4. Most of the models monitor and determine service delivery structures to meet demand and capacity balance; 5. All function under the same guiding principles of access, optimizing distribution of resources, quality and efficiency; 6. All transitioned from a network type of structure to a more formalized structure; and, 7. All have mandates to integrate and coordinate.

Similarly, South East LHIN amalgamated their Mental Health and Addiction Services into three (3) Agencies.65 When implemented, the new system was able to provide a common basket of services across the South East through three regional AMH agencies and resulted in:  Improved access and consistency to services;  Enabled consumers/clients and caregivers to navigate more easily between different levels of care throughout the region; and,  Strengthened partnerships with key stakeholders such as municipal housing, social services, and the criminal justice system (including the police and the courts). 2. Access to Inter-Professional Primary Care MH&A Services

Having access to MH&A services within primary care can potentially be beneficial in decreasing ER visits and increasing care transitions for patients within the continuum of care. Often times, patients come to primary care providers (PCP) with multiple comorbidities that are intensified by

65 South east LHIN. Health Care Tomorrow – Putting Patients First. IHSP 2016-2019.

mental health issues. A PCP would commonly refer patients to a mental health specialist, however wait times are commonly weeks or months long leading to no linkage between transitions of care.

The ultimate goal an inter-professional team based model is to integrate the mental health providers into the primary care team where patients can have medical and mental health needs addressed in the same location. Mental Health professionals assess the patient and coordinates with the PCP to develop a treatment plan. The Mental Health provider, in coordination with the care manager, can effectively bridge the gap to keep patients stabilized while the referrals to long- term mental healthcare are in progress.

A report from McMaster University examining the impact of and approaches to addressing the needs of people living with mental health issues indicates that there is a need to transform primary care to include a variety of mental health professionals working as part of interdisciplinary teams. Teams would be able to provide mental health promotion and prevention activities, as well as provide support for substance use through what is known as “SBIRT” (screening, brief intervention, and referral to treatment). These teams would also be able to support collaborative chronic care for individuals with mental health conditions.66

For example, at Intermountain Healthcare, 80% of mental health services are provided by primary care physicians.6768 In this case, a Registered Nurse could be assessing a patient with diabetes, but also initiating mental health referrals if necessary. Implementation required a shift in the underlying view of mental health care, addition of new roles and expertise, as well as re-education of primary care physicians and all their staff.

The model is based on adding mental health professions to locations where they can do the best. Mental health professions support existing populations that PCPs serve and are assigned in blocks of time based on complexity of the population.  PCP and mental health specialist (psychiatrists, psychologists and psychiatric advanced practice registered nurses for screening and coordination, RN care managers, social workers, peer mentors) work together and in-turn communicate with patients and family members.  This revised approach has been shown to be effective in rural areas where mental health specialists are limited.  Team based primary care settings have been reported to result in better clinical outcomes for patients, lower rates of healthcare utilization, and lower costs. For example,

66 McMaster Health Forum. Rapid Synthesis: Examining the Impact of and Approaches to Addressing the Needs of People Living with Mental Health Issues. April 2016. 67 Retrieved online: https://intermountainhealthcare.org/news/2016/08/new-jama-study-shows-that-integrating-mental-and- physical-health/ 68 Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost. August 2016. Retrieved online: http://jamanetwork.com/journals/jama/fullarticle/2545685

integrated mental health clinic patients with depression were 54% less likely to require emergency department visits than patients treated in traditional clinics.

A similar team based model is being taught to more than 50 family doctors in British Columbia. Training is based on a module developed for adult mental health, which helps family doctors treat patients with mild to moderate mental health problems and mental illnesses.

Fraser Health has also created a Rapid Access Clinic69 that provides quick access to a one-time psychiatric consultation to provide treatment recommendations to a client’s primary care physician or nurse practitioner. Clients who meet the RAC program eligibility criteria (i.e., are 19 years or old, have a mild to moderate psychiatric condition and live within the mental health clinic region) can be referred to the services by their primary care provider and will be scheduled for a consultation with a psychiatrist within approximately 2-5 weeks of referral. Once an appointment has been scheduled clients are contacted by a clinic nurse to discuss what to expect from the appointment. Following the consultation, the client’s primary care provider is sent a summary report that describes the client’s psychiatric diagnosis and treatment recommendations. The care is then continued by the primary care provider. 3. Supportive \Services

Various programs have helped to improve patient flow as well as more easily allowing patients to access services, when and where they need them. These community programs divert patients from the hospital emergency department and allow them to receive more appropriate treatment in an alternative location that better suits their healthcare needs. The main focus is on getting the right patients to the right place the first time.  Ontario is investing in local mental health and addictions organizations in Mississauga Halton LHIN, to provide care closer to home for those who are experiencing mental health and addictions challenges. Mississauga Halton LHIN’s one-Link, will enable equitable access and coordinated care to make it possible for people to receive the right addiction and mental health care, at the right time and in the right place. one-Link will provide a central intake, screening and triage, information and referral, wait list support and peer facilitation, connecting residents 16 years and older to addiction and mental health services.  A report from McMaster University examining the impact of and approaches to addressing the needs of people living with mental health issues indicates that effective evidence-based interventions should be delivered within and across multiple settings, including: at a population level (e.g., through prevention and awareness campaigns and policies that reduce access to alcohol); for specific communities or groups (e.g.,

69 Retrieved online: http://www.fraserhealth.ca/health-info/mental-health-substance-use/mental-health-substance-use- community-services/rapid-access-clinic/

interventions targeted to groups that share a common characteristic such as age or culture, or a common setting such as schools or jails); and within the healthcare system (which includes interventions that address self-management and care, primary and community health care, and hospital care).70  The Nova Scotia Health Authority uses a Choice and Partnership Approach (CAPA).71 Patients and their families get to identify what is most important to them, and working with their mental health professional, choose the services they need to reach their goals. Under CAPA, patients and their families receive an appointment with a mental health clinician to discuss their own goals and develop a plan to achieve them. For example, using CAPA, in Cumberland County, most children and youth were waiting 421 days for community mental health services. By the end of 2015, the wait dropped to 88 days. Overall, in Nova Scotia, children and youth waits have dropped from 501 to 118 days. For adults who require mental health services but are not in crisis, wait times have decreased from 442 days to 273 days. It is important to note that CAPA has been launched at CHEO as well as at the Youth Services Bureau and the Royal’s Youth and Mood programs.  In the Windsor Region, urgent cases who show up at a hospital emergency but who don’t need to be admitted, can go to a new urgent clinic and see a psychiatrist within 72 hours. The urgent clinic prevents people with urgent mental health problems from being held in the hospital until a psychiatrist can see them.  Mobile Crisis Intervention Teams (MCIT)72 are collaborative partnerships between participating hospitals and the Toronto Police Service. The program partners a mental- health nurse and a specially trained police officer to respond to 9-1-1 emergency and police dispatch calls involving individuals experiencing a mental health crisis. The team will assess needs and connect the person in crisis with the most appropriate services.  Targeted Engagement and Diversion (TED) program in Ottawa is designed to divert the homeless population to Ottawa Inner City Health where they are observed and then receive appropriate care, such as addictions services. This is an example of targeted care resulting in a decrease in patient volume in emergency department. Psychiatric services are also available in TED through partnership with the Royal’s Psychiatric Outreach Team, with in its community mental health program. Patients that have used the TED program have received better and more appropriate care than they would have received in the previous, all patients go to the emergency room. Psychiatric services are also available in TED through partnership with the Royal’s Psychiatric Outreach Team, with in its CMHP

70 McMaster Health Forum. Rapid Synthesis: Examining the Impact of and Approaches to Addressing the Needs of People Living with Mental Health Issues. April 2016. 71 Nova Scotia. Together We Can Progress Update. January 2016. 72 Toronto Police Services. Mental Health. Mobile Crisis Intervention Teams (MCIT) Retrieved online: http://www.torontopolice.on.ca/community/mcit.php

 Peer Navigators work in the emergency departments of North York General and Southlake hospitals.73 Drawing from lived experience with mental health and/or addiction challenges, the Peer Navigator assist individuals who present at the hospital emergency department. The goal of the Peer Navigator is to enhance recovery and improve the quality of the patient experience both in the emergency department and with system navigation after the visit. o Parents Lifelines of Eastern Ontario (PLEO) utilizes peer navigators to provide support and navigation services to parents across the LHIN who have children with mental health and addictions issues.  Access CAMH74 is a phone service that provides centralized information on mental health and addictions supports including referral eligibility requirements, and self-referral information for addictions supports. It also provides centralized intake and scheduling for most hospital services to patients and families, as well as clinicians, community health providers and other stakeholders. Access CAMH is intended to prevent clients from being bounced around from person to person when they are trying to access services. The program has an inter-professional team that includes social workers, nurses, clinicians and administrative support. The centralized intake structure has one referral form and one access line. Staff work with callers to identify the most appropriate mental health support services in one phone call and to schedule the client in to see a service provider as quickly as possible.  Providence Health Care has implemented a specific program to reduce and redirect entry of patients with mental health disorders from the emergency department to more appropriate service types75. The program was developed through a partnership between Providence Health Care and Vancouver Coastal Health (VCH) that is implementing three important initiatives, the Hub, the Rapid Access Addictions Centre at St Paul’s Hospital and the VCH’s Access and Assessment Centre. These programs were modelled off of the VCH’s Access and Assessment Centre (AAC)76 which was also created to alleviate entry of clients with mental health needs to the emergency department. The AAC providers 24/7 short-term, on-site, mobile and telephone support to clients facing non-life threatening mental health and/or substance use issues. It is a single access entry point staffed by a multi-disciplinary team that specializes in mental health and addictions support services. o The Hub at St. Paul’s Hospital is intended to divert patients seeking mental health services out of the emergency department by redirecting them to a new rapid

73 Central LHIN. Mental Health and Addictions. Retrieved online: http://www.centrallhin.on.ca/goalsand achievements/moreinitiatives/mentalhealthandaddictions.aspx 74 Retrieved online: http://www.camh.ca/en/hospital/about_camh/newsroom/CAMH_in_the_headlines/stories/ Pages/Making-it-easier-to-Access-CAMH.aspx 75 Retrieved online: http://mh.providencehealthcare.org/hub-and-spoke 76 Retrieved online: http://www.vch.ca/your-care/mental-health-substance-use/vancouver-access-assessment-centre

response care program dedicated to providing specialized mental health services. The Hub collocates a clinical unit (Rapid Access Addictions Centre) and a Transitional Centre that provides access to immediate and follow-up services. o The Rapid Access Addictions Centre77 accepts referrals from the emergency department, physicians, nurses, social workers or clients who can also self-refer. The Centre provides services to individuals with concurrent mental health and substance use disorders. The RAAC has a multi-disciplinary team made up of social workers, nurses and physicians who provide short-term outpatient consultation support to stabilize patients with substance abuse disorders. Care is provided in a client-centered, trauma informed healing environment. The Centre works closely with the Emergency Department and clients are provided with immediate support as well as ongoing support through hospitalization and after discharge as patients begin their treatment. This service is intended to divert patients from the emergency department to more specialized services. o The Transition Centre provides ongoing follow-up supports to individuals returning to the community after receiving mental health services. It is intended to reduce re-entry to the emergency department by providing clients with access to community services through case management, outreach and transition teams. 4. Standards of Care and System Performance

Unclear processes and procedures result in inconsistent patient experience and expectations depending on a patient’s health service provider. Unclear standards of care, care pathways, as well as minimum standards or scope of services contribute to differences in baseline care received at different sites across Champlain. This differentiation is also affected by a lack of common tools across sites to support admission, assessment, and discharge.

Various areas of health clinical standards are being developed that improve care, however this needs to be expanded in MH&A to ensure minimum service standards are available and achieved. Measures of performance are also quite common in other areas of healthcare, however, there are no clear sets of measures that are used in the area of MH&A.  Provincial Council for Maternal and Child Health (PCMCH) brings together clinical and administrative leaders in maternal and child health to identify areas of improvement in the delivery of maternal child health care services. As part of this work it has developed clinical practice guidelines in collaboration with frontline health care providers to be implemented across the health system. Clinical practice guidelines establish minimum standards of care and are promoted by PCMCH’s champions and key opinion leaders

77 Retrieved online: http://www.providencehealthcare.org/rapid-access-addiction-clinic-raac

across delivery settings to ensure the best possible care for moms and babies. The Standardized Maternal and Newborn Levels of Care Definitions78 establish minimum expectations for each category of maternal and newborn care. Organizations are expected to align to these minimum expectations to ensure that infants are being delivered in only those facilities with the appropriate staff, expertise and equipment to manage their care needs. For each maternal-newborn level definition there are associated minimum services (e.g., diagnostic tests, treatment types, etc.) that must be available and recommended human resources that should be on staff to be able to provide a minimum standard of care.  The Agency for Clinical Innovation (ACI) has developed the Minimum Standards for the Management of Hip Fracture to assist hospitals in identifying key components of best practice management for hip fracture that will support optimal patient care and lead to better outcomes for patients across New South Wales (NSW). o Similarly in Ontario, Health Quality Ontario (HQO) developed quality based procedures clinical handbook for hip fractures. HQO has also developed multiple quality standards including some of the following: . Behavioural Symptoms of Dementia; . Major Depression; . Schizophrenia; . Heart Failure; and, . Opioid Use Disorder.  The Guidelines and Audit Implementation Network (GAIN) role is to promote leadership in safety and quality in health and social care in Northern Ireland. These guidelines describe the four minimum standards of care for people with diabetes living in care homes and includes background information for those caring for people with diabetes.

Performance measurement is used to evaluate organizational and clinical performance to understand whether resources and activities align with intended health outcomes for patients and families. In healthcare it is also important that performance measures align across different organizations and service settings to ensure patients and families receive the same standards of care regardless of where they access services79. This also ensures that organizations and providers are evaluated against the same set of standards within the health system and are working together to improve care. Where one organization is performing well, it is able to share best practices across settings to improve care across the system.

78 Provincial Council for Maternal and Child Health. Standardized Maternal and Newborn Levels of Care Definitions. Last updated August 1, 2013. 79 Retrieved online: http://www.who.int/management/district/performance/PerformanceMeasurementHealth SystemImprovement2.pdf

Historically clinical outcomes have been measured through more blunt instruments, such as patient mortality rates, however increasingly health systems are implementing the use of patient- reported outcome measures (PROM)80. PROM’s are evaluated using simple surveys that are completed by patients throughout their clinical journey. Typically PROM’s evaluate multiple aspects of health service delivery, including population health, individual health outcomes, clinical quality and appropriateness of care, responsiveness of the health system, equity and productivity81.

Some jurisdictions have begun to administer the same PROM questionnaires across health systems to evaluate the effectiveness of different organizations and providers across settings. For example, the National Health Service (NHS) mandated the use of the EQ-5D instrument for all NHS patients undergoing four common procedures to assess the costs of routine use of PROMs and clinician resistance to this evaluation approach. The Picker Institute out of Boston University, developed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which has since been adopted by the Centers for Medicare and Medicaid Services to evaluate the provision of care in a standardized way, from the perspective of patients82. It is the first United States national standardized survey that is publicly reported and used to evaluate patient’s perceptions of their hospital experience83. In Canada, the Canadian Institute for Health Information (CIHI) and Statistics Canada partnered in the development of a health indicators framework to evaluate health system performance and population health. This framework is not intended to measure the performance of individual organizations through alignment to one’s strategic plan or balance scorecard, but to evaluate overall performance at a system level.

A lot of research has gone into the development of performance indicators for acute hospitals, primary care and population health, however research on mental health indicators is still in its infancy84. More recently, the Ontario Hospital Association (OHA) launched its own longitudinal patient experience survey instruments, developed through consultations with Health Quality Ontario, the Ministry of Health and Long-term Care, Local Health Integration Networks and as well as hospitals, patients and clinicians. The OHA’s patient experience survey is recommended for adoption across the province and uses performance indicators for different types of clients. For example, it will be launching a new survey to evaluate Mental Health and Addictions supports from the perspectives of clients. This tool was developed in partnership with the Centre for

80 Ibid. 81 Ibid. 82 Retrieved online: http://www.hqontario.ca/Portals/0/modals/qi/en/processmap_pdfs/tools/patient-centered%20 care%20improvement%20guide.pdf 83 Retrieved online: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospital qualityinits/hospitalhcahps.html 84 Retrieved online: http://www.who.int/management/district/performance/PerformanceMeasurement HealthSystemImprovement2.pdf

Addictions and Mental Health (CAMH) to standardize how agencies across the health system that provide substance use, mental health and concurrent disorders services obtain client perception of care feedback85. 5. Technology

There is a strong desire for the use of technology in today’s healthcare system. Hospitals in the Champlain LHIN are currently taking advantage of the Ontario Telemedicine Network for some provision of care. However, there are many opportunities to use virtual care or online portal systems to more effectively and efficiently deliver care to patients.

A report from McMaster University examining the impact of and approaches to addressing the needs of people living with mental health issues indicates that institutions need to leverage online platforms and other technologies that allow individuals with mental health problems and/or their families and caregivers to access some forms of treatment and supports on their own time and in their preferred language. This may also have the potential to reduce geographic barriers to care.86

There is opportunity for Champlain to move forward with innovation and to use technology to more efficiently utilize resources.  There are a number of examples of Ontario organizations that are providing care via technology in MH&A; however, most are for patients with restricted access. Providers in the North East and North West LHINs are early adopters of OTN facilitated treatment in mental health and psychiatry. Ontario Shores has recently implemented a telepsychiatry program for geriatric patients. Sinai Health System also a Perinatal Mental Health Program for high-risk pregnant women and new mothers.  Ontario Shores Centre for Mental Health Sciences uses an online portal system, HealthCheck, to help patients manage their own health information.87 HealthCheck is an internet-based patient portal which is secure, private and confidential. It is available to all patients 16 years of age and over, who are not undergoing a forensic assessment. It is also available for friends and family who have the legal right to access personal health information of a patient. HealthCheck allows patients to access their visit history, lab results, clinical reports, and allergies. Patients can also request medication renewals and send notices to their clinicians.  The Scarborough Hospital offers Internet Assisted Cognitive Behavioral Therapy (iCBT).88 The iCBT program is the first and only program of its kind within a Mental Health Adult Outpatient setting in a Canadian hospital, and uses traditional (face-to-face) CBT modules

85 Retrieved online: http://eenet.ca/project/implementation-ontario-perception-care-tool-mental-health-and-addictions#about 86 McMaster Health Forum. Rapid Synthesis: Examining the Impact of and Approaches to Addressing the Needs of People Living with Mental Health Issues. April 2016. 87 Retrieved online: http://www.ontarioshores.ca/patients___families/ontario_shores__health_check 88 Retrieved online: http://www.tsh.to/moving-beyond-bricks-and-mortar-with-mental-health-therapy/

adapted for email. The programs require a physician referral and allow patients to complete one module per week, email the completed module back to their therapist and receive feedback.  The Integrated Assessment Record (IAR) is a provincial (Ontario) initiative to provide authorized health practitioners within a patient’s circle of care with secure web-based access to assessment information. Systems such as this provide health support tailored to a patient’s needs and also ensure that providers have the most up-to-date and complete patient record and history. The IAR also holds many common assessment tools including the RAI-MH and OCAN. Various Local Health Integration Networks (LHINs) are working to implement the IAR.  The Nova Scotia Health Authority implemented a provincial bed-utilization management system allowing for: Clinical Criteria Assessment (daily patient status and Ready for Discharge) completed by nursing staff based on standardized set of clinical criteria specific to each service (Surgical, ICU, mental health); Bed Management; and, Completion of Forms and Assessment (plan and manage safe care transitions).89 o Identified issues: no standardized approach to managing beds, different approached to repatriating patients in tertiary care facilities ready to return to their home hospitals. o Hospital performance issues: ED overcrowding, long admission wait times, long length of stay, high percentage of avoidable acute care days, and high level of ALC patients. o Solution: Information displayed in real time includes how long a patient has been in hospital. Daily assessment results, is the patient in the appropriate type of bed, barriers to discharge, and estimated date of discharge. o Result: The system has allowed the district to move complex ALC patients to the most appropriate area of care, which is community rather than hospital. The system also allows for the collection of data and analysis of key performance indicators. The Hospital and Region are better able to discuss issues and challenges in one language and with little disagreement.

89 Retrieved online: http://www.aptean.com/assets/pdfs/resources/documents/medworxx/APT-MW-CaseStudy-NovaScotia-EN.pdf

4. Appendix

4.1 LHIN Demographic Profile Table 12 Champlain LHIN Demographic Profile

Source: LHIN Sub-Region Profiles

Table 13 Champlain LHIN Sociocultural Profile

Source: LHIN Sub-Region Profiles

Table 14 Champlain LHIN Social Economic Status Profile

Source: LHIN Sub-Region Profiles

4.2 Champlain Inpatient Mental Health and Addiction Programs and Services Pembroke Strategy Mission: We are a regional community hospital committed to delivering a wide range of quality health services. Following Catholic tradition, we will meet the physical, emotional, and spiritual needs of all. Vision: Delivering the safest and highest quality of care to every person, every encounter, and every day. Inpatient Services Service Description Voluntary Inpatient Unit  Described as a Schedule 4 (i.e. exempt from providing requirement of day care service).  Services offered include those related to psychiatric evaluation, diagnosis and pharmacological treatment.

Cornwall Strategy Mission: Our Health Care Team collaborates to provide exceptional patient centered care. Vision: Exceptional Care. Always. Inpatient Services Service Description Consultation / Liaison Services  Service has been provided by the Department of Psychiatry and occasionally by psychiatric nurses of the Mental Health Patient Care Unit who consult with their colleagues in other services (surgical, medical, rehabilitation, and critical care) to assist them with the management of certain patients whose care includes behavioural or psychiatric elements. Patient Care Unit (PCU)  Provides assessment, stabilization and short-term inpatient treatment.

Queensway Carleton Strategy Mission: As a patient and family-centred hospital:  We provide a broad range of acute care services to the people of Ottawa and the surrounding region.  We respond to the needs of our patients and families through our commitment to exemplary performance, accountability and compassion.

 We partner with other health care and community service organizations to ensure coordinated and integrated care.  We actively promote a learning environment in which our staff, physicians, students and volunteers are progressive and responsive. We are an active teaching partner with colleges, universities and other healthcare programs. Mental Health Mission: As a Schedule 1 designated psychiatric facility under the Mental Health Act, our purpose is to provide short- term, safe, secure and therapeutic assessment and treatment to individual adults who may be suicidal, aggressive or unable to address their basic needs due to acute mental health and addictions issues. Inpatient Services Service Description Inpatient Services  Provide treatment and stabilization of acute MH/addictions issues using the recovery model of care. Consultation Liaison  This practice consists of designated psychiatrists going to other QCH inpatient units to consult on MH issues and potentially providing consultation/follow-up in Outpatient area.

The Ottawa Hospital Strategy Mission:  TOH is a compassionate provider of patient-centred care with an emphasis on tertiary-level and specialty care, primarily for residents of Eastern Ontario.  TOH educated future health-care professionals in partnership with the University of Ottawa and other affiliated universities, community colleges and training organizations.  TOH develops, shares and applies new knowledge and technology in the delivery of patient care through world-leading research programs in partnership with the Ottawa Hospital Research Institute.  TOH also plays an active role in promoting and improving health within our community. TOH collaborated with a wide range of partners to address the needs of the community and to build a strong, integrated system for regional health-care delivery.  TOH functions in English and French while striving to meet the needs of the culturally diverse community we serve. Vision: To provide each patient with the world-class care, exceptional service and compassion we would want for our loved ones. Inpatient Services Service Description

Inpatient Unit  Located at the General (4North) and Civic (D6) Campuses with a total of 87 inpatient beds, including six beds specifically funded for the provision of specialized services for the treatment of eating disorders.  Includes Psychopharmacology, ECT, and OT Life Skills.

Montfort Strategy Mission: Montfort, Ontario's Francophone academic hospital, offering exemplary patient-centered care. Vision: Your hospital of reference for outstanding services, designed with you and for you. Inpatient Services Service Description Intensive Care Beds  The in-patient intensive care unit is stabilization unit which provides crisis stabilization, intensive care, observation and general acute care and has a mean length of stay of between 3 to 10 days. Acute Short Term  The acute short term care unit provides acute care for clientele whose conditions are more stable but still require in-patient care. The average length of stay on this unit is between 10 to 14 days. Long-term Specialized Mental  Beds provide services for geriatric psychiatry. Health Beds

The Royal Strategy Mission: Delivering excellence in specialized mental health care, advocacy, research and education. Vision: Mental health care transformed through partnerships, innovation and discover. Inpatient Services Service Description Crisis Inpatient  Provides short-term specialized diagnostic clarification, assessment, treatment, and stabilization of persons experiencing an acute episode resulting from any mental illness, predominately schizophrenia and mood disorders.

Champlain Forensic  Provides specialized interdisciplinary assessment, treatment, and rehabilitation for adults with severe psychiatric illness who have come into conflict with the criminal justice system. Geriatric  Cares for patients over the age of 65 (or younger patients living with Alzheimer’s or Frontotemporal Dementia) with severe multiple and/or complex psychiatric illnesses. Mood and Anxiety  Program provides specialized diagnostic clarification, assessment, evidence-based treatment for patients with recurrent, chronic treatment resistant and co-morbid mood disorders. Recovery  Highly skilled multidisciplinary team of mental health professionals that provides specialized recovery oriented treatment and evidence informed care to individuals with diagnoses of treatment resistant schizophrenic related illness with comorbidities or psychosis. Schizophrenia  Highly skilled multidisciplinary team of mental health professionals that provides specialized recovery oriented treatment and evidence informed care to individuals with diagnoses of treatment resistant schizophrenic related illness with comorbidities or psychosis. SUCD-ASU  Multidisciplinary team provides specialized, evidence based medical detoxification (alcohol) and/or stabilization on OST for patients with severe substance use disorders who cannot be stabilized as an outpatient. Youth  As part of the Young Minds Partnership with CHEO primarily all of our admissions are direct transfers from the Inpatient Psychiatry Unit at CHEO. These are youth between the ages of 15.5 and 18 years of age who require intensive specialized treatment services such as: o Assessment o Stabilization o Diagnostic clarification o Transition to adult as appropriate o Transition to outpatient as appropriate Concurrent Disorders Unit  Multidisciplinary team provides integrated, specialized, evidence-based concurrent disorders stabilization, assessment, diagnostic clarification, and treatment services to clients with severe, complex, active and symptomatic substance use and mental health disorders to optimize health and well-being.

CHEO Strategy Mission: To Help Kids and Families be their Healthiest. Vision: Our care will change young lines in our community; our innovation will change young lives around the world. Inpatient Services Service Description Psychiatric Inpatient Unit  Tertiary care unit serving children and youth who are experiencing an acute MH crisis.  Bipolar, depression, extreme risk harm to self/others, psychosis and suicidality are the predominant presentations.  Unit provides crisis stabilization and treatment. Eating Disorder Unit  Serving medically stable youth with an eating disorder.

Tables below detail the admission and discharge criteria for each inpatient mental health and addiction program. Pembroke Inpatient Services Admission / Exclusion Criteria Discharge Criteria Voluntary Inpatient  Exclusions: Involuntary patients, or medically  Main discharge criteria is linked to patient Unit unstable, or psychiatric symptom 2nd to delirium, goal(s) being met or addressed to the extent dementia, stroke or other acquired brain damage, of the service resources substance abuse with detoxification needs

Cornwall Inpatient Services Admission / Exclusion Criteria Discharge Criteria Patient Care Unit  Admissions are 24/7 and arrive via ER, MHCT or  no set criteria (PCU) referring family physician in consultation with CCH psychiatrist

Queensway Carleton Inpatient Services Admission / Exclusion Criteria Discharge Criteria Inpatient Services Not reported Not reported

The Ottawa Hospital Inpatient Services Admission / Exclusion Criteria Discharge Criteria Inpatient Unit  No elective admissions.  Discharge readiness is determined on a case by  All admissions come through: ED / Psychiatric case basis by MRP and treating team to ensure Emergency Services (PES), CritiCall transfers patient is stable and safe for discharge. from across the Region, Transfers from TOH  Those with a longer stay need are typically put inpatient wards, Hospital to hospital transfers on transfer list to The Royal. and occasionally through outpatient

Montfort Inpatient Services Admission / Exclusion Criteria Discharge Criteria Intensive Care Beds  Must have received a comprehensive psychiatric  The main goal of treatment is symptoms Acute Short Term assessment by a psychiatrist / resident / PES reduction, stabilization, and treatments Long-term Specialized (Psychiatric Emergency Services/SCUP in the geared towards preventing readmissions and Mental Health Beds emergency room or in the out-patient clinic. relapse  Montfort mental health has established a partnership with TOH. During periods of overcapacity at TOH, francophone patients that require admission following a comprehensive psychiatric assessment are transferred seamlessly directly to Montfort inpatient mental health unit.

The Royal90 Inpatient Services Admission / Exclusion Criteria Discharge Criteria Crisis Inpatient  The patient requires a crisis admission  Patients are discharged after a period of assessment, stabilization and /or treatment, OR objectives of the admission are met and

90Substance Use and Concurrent Disorders (SUCD) contains Assessment and Stabilization Unit (ASU) and Concurrent Disorders Unit (CDU).

 If the anticipated length of stay exceeds 14 days, additional benefit from further they could be transferred to the inpatient unit of hospitalization is not foreseen. their main outpatient program within 14 days  Not criminally responsible patient requiring inpatient admission  Patient of ROMHC, any program  Patients of Assessment & Stabilization Unit / Concurrent Disorders Unit or geriatrics discussed first with inpatient clinical lead prior to transfer to crisis from outside hospital  Non-Not Criminally Responsible forensics patients discussed with outpatient department physician prior to transfer from other hospital Champlain Forensic  Court or Ontario Review Board ordered  Court ordered assessment completed, detention/warrant of committal warrant of committal expiry.  Review Board disposition order allows access to the community and discharge. Geriatric  65 years or older with complex mental health  Patients are discharged after a period of needs or adults younger than 65 who have assessment, stabilization and /or treatment, Alzheimer’s or Frontotemporal dementia. objectives of the admission are met and  Medically stable additional benefit from further  The patient must require acute psychiatric hospitalization is not foreseen. treatment provided in the most appropriate and least restrictive care environment. Mood and Anxiety  Outpatients of the Mood and Anxiety outpatient  Patients are discharged after a period of program, exhibiting acute psychiatric symptoms assessment, stabilization and /or treatment, resulting in functional impairment or in need of objectives of the admission are met and medication adjustment or treatment which additional benefit from further cannot be appropriately managed on an hospitalization is not foreseen. outpatient basis  Patients admitted at other hospitals within LHIN with:

o A primary DSM5 diagnosis of depressive disorders, bipolar and related disorders o OR Primary DSM5 anxiety disorders or trauma and stressor related disorders where acute safety risk is present.  Persons who require intensive, specialized treatment who require longer length of stay than can be accommodated by referring source  Specialized service is not offered for primary obsessive compulsive and related disorders  Patients to return to referral source (if non- ROMHC patient) for follow up or if awaiting placement from hospital  Referrals are received from the community and peer hospitals within inpatient department of the Champlain LHIN (crisis and mood) or patients meeting mood repatriation criteria (Mood)  Community referrals (Mood only) and ROMHC referrals (Mood and Crisis) from outpatient psychiatry for inpatient stabilization and treatment Recovery Impairment in ability to function in the community  Recovery LOS 180 days: ready to integrate demonstrated by lack of meaningful activity, social back into community at the highest level roles or functional ability to manage self-care or live in possible the community with minimal formal support  Patient derived Psychosocial Goals, which might include: o Improving basic tasks of independent living o Achieving a higher level of independence in housing

o Greater autonomy and independence in financial matters o Additional education or occupation functioning o Enhancing skills to establish or maintain social support system o Achieve a sense of mental wellness  Physician referral  Be 18 years of age or older  Meet the DSM V criteria for Schizophrenia or Schizophrenia Spectrum Illnesses  No longer requires services best delivered in: o Psychiatric Emergency o Acute Care Inpatient Unit o Outpatient or Community Care Setting  To best promote the safety of both staff and patients, patients are expected to have been stabilized in a primary or secondary level of care and need for tertiary level of care is demonstrated Schizophrenia  Unstable symptoms with failure to respond well  Schizophrenia LOS 90 days: No further to medication requirement for tertiary services and can be  Have been offered algorithmic treatment safely transferred to appropriate level of care  Adequate risk management  Need for multidisciplinary care requested / demonstrated  Referring physician is willing to repatriate person being admitted (as inpatient or outpatient as required) to the Royal’s Schizophrenia program  Physician referral  Be 18 years of age or older  Meet the DSM V criteria for Schizophrenia or Schizophrenia Spectrum Illnesses

 No longer requires services best delivered in: o Psychiatric Emergency o Acute Care Inpatient Unit o Outpatient or Community Care Setting  To best promote the safety of both staff and patients, patients are expected to have been stabilized in a primary or secondary level of care and need for tertiary level of care is demonstrated SUCD-ASU All patients are voluntary admissions and must have  Completed medical detoxification or one of the following: stabilization on OST  Severe alcohol use disorders, history or at risk of seizure or delirium tremens  Inability to stabilize on Opioid Substitution Therapy (OST) in the community  Severe benzodiazepine use disorder (high dose)  May have: o Complicating medical conditions, including pregnancy o Complex polysubstance use disorders with failure to stabilize at community withdrawal management services o Complicating mental health problem Youth  Exclusion:  Patients are discharged after a period of o Primary diagnosis of conduct disorder, assessment, stabilization and /or treatment, substance dependence or eating disorder objectives of the admission are met and o Mental health concerns concurrent with additional benefit from further developmental delay hospitalization is not foreseen. Concurrent Disorders All patients are voluntary admissions and must have:  Increased stabilization to step-down to SUCD Unit  Severe, complex, active and symptomatic day program or other community services substance use and mental health disorders  Made progress towards identified treatment  Significant impairment in functioning due to goals complex mental health and addiction issues  Requires a different level of care

 Identified treatment goals  May have: o High system utilization o Difficulty accessing or maintaining involvement with other mental health and addiction services o Complicating physical health problems o Failure to stabilize at lower levels of treatment intensity o Unstable housing and street-affected o American Society of Addiction Medicine placement criteria is used to match clients with appropriate level of service intensity

CHEO Inpatient Services Admission / Exclusion Criteria Discharge Criteria Psychiatric Inpatient  Most admissions come through emergency  Discharge criteria are determined on case-by- Unit department at CHEO or other hospital in Eastern case basis by the attending psychiatrist, Ontario. specifically related to attaining stabilization of the illness and pharmacological treatment.  Discharge planning is done in coordination with family physician Eating Disorder Unit  Criteria for admission onto the inpatient unit – must be medically stable but with a low body weight (average body weight at admission of 80- 82%)

4.3 Patient Acuity Measures Figure 57 Percentage of Patients with Aggressive Behaviour Scale Assessment >391

Percentage of Patients with Aggressive Behaviour Scale Assessment >3 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

Figure 58 Percentage of Patients with Cognitive Performance Scale >392

Percentage of Patients with Cognitive Performance Scale >3 25.00%

20.00%

15.00%

10.00%

5.00%

0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

91 Admission Assessment and Short-Stay included. 92 Admission Assessment and Short-Stay included.

Figure 59 Percentage of Patients with Depressive Severity Index >793

Percentage of Patients with Depressive Severity Index >7 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

Figure 60 Percentage of Patients with Risk of Harm to Other Scale >394

Percentage of Patients with Risk of Harm to Others Scale >3 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

93 Admission Assessment and Short-Stay included. 94 Admission Assessment and Short-Stay included.

Figure 61 Percentage of Patients with Self-Care Index >395

Percentage of Patients with Self-Care Index >3 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

Figure 62 Percentage of Patients with Severity of Self-Harm Scale >396

Percentage of Patients with Severity of Self Harm Scale >3 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

95 Admission Assessment and Short-Stay included. 96 Admission Assessment and Short-Stay included.

Figure 63 Percentage of Patients with Positive Symptoms Scale >797

Percentage of Patients with Positive Symptoms Scale >7 20.00%

15.00%

10.00%

5.00%

0.00% Pembroke Cornwall Queensway Ottawa Civic Ottawa General Montfort The Royal Regional Carleton

2014 2015 2016

Source: OMHRS

97 Admission Assessment and Short-Stay included.

Figure 64 Peer Score Comparison Per Measure of Acuity98

Peer Score Comparison for Acuity Measures 60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00% ABS CPS DSI Risk Harm Self Care Self Harm Positive Symptoms

Pembroke Regional Cornwall Queensway Carleton Ottawa Civic Ottawa General Montfort The Royal

Source: OMHRS

98 Admission Assessment and Short-Stay included.

4.4 Admission Diagnosis Figure 65 Percentage of Admissions by Diagnosis99

Champlain LHIN-wide Admissions by Diagnosis Depressive disorders

3% 7% Schizophrenia spectrum and other psychotic disorders 6% 22% Substance-related and addictive disorders Neurocognitive disorders 10% Anxiety disorders

3% Bipolar and related disorders 4% Personality disorders 11% 34% Trauma- and stressor-related disorders Unreported

Source: OMHRS

99 Admission Assessment and Short-Stay included.

Figure 66 Percentage of Admissions by Diagnosis

Montfort Depressive disorders 2% Schizophrenia spectrum and 4% other psychotic disorders 7% 20% Substance-related and addictive disorders Neurocognitive disorders 13% Anxiety disorders

3% Bipolar and related disorders 3% Personality disorders 11% 37% Trauma- and stressor-related disorders Unreported

Source: OMHRS

Figure 67 Percentage of Admissions by Diagnosis

Pembroke Regional

2% Depressive disorders

6% Schizophrenia spectrum and other psychotic disorders 7% Substance-related and addictive disorders Neurocognitive disorders 10% 42%

Anxiety disorders 7% Bipolar and related disorders

1% Personality disorders 9% Trauma- and stressor-related 16% disorders Unreported

Source: OMHRS

Figure 68 Percentage of Admissions by Diagnosis

Cornwall

Depressive disorders 2% 5% Schizophrenia spectrum and 4% other psychotic disorders Substance-related and addictive 27% disorders 12% Neurocognitive disorders

Anxiety disorders 8% Bipolar and related disorders

2% Personality disorders 24% 16% Trauma- and stressor-related disorders Unreported

Source: OMHRS

Figure 69 Percentage of Admissions by Diagnosis

The Royal Depressive disorders 3% 2% 3% Schizophrenia spectrum and other psychotic disorders 18% 9% Substance-related and addictive 2% disorders Neurocognitive disorders

11% Anxiety disorders

Bipolar and related disorders 30% Personality disorders 22% Trauma- and stressor-related disorders Unreported

Source: OMHRS

Figure 70 Percentage of Admissions by Diagnosis

Queensway Carleton Depressive disorders

3% Schizophrenia spectrum and other psychotic disorders 12% Substance-related and addictive 28% disorders 7% Neurocognitive disorders

Anxiety disorders 11% Bipolar and related disorders

5% Personality disorders

6% 0% 28% Trauma- and stressor-related disorders Unreported

Source: OMHRS

Figure 71 Percentage of Admissions by Diagnosis

Ottawa Civic Depressive disorders

Schizophrenia spectrum and 1% 13% 12% other psychotic disorders Substance-related and addictive disorders 6% Neurocognitive disorders

8% Anxiety disorders

Bipolar and related disorders 2% 5% Personality disorders 46% 7% Trauma- and stressor-related disorders Unreported

Source: OMHRS

Figure 72 Percentage of Admissions by Diagnosis

Ottawa General Depressive disorders

Schizophrenia spectrum and 14% other psychotic disorders 2% 24% Substance-related and addictive disorders 5% Neurocognitive disorders

Anxiety disorders 10% Bipolar and related disorders

1% Personality disorders 3% 6% 35% Trauma- and stressor-related disorders Unreported

Source: OMHRS

4.5 ALC Destination Waiting for by Hospital, Last FY

Figure 73 ALC Discharge Destination Waiting For Per Hospital

Queensway Carleton 6.0% TBD

5.0% Unknown

Supervised or Assisted Living 4.0% Rehab

3.0% Long Term Care

Home without Support 2.0% Home with Community Services

1.0% Home with CCAC

Convalescent Care 0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16 Complex Continuing Care

Source: Access to Care, 2017

Figure 74 ALC Discharge Destination Waiting For Per Hospital

Royal Ottawa 10.0%

9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16

Source: Access to Care, 2017

Figure 75 ALC Discharge Destination Waiting For Per Hospital

Montfort 8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16

Source: Access to Care, 2017

Figure 76 ALC Discharge Destination Waiting For Per Hospital

Cornwall 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16

Source: Access to Care, 2017

Figure 77 ALC Discharge Destination Waiting For Per Hospital

Pembroke 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16

Source: Access to Care, 2017

Figure 78 ALC Discharge Destination Waiting For Per Hospital

Ottawa Civic 16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16

Source: Access to Care, 2017

Figure 79 ALC Discharge Destination Waiting For Per Hospital

Ottawa General 18.0%

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0% FY 11/12* FY 12/13 FY 1314 FY 14/15 FY 15/16

Source: Access to Care, 2017