catch ed: coordinated access to care from hospital emergency departments vicky stergiopoulos, msc,...
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CATCH ED:Coordinated Access to Care from Hospital Emergency Departments
Vicky Stergiopoulos, MSc, MD, MHSc, FRCPCScientist, Centre for Research on Inner City Health, St. Michael’s Hospital
Director, Division of Adult Psychiatry and Health SystemsAssociate Professor, University of Toronto
BRIDGES ConferenceMarch 31, 2015
Frequent ED users Challenges of frequent users of Emergency Departments
(EDs) include low socioeconomic status, mental illness/addictions and multiple medical co-morbidities.
In 2010/11, 2% of adult ED users who made a mental health or addictions-related visit made >21 visits each (TC-LHIN)
Across Ontario, 16,692 adults made >5 visits to a single ED, at least one of them for a mental health/addictions (MHA) related concern in 2012/13
CATCH ED Program DescriptionCoordinated Access to Care from Hospital EDs (CATCH-ED)
provides brief intensive case management, priority access to primary care and mental health counseling and peer support for frequent ED usersTarget population >5 visits to a single ED with at least one visit
for a MHA concern.
An adaptation of the Critical Time Intervention model, supporting transitions and continuity of care for disadvantaged populations.Brief case management offered over 4-6 months
CATCH ED Partners
Partnership among 6 hospitals, 3 community mental health agencies, one peer outreach service and 4 community health centers.
Co-sponsored by the TC-LHIN and the Toronto Mental Health and Addictions Acute Care Alliance
Implementation and outcome evaluation led by CRICH, St. Michael’s Hospital.
Implementation Evaluation
Some key findings A centralized multidisciplinary program structure and
regular supervision are necessary to provide program cohesion and consistency/quality in program delivery.
Case managers/counselors with the right skill mix and training are essential to provide high quality community MHA care.
Collaboration of sectors not traditionally working together and endorsement by local health authorities can facilitate program implementation.
Mixed-Methods Outcome Evaluation Randomized Controlled Trial with adults (N=166) with > 5
ED visits, at least one for a MHA concern Outcome measures include ED use, days in hospital, mental
health symptom severity, substance use and quality of life, 12 months after program enrolment
Both self-reported service use and administrative health data linkages with ICES databases
Economic evaluation by the Centre for Excellence in Economic Analysis Research (CLEAR)
Qualitative Evaluation - 33 narrative interviews with patients and service providers
Continuity of care process measures
Participant Characteristics
Mean age: 43.2 years ± 15.551% Male82% Unemployed75% on Disability Income (ODSP/CPPD)77% housed68% of participants reported 3 or more co-morbid health
conditions.
Participant-reported Psychiatric Diagnoses
Eating Disorder
Schizoaffective Disorder
Schizophrenia
Personality Disorder
Post Traumatic Stress Disorder
Drug Use Disorder
Bipolar Disorder
Alcohol Use Disorder
Depressive Disorder
Anxiety Disorder
0% 10% 20% 30% 40% 50% 60%
OutcomesParticipants reported a median of 6 ED visits, 1 hospital
admission, and 3 days in hospital during the six months prior to enrolment79% have a Primary Care physician at baseline
In unadjusted preliminary analysis, the intervention did not seem to impact health and health service use outcomesQuality of health reported health service use poor
Data analysis currently underway at AHRCICES linkage in 2016
Qualitative Evaluation: Preliminary Findings
Precipitants of ED use included MHA-related crises, and acute and chronic health conditions related to pain and injury.
Psychiatric35%
Medical39%
Alcohol or Drug Use
21%
Other5%
Frequent use of the Emergency Department
Choosing the ED: The ED was felt to be the normative destination when in crisis.
Experiences of ED use: Many participants described experiences of stigma and discrimination in the ED, related to their status as mental health patients or ‘frequent flyers.’
Qualitative Evaluation: Preliminary Findings (continued)
Challenges in Continuity of Care
Multiple providers/system fragmentation
Poor past experiences of care, difficulty with engagement.
“Diffusion of responsibility “– no clear accountability in service provision.
The importance of healing relationships /choice
Implications for Ontario
• Across Ontario, 16,692 adults met cohort criteria in 2012/13 for a total cost of $436,492,570.76– Age (median): 44.4 (18.7)– Female: 53.1%– >50% in the lowest two income quintiles– Enrolled in primary care group: 67.8%– Mean number of ED visits: 10 (11.08) – Stable Chronic Medical Conditions: 60.3%
• Met cohort criteria in the following year: 23.8%
CATCH-ED Research Next Steps
Analyzing process measures of continuity of care: timeliness, comprehensiveness, coordination, appropriateness of care and gaps in services.
Data analysis and administrative health data linkage through the Institute for Clinical Evaluative Sciences (ICES) databases
Preparation of conference abstracts and manuscripts
Impact/ValueLessons learned informing program redesign across Toronto hospitals Effective systems and communications within hospitals
are necessary to support referrals of frequent ED users. Dedicated ED resource?
Interventions for the target population need access to psychiatric support /expertise.
Investment is required in workforce training and technical assistance to deliver evidence-based community MHA care.
CATCH ED Program Next Steps
Model redesign in the context of Health LinksEach hospital considering an approach that best
suits local realitiesPotential Options:
Integration with Health Link TeamsIntegration within Hospital Urgent Care programsOther options…
AcknowledgementsFunders BRIDGES Toronto Mental Health and Addictions Acute Care Alliance Centre for Research on Inner City Health, St. Michael’s Hospital TC-LHIN
Research TeamPrincipal Investigator: Dr. Vicky StergiopoulosCo-Investigators: Drs. Zuhair Alsharafi, Tim Guimond, Stephen Hwang, Meldon Kahan, Paul Kurdyak, Molyn Leszcz, Patricia O’Campo, Howard Ovens, Julie Spence, Peter Voore, Don Wasylenki
