Competency Development to Meet Rural and Remote Mental Health Needs: A Case Study of Child and Youth Mental Health Policy in Yukon, Canada

1. McMaster University, Hamilton, Ontario; 2. Dalhousie University, Halifax, Nova Scotia; 3. Health & Social Services, Whitehorse, Yukon

G. Mulvale1., S. Kutcher2., M. Fast3., J. Winkup1., G. Randall1., P. Wakefield1., C. Lon-go1., & J. Abelson1.

BackgroundYukon faces problems of rural and remote service delivery

Access issues for child/youth mental health services• Acute need in rural and remote areas and First Nation (FN) communities

In 2013/4, Yukon Government, McMaster & Dalhousie researchers to-gether developed a child and youth mental health and addictions frame-work.

Research Questions: What are the unique features and needs for a comprehensive child and youth mental health and addictions framework in Yukon? How can experiences of similar jurisdictions inform the frame-work?

• Population base• Funding

• Geography• Recruitment, retention

Methodsparticipatory policy research

PolicyAdvisors

Clinician and Service

Provider Input

First NationsInput

Youth andFamily LivedExperience Other

Jurisdictions

Best Evidence

Expert Opinion

• A mixed methods case study design (Yin, 2003)• Data sources: document analysis, focus groups, key informant inter- views

• Two conceptual frameworks: √3-I(Interests,InstitutionsandIdeas)PolicyAnalyticFramework √EvergreenChildandYouthMentalHealthFramework

•Commonelementsacrosssourceswereusedtodevelopadraftframe- work.

• Feedback from three interactive sessions; (i) working group members, (ii) clinicians, and (iii) stakeholders at a policy dialogue was incorporated infinalframework.

Project Phases

Phase 1

UnderstandingYukon Context

Phase 2

Learning from Other Jurisdictions

Phase 3

DevelopFramework

Yukon interviews: Participants by Location

Type whitehorse Haines Junction Kdfn TKFN Total

Policy Advisor 15 0 0 0 15

Service Provider 24 6 2 2 34

Politician 1 0 0 0 1

FN Leaders* 1 1 2 0 4+10*

Family 7 3 3 0 13

Youth 10 3 2 0 15

Other Agencies 1 5 0 0 6

Total 59 18 9 2 98

* Also 10 participants in one Yukon-wide focus group with First Nations Health and Social Directors

salient characteristics

Characteristic Description

Geographic One large centre, small rural/remote communities; HR is-sues; weather challenges

Population Small base, highly dispersed; FN needsGovernance/Funding Federal/territorial/FN complexities; limited resourcesCultural Diversity among service providers vs. users; culturally-specif-

ic approaches; legacies of residential school policiesSocio-political ‘Closeness’ofpoliticiansandpublic;cultureofriskaversionStructure/Organization

Separate planning, limited care coordination/information-shar-ing across departments and agencies

Service/ClinicalApproaches

Marked differences in care philosophies, language acrossservices

Resources Imbalanced allocation, limited funding for child and youth MHCommon problems become particularly acute in Yukon context

FindingsPhase 1: Feedback on yukon Programming

● Access: “Mental health – it’s a 24 hours thing you know, people don’t go into crisis from 9-4 … so they’re always dealing with it after-the-fact and it’s very frustrating.”

- Family member

● Community-based Care: “We really… focus on professionals com- ing into our community and helping us but we need to get those pro fessionals to help us develop the skills because we’re the ones that need it.”

- First Nation participant

● Child and Youth Mental Health Competencies: “So as primary care providers I think we need better education…in terms of youth…. I would do a better job…. So in a crisis situation we can get the crisis over with and then use the other services…”

- Service provider 1

Phase 1: Feedback on yukon Programming

● Care Coordination: “…you know, they are seeing someone else for trauma and someone else for addictions, and it’s really hard to keep it all coordinated. And I thought to myself, if it’s hard for you I wonder what it’s like for the client.”

- Service provider 2

● Freeing Up Resources: “…we need to get through the silos to free up resources ….”

- Policy advisor

● More Promotion and Prevention: “…and I’m not convinced we are doing enough upstream work in the Yukon….”

- Policy advisor

Suggestions for improvement

● Expand school based socio-emotional learning programs and coun- seling.

● Adopt a holistic approach that goes beyond medical approaches.

● Locate services within or close to communities to address acute needs in rural communities.

● Improve coordination and promote information-sharing among all those caring for youth with mental disorders and addictions.

● Expandsuccessfulculturally sensitive programs.

● Improve child and youth mental health and addictions competencies across workforce.

Phase 2: input from other jurisdictions8 key informant interviews, 11 informants

Frameworks

Alberta PositiveFutures/CreatingConnectionsManitoba HealthyChildManitobaOntario MCYSFramework,MHStrategyNew Zealand Mental Health Framework, Aboriginal Strategies

Programming

B.C. RapidAccesstoConsultativeExperienceNorway Family HouseHawaii Families as Allies/Youth Helping YouthAlaska NUKA model; Bring the Kids Home; Family Wellness

Warriors

Content and implementation

● Use technologies and hub and spoke model to deliver services to rural communities● Develop workforce capacities within rural communities, including First Nations community members to enhance cultural sensitivity ser- vices.● Offercoordinated, interdisciplinary approaches to service delivery. ● Provide programming across the continuum of promotion, preven- tion, early intervention and treatment.● Ensureprovidersareknowledgeableinevidence-based clinical in- terventions. ● Dedicate funding to enhancing mental health literacy of human service workers and volunteers.● Require evidence-based programs/ interventions and ongoing evalu- ation and accountability.

Phase 3: common themes across sources

input/ element

community based

competencyDevelopment

tele/videohealth

commondataset

websitesupport

SalientCharacteristics

√ √ √

Program Feedback

√ √ √ √

ComparatorJurisdictions

√ √ √

Delphi Consensus

√

Clinician’sWorkshop

√ √

Evergreen √ √ √ √ √Policy Dia-logue

√

rolesAll communities Regional Hubs Whitehorse

WHO:Existingcommu-nity based health and human service work-ers(YG/FN/NGO)

WHO: Primary care providers & human services workers

WHO: MHSstaff,pedi-atricians, psychiatrists, family physcians, psy-chologists

ROLE: Provide basic mental health care

ROLE: Provide on-site consultations and collaborative care for youth referred by communities

ROLE: Treat most se-rious mental disorders, consultations

Competency development

Competency developmentcompetencies

All communities Regional Hubs Whitehorse BASIC:• Understanding mental disorders•Culturallyinformed,ev- idence-based intervention•Crisisintervention, management • Identifying disorders •Engagingyouth/families• Support, problem solving •Consultation/referral• Use of Telehealth • Harm reduction strate- gies

ADVANCED:• Assessment/Diagnosis• First-line treatment planning •Engagingyouthand families in treatment •Consultation/collabora- tive care • Triage/referral •Cognitivebehavioral therapy • Basic psychopharma- cology

ENHANCED:• Acute inpatient care•Crisismanagement• Advanced psychophar- macology • Psycho-therapeutic op- tions • Wrap around care/case management •Offerskillstraining(ba- sic/advanced) • Non-residential addic- tions interventions

Improve Competencies: teachers, support/administrative staff;youthserviceorganizationworkers

Mental Health Promotion and Prevention across these sites and in schools

a cascading model of service deliveryReferrals

Smaller Communities

SmallerCommunities

Basic Competency Training

Regional Hubs

Basic + Advanced Competency Training

Basic + Advanced+ Enhanced Competency Training

Core Elements - Across the Yukon • Necessary competencies in mental health in all communities • Telehealth capabilities in all communities • Common data set (electronic health record) • Facilitated electronic mental health information and support

Whitehorse and OOT

Regional Hubs

Smaller Communities

Telehealth &Electronic Support

Discussion Framework Overview

DiscussionThe Framework enhances mental health competencies of all health and human service workers to transform traditionally siloed mental health care delivery. While building a common foundation to improve coordination and collaboration to meet mental health promotion, prevention, care and service delivery needs across Yukon.

Framework:

• Allows children, youth, families to receive care in home communities to the greatest extent possible;

•Offersrational,efficientreferralofcomplexneedstomorespecialized services and providers; and

• Recognizes resource constraints while transforming structures and mindsets.

ConClusion • Addressing rural/remote access requires attention to local context, while taking a systems level view.

•Enhancingcapacityofexistingresourcesinruralandremoteregions may enhance cultural sensitivity in care provision.

•Competencydevelopmentpluselectronicsupportandreferralcanbe a core strategy to expand reach of existing mental health services.

• Approach may be adaptable to other jurisdictions that face similar chal- lenges.

• Leadership, realistic expectations, staged approaches are essential for implementation.

acknowledgements●TheCanadianInstitutesforHealthResearch(CIHR)fundedthisre-searchthroughanEvidence-InformedPolicyRenewalGrant.

●ThankyoutothekeyinformantsfromYukonandotherjurisdictions, and the clinical workshop and policy dialogue participants. Special thanks to the Yukon Working Group and leadership in the department of Health and Social Services.

●SpecialthankstoAlisonMulvaleforexcellentresearchassistanceand poster design.

References1.Mulvale,G.,Kutcher,S.,Randall,G.,Wakefield,P.,Longo,C.,Abelson,J.,Winkup, J.,Wishart,J.(2015).AChildandYouthMentalHealthandAddictionsFrame work for Yukon: Final Research Report. Hamilton: McMaster University.

2.Mulvale,G.,Kutcher,S.,&Winkup,J.(2014).AChildandYouthMentalHealthand Addictions Framework for the Yukon. Hamilton, ON: McMaster University.

3.Yin,R.(2003).Casestudyresearchdesignandmethods(Thirded.Vol.5).Thou- sandOaks,California:SagePublications.

4.Howlett,M.,Ramesh,M.,&Perl,A.(2009).StudyingPublicPolicy:PolicyCycles and Policy Subsystems. Toronto, ON: Oxford University Press.

5.Kutcher,S.,&McLuckie,A.(2010).Evergreen:Achildandyouthmentalhealth frameworkforCanada.Calgary,AB:MentalHealthCommissionofCanada.