Improving Transitions in Care for Children and Youth With Mental Health Concerns

Mental Health Clinical Trial

Official title:

Improving Transitions in Care for Children and Youth With Mental Health Concerns: Implementation and Evaluation of an Emergency Department Mental Health Clinical Pathway

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT02590302
• Other study ID #: ChildrensHEO
• Status: Recruiting
• Phase: N/A
• Start date: December 1, 2017
• Est. completion date: December 2019

Study information

• Verified date: July 2018
• Source: Children's Hospital of Eastern Ontario
• Contact: Mona Jabbour, MD
• Phone: 613-737-7600
• Email: jabbour[@]cheo.on.ca
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The overarching goal of this project is to improve timely access to appropriate mental health (MH) care for children and youth. The investigators will conduct and rigorously evaluate implementations of this pathway in four exemplar hospitals and associated CMHA dyads within a local health region. Outcomes-based validation of this pathway is important for effective adoption in other communities. A multiple baseline study design and conduct interrupted time-series analysis will be used to evaluate whether the EDMHCP has resulted in improved health care utilization, medical management, and health sector coordination. To ensure EDMHCP feasibility in various settings, implementation will occur in four exemplar hospital-community dyads with different workflows and patient populations.

Description:

Commissioned by the Ontario Ministries of Health and Long Term Care(MOHLTC) and Child and Youth Services(MCYS), an expert-developed clinical pathway(CP) has been created with two main goals: 1) to guide risk assessment and disposition decision-making for children and youth presenting to the emergency department(ED) with MH concerns, and 2) to ensure seamless transition to follow-up services with community MH agencies(CMHAs) and providers. This pathway, referred to as the EDMHCP, is unique in undertaking to provide a seamless transition of care for children/youth and caregivers between hospital EDs and CMHAs.

Working with 4 exemplary hospital EDs and 2 Community Mental Health Agencies across Eastern Ontario, the investigators will conduct a 3-year mixed methods health services research project with three components to i) implement the EDMHCP using a theory driven, evidence-based approach, ii) evaluate EDMHCP effectiveness through measurement of relevant outcomes, and iii) conduct a process evaluation to document and assess the EDMHCP implementation strategy against the outcomes achieved.

This 3 year study will take place in five different phases, which include:

• Preparation: Qualitative interviews with ED team members and strategy development

• Implementation: Working with each ED team to implement the clinical pathway (including standardized assessments) within 8 months

• Post-implementation: Qualitative interviews with ED team members

• Data collection: 9-month pre/post chart audits of patients with mental health and caregiver satisfaction surveys

• Follow up: to discuss findings, database creation, and dissemination strategy.

To ensure the findings directly impact relevant service delivery areas, the investigators have specifically recruited study team members with decision-making authority and/or influence on delivery of care for children and youth with MH concerns. This project will provide an implementation model for the EDMHCP to be used in any ED and CMHA setting, and will demonstrate decreased wait times and increased access with EDMHCP adoption. The findings will guide policy decision-making on access to timely and appropriate MH care and add to current knowledge of implementation science. In addition to knowledge translation via team member dissemination within their areas of influence, the investigators plan to disseminate the findings through presentation at scientific and healthcare conferences, and publication in relevant peer-reviewed journals.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 3095
• Est. completion date: December 2019
• Est. primary completion date: September 2018
• Accepts healthy volunteers: No
• Gender: All
• Age group: 6 Years to 18 Years

Eligibility

Inclusion Criteria:

• Ages > 5.99 and < 18 years

• Presented to the ED of the four chosen hospitals within a selected 8 month time frame (between January, 2016 to May 2017)

• Mental health issue as their primary complaint (all complaints identified at triage as involving MH [psychosocial, emotional, behavioural])

• Proficient in English.

Exclusion Criteria:

• CTAS of 1 (Resuscitation)

• Patient is not medically stable

• Intubation/PICU care required

• Direct admission to hospital for ongoing medical management and observation

• Patients presenting with head injury or post-concussional syndrome

Related Conditions & MeSH terms

• Mental Health

Intervention

Other:
• Implementation Phase
Core Components of the implementation intervention include: Hospital and CMHA project commitment Site champion teams (from hospital and CMHA) Memorandum of Agreement between Hospital and CMHA Pre-intervention site visits Education sessions Posters/reminders Instructional videos (HEADS ED video) Completed pathway implementation includes EDMHCP site-customization and committee approvals, consequent planning and agreements among ED-CMHA partners, delivery of at least two educational workshops, and EDMHCP availability in the ED. An 8-month period for EDMHCP implementation, with negotiated interim target dates was set for each site.

Locations

Country	Name	City	State
Canada	Children's Hopsital of Eastern Ontario	Ottawa	Ontario
Canada	Winchester District Memorial Hospital	Winchester	Ontario

Sponsors (7)

Lead Sponsor	Collaborator
Children's Hospital of Eastern Ontario	Canadian Institutes of Health Research (CIHR), Cornwall Community Hospital, Ontario Ministry of Health and Long Term Care, Queensway Carleton Hospital, Winchester District Memorial Hospital, Youth Services Bureau

Country where clinical trial is conducted

Canada, 

References & Publications (29)

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Chandra A, Minkovitz CS. Stigma starts early: gender differences in teen willingness to use mental health services. J Adolesc Health. 2006 Jun;38(6):754.e1-8. — View Citation

Children's Hospital of Eastern Ontario. Advocacy Mental Health. Ottawa, Canada: http://www.cheo.on.ca/en/mentalhealth. Accessed August 22, 2014.

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Jabbour M, Curran J, Scott SD, Guttman A, Rotter T, Ducharme FM, Lougheed MD, McNaughton-Filion ML, Newton A, Shafir M, Paprica A, Klassen T, Taljaard M, Grimshaw J, Johnson DW. Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial. Implement Sci. 2013 May 22;8:55. doi: 10.1186/1748-5908-8-55. — View Citation

Jensen PS, Eaton Hoagwood K, Roper M, Arnold LE, Odbert C, Crowe M, Molina BS, Hechtman L, Hinshaw SP, Hoza B, Newcorn J, Swanson J, Wells K. The services for children and adolescents-parent interview: development and performance characteristics. J Am Acad Child Adolesc Psychiatry. 2004 Nov;43(11):1334-44. — View Citation

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Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011 Apr 23;6:42. doi: 10.1186/1748-5908-6-42. Review. — View Citation

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Newton AS, Rathee S, Grewal S, Dow N, Rosychuk RJ. Children's Mental Health Visits to the Emergency Department: Factors Affecting Wait Times and Length of Stay. Emerg Med Int. 2014;2014:897904. doi: 10.1155/2014/897904. Epub 2014 Jan 19. — View Citation

Newton, A. S., Rosychuk, R. J., Ali, S., Cawthorpe, D., Curran, J., Dong, K., … Urichuk, L. (2011). The Emergency Department Compass: Children's Mental Health. Pediatric mental health emergencies in Alberta, Canada: Emergency department visits by children and youth aged 0 to 17 years, 2002-2008. Edmonton, AB.

Ontario Ministry of Health and Long-Term Care. Ontario's action plan for health care: Better patient care through better value from our health care dollars. Toronto, Canada: Government of Ontario; 2012. Available at: http://www.health.gov.on.ca/en/ms/ecfa/ healthy_change/docs/rep_healthychange.pdf. Accessed August 22, 2014.

Ontario. Legislative Assembly. Select Committee on Mental Health and Addictions Final report, navigating the journey to wellness : the comprehensive mental health and addictions action plan for Ontarians; 2010 Available at: http://www.ontla.on.ca/committee-proceedings/committeereports/ files_pdf/Select%20Report%20ENG.pdf Accessed October 15, 2014.

Open Minds, Healthy Minds. (2011). Ontario's comprehensive mental health and addictions strategy. Ottawa (ON): Government of Ontario. Available at: http://www.health.gov.on.ca/en/common/ministry/publications/reports/mental_health201 1/mentalhealth_rep2011.pdf Accessed October 15, 2014

Provincial Council for Maternal and Child Health. Implementation Toolkit: Emergency Department Clinical Pathway for Children & Youth with Mental Health Conditions. Prov Counc Matern Child Heal. Available at: http://pcmch.on.ca/sites/default/files/Toolkit- ED_Clinical_Pathway-Tookit_ Sept_ 30_2013-FINAL_0.pdf. Accessed January 14, 2014.

Scott SD, Grimshaw J, Klassen TP, Nettel-Aguirre A, Johnson DW. Understanding implementation processes of clinical pathways and clinical practice guidelines in pediatric contexts: a study protocol. Implement Sci. 2011 Dec 28;6:133. doi: 10.1186/1748-5908-6-133. — View Citation

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* Note: There are 29 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Proportion of patients receiving post-ED follow-up on the Services for Children and Adolescents Parent Interview questionnaire	The primary clinical outcome is the proportion of patients that receive the post ED follow-up as per the clinical pathway recommendations as measured by the Services for Children and Adolescents Parent Interview questionnaire	24 hours or 7 days
Primary	Proportion of patients with documented mental health recommendations in the medical chart	The primary process outcome is the proportion of patients with documented MH-specific recommendations (as defined by the project team) in the medical chart.	24 hours or 7 days
Secondary	Proportion of completed CP assessment forms filed in the health record to determine clinical pathway uptake in the Emergency Department	CP uptake in the ED will be measured through audits as the proportion of completed clinical pathway assessment forms filed in the health record	9 months
Secondary	Patient perspectives of post-ED mental health service using The Services for Children and Adolescents-Parent Interview	Post ED uptake of recommended community MH services will be measured by The Services for Children and Adolescents-Parent Interview	7-10 days
Secondary	Alignment of HEADS-ED assessment and mental health services	Alignment of recommended services documented in the patients health record (audit) to the HEADS-ED mental health screening tool assessment	7-10 days
Secondary	Decreased length of stay	ED length of stay will be obtained from health record and NACRS administrative database	26 months
Secondary	Patient satisfaction with ED visit measured by the Client Satisfaction Questionnaire	Patient/caregiver satisfaction with the ED visit will be measured by the Client Satisfaction Questionnaire	7-10 days
Secondary	Decreased number of hospital admissions obtained from health record and NACRS administrative database	Hospital Admission will be obtained from health record and NACRS administrative database	26 months
Secondary	Decreased number of ED Revisits from the health record and NACRS administrative database	ED revisits will be obtained from the health record and NACRS administrative database	10 day and 3 months