Early Psychosis Intervention-Spreading Evidence-based Treatment (EPI-SET) : Protocol for an effectiveness-implementation study of a structured model of care for psychosis in youth and emerging adults

Introduction While early psychosis intervention (EPI) has proliferated in recent years amid evidence of its effectiveness, programmes often struggle to deliver consistent, recovery-based care. NAVIGATE is a manualised model of EPI with demonstrated effectiveness consisting of four components: individualised medication management, individual resiliency training, supported employment and education and family education. We aim to implement NAVIGATE in geographically diverse EPI programmes in Ontario, Canada, evaluating implementation and its effect on fidelity to the EPI model, as well as individual-level outcomes (patient/family member-reported and interviewer-rated), system-level outcomes (captured in provincial administrative databases) and engagement of participants with lived experience. Methods and analysis This is a multisite, non-randomised pragmatic hybrid effectiveness-implementation type III mixed methods study coordinated at the Centre for Addiction and Mental Health (CAMH) in Toronto. Implementation is supported by the Provincial System Support Program, a CAMH-based programme with provincial offices across Ontario, and Extension of Community Healthcare Outcomes Ontario Mental Health at CAMH and the University of Toronto. The primary outcome is fidelity to the EPI model as measured using the First Episode Psychosis Services-Fidelity Scale. Four hundred participants in the EPI programmes will be recruited and followed using both individual-level assessments and health administrative data for 2 years following NAVIGATE initiation. People with lived experience will be engaged in all aspects of the project, including through youth and family advisory committees. Ethics and dissemination Research ethics board approval has been obtained from CAMH and institutions overseeing the local EPI programmes. Study findings will be reported in scientific journal articles and shared with key stakeholders including youth, family members, programme staff and policymakers. Trial registration number NCT03919760; Pre-results

Evaluating System-level Implementation of Telepsychiatry in Ontario from 2008-2016: Implications for the Sustainability and Growth of Telepsychiatry

Objectives The objective of this thesis was to understand the implementation of clinical telepsychiatry in Ontario. To do this, paper 1 described the characteristics of psychiatrists who delivered and patients who received telepsychiatry, calculated how many in-need patients received telepsychiatry, and identified trends in the distribution of telepsychiatry (where care was delivered to and from). Paper 2 described characteristics and predictors of family physicians who referred patients to telepsychiatry and paper 3 compared the costs of telepsychiatry with other traditional models of psychiatric outreach. Study Designs This thesis employed several study designs, including a serial panel study and retrospective cross-sectional studies using linked data from ICES, as well as a cost-minimization analysis. Results Paper 1 found that, in fiscal year (FY) 2012, a total of 3,801 people had 5,635 telepsychiatry visits, and 7% of Ontario psychiatrists provided these visits. Of 48,381 people discharged from a psychiatric hospitalization, 60% saw a local psychiatrist, 39% saw no psychiatrist, and less than 1% used telepsychiatry within 1 year of discharge. Paper 2 showed that the number of patients using telepsychiatry, and the number of family physicians referring to telepsychiatry increased fifteen-fold and nine-fold, respectively, from FY 2008 to FY 2016. 32% of Ontario family physicians referred to telepsychiatry in FY 2016, however, less than 1% of their rostered patients used telepsychiatry (n =12,449/3,513,638). Family physicians that referred to telepsychiatry were more likely to be from a rural residence, to have more nurse practitioners in their practice, and to be part of a Family Health Team, while their patients were more likely to live in rural areas, have increased complexity, and higher rates of mental health service utilization. Paper 3 found that costs per visit were lowest in telepsychiatry ($360), followed by travelling physicians ($558) and patient reimbursement for travel ($620). Conclusions This dissertation has demonstrated that while telepsychiatry has been increasingly adopted by providers, adoption by patients remains fairly low. Telepsychiatry is less costly than other in-person outreach models and shows signs of sustainability, such as the persistent increase in adoption and penetration throughout Ontario over the study period.Ph.D.2021-01-12 00:00:0

Describing implementation outcomes for a virtual community of practice: The ECHO Ontario Mental Health experience

Abstract Background Project ECHO is a virtual education model aimed at building capacity among healthcare providers to support optimal management for a range of health conditions. The expansion of the ECHO model, further amplified by the pandemic, has demonstrated an increased need to evaluate implementation success to ensure that interventions are implemented as planned. This study describes how Proctor et al.’s implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) were adapted and used to assess the implementation of ECHO Ontario Mental Health (ECHO-ONMH), a mental health-focused capacity-building programme. Methods Using Proctor et al.’s implementation outcomes, the authors developed an implementation outcomes framework for ECHO-ONMH more generally. Using this, outcome measures and success thresholds were identified for each outcome for the ECHO-ONMH context, and then applied to evaluate the implementation of ECHO-ONMH using data from the first 4 years of the programme. Results An ECHO-ONMH implementation outcomes framework was developed using Proctor’s implementation outcomes. ECHO-ONMH adapted implementation outcomes suggest that ECHO-ONMH was implemented successfully in all domains except for penetration, which only had participation from 13/14 regions. Acceptability, appropriateness and adoption success thresholds were surpassed for all 4 years, showing strong signs of sustainability. The programme was deemed feasible all 4 years and was found to be more cost-effective. ECHO-ONMH also showed high rates of fidelity to the ECHO model, and high rates of penetration. Conclusions This is the first study to use Proctor et al.’s implementation outcomes to describe implementation success for a virtual capacity-building model. The proposed ECHO implementation outcomes framework provides a base for similar interventions to evaluate implementation success, which is an important precursor to understanding learning, service or health outcomes related to the model. Additionally, these findings can act as a benchmark for other international ECHOs and educational programmes

Technology-Enabled Collaborative Care for Concurrent Diabetes and Distress Management During the COVID-19 Pandemic: Protocol for a Mixed Methods Feasibility Study

BackgroundThe COVID-19 pandemic disrupted the delivery of diabetes care and worsened mental health among many patients with type 2 diabetes (T2D). This disruption puts patients with T2D at risk for poor diabetes outcomes, especially those who experience social disadvantage due to socioeconomic class, rurality, or ethnicity. The appropriate use of communication technology could reduce these gaps in diabetes care created by the pandemic and also provide support for psychological distress. ObjectiveThe purpose of this study is to test the feasibility of an innovative co-designed Technology-Enabled Collaborative Care (TECC) model for diabetes management and mental health support among adults with T2D. MethodsWe will recruit 30 adults with T2D residing in Ontario, Canada, to participate in our sequential explanatory mixed methods study. They will participate in 8 weekly web-based health coaching sessions with a registered nurse, who is a certified diabetes educator, who will be supported by a digital care team (ie, a peer mentor, an addictions specialist, a dietitian, a psychiatrist, and a psychotherapist). Assessments will be completed at baseline, 4 weeks, and 8 weeks, with a 12-week follow-up. Our primary outcome is the feasibility and acceptability of the intervention, as evident by the participant recruitment and retention rates. Key secondary outcomes include assessment completion and delivery of the intervention. Exploratory outcomes consist of changes in mental health, substance use, and physical health behaviors. Stakeholder experience and satisfaction will be explored through a qualitative descriptive study using one-on-one interviews. ResultsThis paper describes the protocol of the study. The recruitment commenced in June 2021. This study was registered on October 29, 2020, on ClinicalTrials.gov (Registry ID: NCT04607915). As of June 2022, all participants have been recruited. It is anticipated that data analysis will be complete by the end of 2022, with study findings available by the end of 2023. ConclusionsThe development of an innovative, technology-enabled model will provide necessary support for individuals living with T2D and mental health challenges. This TECC program will determine the feasibility of TECC for patients with T2D and mental health issues. Trial RegistrationClinicalTrials.gov NCT04607915; https://clinicaltrials.gov/ct2/show/NCT04607915 International Registered Report Identifier (IRRID)DERR1-10.2196/3972