Downtown East Toronto Ontario Health Team

Patient Referrals

New Primary Care Program to Serve Underserved Populations of Downtown East Toronto

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Overview

DET OHT is committed to connecting its diverse communities to the primary care services. To advance this priority, the DET OHT is launching one of its most significant primary care initiatives to date in Fall 2024. This program will address the service gaps for individuals facing substantial social and economic challenges in accessing team-based, interprofessional primary care. These groups include:

  • Indigenous communities
  • Black communities
  • People experiencing housing insecurity
  • 2SLBTQIA+
  • Refugees
  • People with disabilities
  • People who use drugs
  • Others facing barriers to comprehensive team-based care

About the Program

The program will encompass a two-pronged approach to improve client navigation:

  1. Increasing access to team-based primary care services
  2. Increasing attachment to these services.

It will follow the principles of health equity and population health to reduce disparities in health outcomes across diverse DET community.

The DET OHT is undertaking this program in collaboration with four of its Team Members, representing a diverse mix of partnering primary care organizations (PCOs) including Community Health Centres, Academic Family Health Teams (AFHT), and Family Health Teams (FHT):

  1. Sherbourne Health FHT
  2. Regent Park CHC
  3. St. Michael’s AFHT
  4. Inner City FHT

The care model will embed Nurse Practitioners (NPs) in the four PCOs mentioned above to strengthen clients’ access and attachment to primary care. The NPs will offer low-barrier primary care services outside of the traditional primary care office, including pop-up clinics, weekly drop-in clinics, and walk-in services, to enhance access to and reach of primary care services.

Caseworkers will work alongside the NPs to provide navigation and service coordination support. Moreover, over time, other care providers will join the circle of care; these will include, but are not limited to, community ambassadors, system navigator(s), a chiropodist, a social worker, a mental health practitioner, and a physiotherapist.

The partnering PCOs will collaborate closely with referring community partners, specifically Black- and Indigenous-focused organizations, to proactively identify clients.

Integrated Pathway Design

Following the learnings and insights from the planning and pathway design held earlier this year, the DET OHT hosted the second design session in August 2024. The four partnering PCOs, clients, community members, and referring partners were among the attendants.

The multidisciplinary approach brought diverse perspectives to the table when addressing potential barriers in the client navigation pathway. The session was centered on developing strategies tailored to the unique needs of the target population.
The interactive four-hour session provided additional key insights for structuring and planning the integrated primary care pathway.

The pathway design process is iterative and ongoing. There are plans for continued engagement sessions and rapid testing involving clients from referring partners, both before and after the program’s launch.

Downtown East Toronto family doctors find this new mental health care model helpful during lengthy wait times

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This news story concludes a two-part series on the Stepped Care Pilot (read part one). We had a conversation with two family physicians, Dr. John Goodhew and Dr. Curtis Handford. We wanted to learn about their perspectives on how the Stepped Care model makes it easier for patients to access mental health support and services. Handford is the Medical Director of the Primary and Community Care Program at Unity Health’s St. Michael’s Hospital site. He also leads the Downtown East Toronto Family Physician Network. Goodhew is a primary care physician specializing in care and treatment of people living with and at risk of HIV and the larger LGBTQ+ community. Both Handford and Goodhew were involved in the design and implementation of the Stepped Care Program.

Dr. John Goodhew can now spend more time assessing his clients seeking mental health support. Instead of grappling with the administrative hurdles of finding the right service, he now contacts a mental health navigator. This navigator, part of both the Stepped Care Program and St. Michael’s Hospital Seamless Care Optimizing the Patient Experience (SCOPE) Program, assists in guiding his clients to the appropriate support they need.

Goodhew’s clients have also found it helpful to have a navigator manage their case while waiting for formal counselling. Wait times are unavoidable. However, when a mental health professional reaches out to support clients and reassure them that things are moving forward, it makes waiting easier.

“It’s like waiting for an MRI or anything else. You know it’s going to be a long wait,” says Goodhew. “The mental health navigator checks in with people and lets them know they haven’t been forgotten, and that it is going to happen.”

With a trained navigator providing brief therapy during the waiting period, Goodhew notes his clients are more confident. They believe the service they receive eventually will be the best match for their condition.

After years of practice, he recognizes that no single physician can be familiar with all available services. In a system functioning in silos, accessing services becomes increasingly difficult. Each organization often has its own specific eligibility criteria.

“When you have a patient sitting next to you and they are looking for counselling services, you have a couple of programs that you would frequently refer,” he says. “But you are not always confident it is a good fit.”

Dr. Curtis Handford echoes this sentiment when discussing the available support and services.

“There is a shortage of mental health resources that are publicly available or at least of reasonable cost. In addition, there is a very difficult course to navigate in order to access what is available,” says Handford.

There are even greater struggles in matching tailored mental health supports for equity-deserving clients. When physicians have to juggle clients, paperwork, and specialist referrals, they often have little time left. This leaves them unable to adequately address the unique needs of Black, Indigenous and racialized people, those with disabilities, and LGBTQ+ communities.

Unlike other care models, Handford says the Stepped Care Model offers personalized navigation to each client. He points out that while some clients are adept at self-advocacy and navigating, many others face challenges and fall through the cracks. Therefore, in managing the details of each case, the navigator invests time in understanding the care goals of every client.

Given the long wait times and increasing shortage of health human resources, it has become crucial to use the existing resources effectively and triage clients based on the level of urgency. Waiting without any kind of intervention makes urgent clients even more vulnerable.

In Goodhew’s experience with the program, one of his highly urgent clients was able to receive brief intervention during the waiting period. He says the results were tremendous. Only six counselling sessions made a significant difference to his client’s mental health. Although the client still awaits a longer set of therapy, he has now found himself in a better place.

Goodhew believes this could not have been possible without navigation accuracy, and it goes both ways. Clients should be going to an organization that can meet their needs and organizations should be receiving clients that are appropriate to them.

“When you have that accuracy and connection between the right patient – who is triaged – and the right organization, it is a win all around the table.”

Efficient capacity utilization can make such triage possible, especially for the most vulnerable individuals.

When the navigator undertakes the task of determining urgency levels and finding referrals, it encourages more providers to collaborate, thereby making room for new clients. Given the limited new resources and capacity in the healthcare system, the navigator is a catalyst in strengthening existing working relationships and system connections within the DET OHT.

Handford and Goodhew say the value of the Stepped Care Model is to bring clients to the right place at the right time ‘the first time’. Although breaking down silos and building effective care pathways remain a long journey, more family physicians and mental health organizations can make lasting progress by actively participating in the program.

If you would like to learn more about how your organization can participate in the SCOPE and DET OHT Stepped Care program, please contact [email protected].

“The real secret sauce – the magic ingredient – was the structure underneath the pathway”: design thinking expert reflects on the lower limb care strategy

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We engaged in a dialogue with Julian Goss, a design strategy consultant with the Downtown East Toronto Ontario Health Team (DET OHT) Lower-Limb Preservation (LLP) project. Goss specializes in incorporating design thinking, process, and practice into healthcare strategies. He played an instrumental role in defining key elements of lower limb care, and helped integrate these elements to develop a client-focused design for the LLP pathway. During this discussion, Goss shared his thoughts on the model’s strengths, feasibility, and scalability.

Looking back, what were some of the initial thoughts and considerations when you and the LLP team were in the process of developing the clinical pathway for lower limb care?

Julian Goss: They were not so much as thoughts, but rather concerns. One of my concerns was, does this pathway reflect feasibility, and what assumptions are we making? After developing a pathway, key stakeholders such as primary care providers, solo providers, chiropodists, or vascular surgeons have a role to play. Once we include them as either means or ends, how do we ensure what we are asking or hoping that they will do is within their capacity – that it is not impossible to do? The other concern was, are we clear on the value of user journey? The values are in a form of five W’s: who is here? What are they doing? Why are they doing it? When in the patient journey or condition is it happening? What level of care needs to happen?

From a design perspective, what insights and outcomes have emerged from the pilot demonstrating the pathway’s scalability?

Julian Goss: The pilot demonstrates the feasibility and scalability of the pathway, which has become an integrative pathway, leading to a big AHA! moment. We realized that ‘screening and prevention’ and ‘escalation of care’ is a continuum. Although they could exist in parallel for different circumstances, they are essentially a continuum. So I have been working under the assumption that once we can tell Ontario Health what we did, how we did it, and the results we have accomplished, we can say that this is now scalable and this is what we need. There is always some kind of resource, like time or money. Hopefully, we have got a very strong value proposition and its impact is cost effective. Preventing someone from losing a lower limb is a lot cheaper than dealing with someone with an ongoing condition of having an amputation.

As a process design expert, could you share your insights on what typically occurs in a complex system like health care that takes away from the clients’ pathway?

Julian Goss: I can give you a couple of design-situated perspectives. First, the solution that we came up with is not just a pathway. The differentiator in this pathway is what we built underneath – the communications structures, connectivity, and conceptual clarity. When you come across a beautiful, simple design, it is tip of the iceberg. The undergirding of a structure that enables it to function is systemic thinking. One of the many problems that healthcare shares with other sectors and organizations is having a complex adaptive system – meaning, it constantly changes and shifts. However, like most organizations, healthcare is working on a good, static organizational framework, which will always lag behind what is really going on.

Secondly, design has a lot to do with subjectivity, particularly product design where you have to work in the head of a consumer – know what they think about, what they need, and how they react. However, in healthcare, there is no guarantee that the nurses and physicians will see the problem on the same scale as we are seeing it. They will look at it with the lens of their capacities and training. A design expert tries to acknowledge that and create a shared mental model of the larger perspectives.

In conclusion, would you like to add something or share a key takeaway from our conversation?

Julian Goss: It is really important to share with everyone involved in the project and tell them, we did good work here – thank you! The other thing I am curious about is when we present our story to Ontario Health, I would be really interested in knowing whether they can look at something like this and resonate with this approach; when we tell them we pulled in a design capacity and it helped us arrive at an apparently simple solution. But the real secret sauce – the magic ingredient – was the structure underneath the pathway.

Bridging Gaps in Accessing Mental Health Care: A Conversation

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We invited Dr. Linda Jackson, Senior Clinical Program Director for Community and Primary Care* at Unity Health Toronto, to share her thoughts on some of the work underway in the DET OHT focused on mental health. Dr. Jackson is currently co-chairing the Stepped Care Pilot‘s Oversight Committee. In this discussion, which is a second installment in a two-part series on the Stepped Care Pilot (read part one here), she shares the significance of the stepped care model and how it can support both family physicians and their patients in accessing mental health services.

As a senior leader for Community and Primary Care at Unity Health, what can you tell us about the challenges that the DET OHT’s priority populations (people experiencing homelessness, mental health illnesses, and addictions) have to face to access mental health care?

There is widespread recognition of challenges among the general population in accessing mental health services, specifically counselling and psychotherapy. These challenges include difficulty in navigating organizations offering these services, long wait times, and a lack of funded or affordable services. Our priority populations experience even greater challenges, often not having the resources and supports to navigate a complex mental health system. This issue of navigating to mental health service has been identified by family physicians and nurse practitioners in the Downtown East area who frequently encounter patients presenting with mild to moderate mental health issues, including anxiety and depression, who require and would greatly benefit from accessing counselling and psychotherapy services.

In your opinion, what distinguishes the Stepped Care Pilot from other delivery models?

The stepped care model has leveraged an existing program called SCOPE to support family doctors and nurse practitioners to refer patients with mental health issues to a trained mental health navigator, who works with these patients to better understand the issues affecting their mental health and their readiness and interest for counselling and psychotherapy. Together, the mental health navigator and patient develop an understanding of the most pressing issues and the options available in the community. The navigator then ensures a warm handover by connecting to appropriate resources and staying engaged with the patient until they are linked to the resource or decide that they are not ready to pursue counselling at this time. For some patients, the opportunity to meet with the mental health navigator for initial exploratory sessions has been the intervention that was needed and they did not wish to link for further counselling.

What do you hope the stepped care model can accomplish for the mental health and addictions community of the downtown core?

The model has assisted primary care providers to link their patients to community based mental health services. It has likely prevented some patients from presenting to emergency departments for this type of navigation. The model has identified where gaps exist in accessing mental health services, which can be a focus for further planning within the DET OHT. Assisting the primary care providers in navigating resources allows greater access to other patients at a time when there are many pressures on primary care. This is particularly important for providers who do not have access to mental health services in their clinics.

Given the rise in mental health crisis, particularly after the COVID-19 pandemic, how can we support the long-term growth and sustainability of programs like Stepped Care Pilot?

The evaluation of this program confirms that patients and providers have benefitted from being connected to the stepped care model as well as the importance of collaborating across organizations to integrate care delivery. Addressing the gaps in the availability of affordable and fully funded mental health services, particularly with a trauma informed approach, should be a focus of the DET OHT to support the sustainability of this program.

*Update – Oct 22, 2024: Dr. Linda Jackson retired from her role as Senior Clinical Program Director for Community and Primary Care at Unity Health Toronto in June 2024.

New Stepped Care Pilot Aims to Bridge Gaps in Mental Health Services – Part One

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The Barriers to Mental Health Care

This is the first of a two-part series (read part two here) on the DET OHT Stepped Care Pilot and focuses on the challenges in doctors’ referrals and accessing individualized counselling and psychotherapy support.

Amid workforce shortage, accessing mental health support and services come with multiple challenges, including lack of one-on-one counselling and psychotherapy services tailored to individual needs, lengthy wait times, and timely referrals. According to the 2023 Ontario Association of Social Workers Survey of 1,265 adults, 10 per cent said that they tried but were unable to access mental health support. Their reasons for inaccessibility included long wait lists (60 per cent), high costs (38 per cent) and not having a referral from a family doctor (33 per cent).

Sara Al-Qasir, a mental health navigator with the Stepped Care Pilot and St. Michael’s Hospital Seamless Care Optimizing the Patient Experience (SCOPE) program, sheds light on the challenges.

Some local organizations are currently holding group counselling sessions. While that is a good option, many clients are looking for timely individualized counselling for their recovery.”

In her interactions with clients/patients, Sara has noticed that patients were not only managing challenges with depression and anxiety, they experienced additional stressors from financial barriers, transportation needs, cultural and language differences, and mental health stigmatization.

Clients/patients is not the only group facing accessibility challenges. Initial interviews conducted by the stepped care project team to understand family physicians’ needs revealed family doctors also face accessibility challenges when seeking counselling or psychotherapy services for their patients with anxiety and depression.

The considerable administrative tasks associated with seeking appropriate referrals often cause family physicians to handle them themselves, diminishing the quality of interaction between a family doctor and a patient.

By introducing a mental health navigator in the referral pathway, the stepped care model relieves some of the commonly occurring and significant challenges for both patients and family doctors, while also making effective use of the health system’s resources.

Sara mentioned the mental health navigator’s role having a four-pronged approach;

  • Case management: Ensuring patients feel supported, developing care plans, following up every 2-3 weeks, and relaying information back to family doctors
  • Brief-talk therapy: Ensuring clients can cope with distressing situations and routine challenges by talking to a trained professional while they wait for specialized care
  • Customized care: Providing accessible list of resources tailored to the patient’s needs and circumstances
  • Warm transfer: Assisting with a three-way call to support patients with completing intakes over the phone, allowing them to build confidence and trust newly found resources

Each step focuses on improving the quality of patients’ lives and adding value to the patient-doctor relationship.

32 family physicians, all members of the DET Family Practice Network and registered with the St. Michael’s Hospital SCOPE program, have enrolled in the pilot.

Participating physicians have collectively referred 243 clients to the mental health navigator, allowing the navigator to provide over 544 counselling sessions between April 2022 and October 2023.

While the project team continues to evaluate the impact of the pilot on patient experiences and outcomes, it is clear in the initial phase of the implementation that the pilot has allowed synergies between family physicians and the mental health navigator.

The project team aims to use their findings to inform the long-term growth and sustainability of the Stepped Care Pilot and similar programs. This will ensure that the positive outcomes not only benefit the local community, but also contribute to the broader mental health landscape.