1. CATCH ED: Coordinated Access to Care from Hospital Emergency Departments Vicky Stergiopoulos, MSc, MD, MHSc, FRCPC Scientist, Centre for Research on Inner City Health, St. Michael’s Hospital Director, Division of Adult Psychiatry and Health Systems Associate Professor, University of Toronto BRIDGES Conference March 31, 2015

2. Frequent ED users sChallenges of frequent users of Emergency Departments (EDs) include low socioeconomic status, mental illness/addictions and multiple medical co-morbidities. s In 2010/11, 2% of adult ED users who made a mental health or addictions-related visit made >21 visits each (TC-LHIN) s 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

3. CATCH ED Program Description sCoordinated 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 users sTarget population >5 visits to a single ED with at least one visit for a MHA concern. sAn adaptation of the Critical Time Intervention model, supporting transitions and continuity of care for disadvantaged populations. sBrief case management offered over 4-6 months

4. CATCH ED Partners sPartnership among 6 hospitals, 3 community mental health agencies, one peer outreach service and 4 community health centers. sCo-sponsored by the TC-LHIN and the Toronto Mental Health and Addictions Acute Care Alliance sImplementation and outcome evaluation led by CRICH, St. Michael’s Hospital.

5. Implementation Evaluation Some key findings sA centralized multidisciplinary program structure and regular supervision are necessary to provide program cohesion and consistency/quality in program delivery. sCase managers/counselors with the right skill mix and training are essential to provide high quality community MHA care. sCollaboration of sectors not traditionally working together and endorsement by local health authorities can facilitate program implementation.

6. Mixed-Methods Outcome Evaluation sRandomized Controlled Trial with adults (N=166) with > 5 ED visits, at least one for a MHA concern sOutcome measures include ED use, days in hospital, mental health symptom severity, substance use and quality of life, 12 months after program enrolment sBoth self-reported service use and administrative health data linkages with ICES databases sEconomic evaluation by the Centre for Excellence in Economic Analysis Research (CLEAR) sQualitative Evaluation - 33 narrative interviews with patients and service providers sContinuity of care process measures

7. Participant Characteristics sMean age: 43.2 years ± 15.5 s51% Male s82% Unemployed s75% on Disability Income (ODSP/CPPD) s77% housed s68% of participants reported 3 or more co-morbid health conditions.

8. Participant-reported Psychiatric Diagnoses

9. Outcomes sParticipants reported a median of 6 ED visits, 1 hospital admission, and 3 days in hospital during the six months prior to enrolment s79% have a Primary Care physician at baseline sIn unadjusted preliminary analysis, the intervention did not seem to impact health and health service use outcomes sQuality of health reported health service use poor sData analysis currently underway at AHRC sICES linkage in 2016

10. Qualitative Evaluation: Preliminary Findings sPrecipitants of ED use included MHA-related crises, and acute and chronic health conditions related to pain and injury. Frequent use of the Emergency Department

11. sChoosing the ED: The ED was felt to be the normative destination when in crisis. sExperiences 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)

12. Challenges in Continuity of Care sMultiple providers/system fragmentation sPoor past experiences of care, difficulty with engagement. s“Diffusion of responsibility “– no clear accountability in service provision. sThe importance of healing relationships /choice

13. 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%

14. CATCH-ED Research Next Steps sAnalyzing process measures of continuity of care: timeliness, comprehensiveness, coordination, appropriateness of care and gaps in services. sData analysis and administrative health data linkage through the Institute for Clinical Evaluative Sciences (ICES) databases sPreparation of conference abstracts and manuscripts

15. Impact/Value Lessons 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.

16. CATCH ED Program Next Steps sModel redesign in the context of Health Links sEach hospital considering an approach that best suits local realities sPotential Options: sIntegration with Health Link Teams sIntegration within Hospital Urgent Care programs sOther options…

17. Acknowledgements Funders sBRIDGES sToronto Mental Health and Addictions Acute Care Alliance sCentre for Research on Inner City Health, St. Michael’s Hospital sTC-LHIN Research Team Principal Investigator: Dr. Vicky Stergiopoulos Co-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

18. Your questions? Contact: Vicky Stergiopoulos Tel: 416-864-6060 x 6415 stergiopoulosv@smh.ca