1. Dr. Marjory Phillips Sarah Glover Dr. Jen Scully Integra Program, CDI
Improving Wait Times: An Innovative Assessment and Consultation Clinic Model for Children and Youth with Complex Needs
Dr. Marjory Phillips
Sarah Glover
Dr. Jen Scully
Integra Program, CDI

2. Outline Defining the Waitlist Problem
Nature of the clinical population
Systems changes: increased referrals
Service structure bottlenecks
Waitlist Solution: new Clinic model
Change management strategies
New service structure
Innovative use of Psychology service
Outcomes and Lessons Learned

3. Learning Objectives
To present an innovative model for intake and assessment of children and youth with Neurodevelopmental Disorders and mental health and behaviour issues
To share assessment tools, templates and strategies for optimizing efficient use of psychological assessment data and other information to guide clinical formulation and treatment planning
To share learnings about implementing systems change across an organization

4. Who are our Clients?
Children and youth ages 8 to 18 years with a diagnosed Learning Disability and Mental Health Issues (LDMH)
On average, clients have been to 3 to 4 mental health providers BEFORE Integra Program
Referrals from educators, psychologists (school, private practice), children’s mental health agencies, hospitals

5. Defining The Problem: Clients with Complex Needs

7. Overlapping Processes for LD & MH
Among Integra’s clinical population of children and youth with LDMH, 2 key processes are common:
Emotion Regulation
Experiential Avoidance

8. Difficulties with Emotion Regulation

9. Neurodevelopmental Disorders and Mental Health
Continuum of behaviours in children
Green zone -> Yellow zone -> Red zone
Wellness -> Stress -> Distress (Mental Illness)
Most kids with LDs experience stress
At Integra, we also see kids with LDs who have more serious mental health issues

10. Integra Clinical Services
We Tailor Evidence-Based Therapy to the Individual’s Style of Learning
We Develop, Evaluate and Disseminate
New Types of Therapy
Therapy is Learning

11. Defining The Problem: Increasing Referrals

12. Defining The Problem: Intake
Intake Worker
Integra Young Warriors
Integra Social Competence Group
Towhee
Child & Family Therapist
Integra MMA
Psych Consult

13. Defining The Problem: Intake
Structure Creates Bottleneck to Service Need to get the Right Service for the Identified Need

14. Impact: Longer Wait for Service

15. Increasing Numbers on Waitlist

16. Increasing Wait Times

17. Need for Change Jan 2015 Problem Ident Mar 2015 Triage Model
Jul-Aug 2015 Pilot
Sep 2015
Clinic Start
May 2015
Clinical Team
Clinic Model

18. Roles Redefined Intake Worker – Task Analysis: Administrative duties:
Screening intake package, following up with families for missing documents, school boards and agencies.
Filing and computer input of information, SIR

19. Roles Redefined Intake Worker – Clinical Tasks:
BCFPI (telephone interview, 30 min-1hour)
‘Holding’ families while on the wait list
Assigning clients to clinicians

20. Roles Redefined Role of Intake worker was removed
BCFPI and Background questionnaire were given as an link once families came to the top of the waiting list.
In order to book 1st appointment for service, families needed to complete both questionnaires.
Administrative tasks became the responsibility of an Administrative Coordinator

21. Roles Redefined Role of Clinical Supervisor was extended to include:
Oversight of the waiting list
Supervision of the assessment and consultation clinic (including schedule creation)
Assignment of families to clinicians
Management of distressed families on the waiting list.

22. Assessment Clinic Second Session:
Clinic First Session:
Parents/Guardians and child or youth
meet with clinician to discuss presenting
problems, strengths, service needs
Assessment Clinic Second Session:
Parents/Guardians and clinician meet
with
Psychologist to review child/youth’s
learning profile; Parents/Guardians and
clinician develop a treatment plan
Ages 8-18
Parents only
Ages 8-18
Ages 9-11
Ages 12-18
Ages 10-18

23. Assessment and Consultation Clinic Structure
Pre-clinic steps:
Intake questionnaires (parent/guardian and teacher)
Psycho-educational assessment report is reviewed– confirms diagnosis of a Learning Disability
Parents/guardians offered access to workshops and training
Offered access to Triple P Parenting sessions

24. Pre-clinic steps continued
Parents/guardians are invited to book Assessment Clinics as their child’s name comes to the top of the waiting list
These appointments are offered to families at a time
Parents/Guardians are asked to complete a BCFPI on-line as well as a Background Questionnaire prior to booking an appointment

25. Assessment Clinics Families book 2, 2 hour appointments
Most appointments are during the day (9:30-11:30am or 1:00-3:00pm)
There is one evening clinic per month

26. Erica: Information from the file
14 years old, Grade 9 (arts school for drama)
Diagnosed Learning Disability (visual-spatial/ ‘nonverbal’)
Diagnosed Anxiety Disorder (generalized, social)
ADHD (inattentive)
Past services: anxiety (CBT), family therapy
BCFPI : challenges with regulation, separation from parents, anxiety, mood, some social, family relationships, some school refusal.
WISC IV
Percentile
Verbal Comprehension
66th
Visual-Perceptual Reasoning
10th
Working Memory
25th
Processing Speed

27. Clinic: 1st Session (2 hours)
Structure: Family, parents alone, Erica alone
Problem Identification (panic attacks at school, fighting with siblings and parents, struggles with school, concerns about self harm, mood)
Previous Services (have tried many services)
When asked if she knew what an LD was, Erica said ‘it means learning is hard’
Parents describe that they don’t like to use the term learning ‘disability’. They prefer ‘learning difference’
Parents already knew about Integra’s MMA program and are interested
Erica says she has a camp she goes to already and that she has friends
Erica is a ‘cool’ looking kid
Attended a private school for grades 5 – 8 to support learning and social challenges
Both parents attend the meeting. They are educated and middle class and have sought out many services and supports for Erica
Erica has an older sister who struggles with her mood and anxiety and a younger sister who is a high achiever and in competitive sports
Father describes that he has struggled ‘just like Erica’

28. 2nd appointment (2 hours)
Parents/guardians, clinician, and psychologist (youth do not usually attend this appointment)
1st hour: Consult with Integra’s psychologist
2nd hour: Review of main concerns, formulation, goals and treatment plan

29. 29 29

30. 30 30

31. Psychology consultation
A core component of Integra’s approach to providing treatment for children and youth with LDMH
Who? Parents, clinician, psychologist
What? Review youth’s profile and prepare summary for parents and for youth’s file
Why? Translate technical information into accessible language so parents can understand youth’s strengths and challenges in terms of learning, behaviour, social, and emotional functioning
Goal: increase parents’ knowledge and build empathy

32. Skills/Ability to Cope Demands of Environment
Behaviour
Challenging Behaviours are seen as a lack of skill not will and arise when: “Kids Do Well If They Can” (Ross Greene)
Skills/Ability to Cope
Demands of Environment 32

33. Information processing: way youth thinks,
reasons, problem solves, remembers, etc .
e.g., language, visual spatial, memory,
processing speed, executive functioning
ASD, ADHD, mood, anxiety
Temperament, puberty
Physiological–health, nutrition, sleep
Sensory (over-or under-regulated)
Life stressors, trauma
Family environment
Learned behaviour/patterns
Social and cultural factors

34. Erica’s strengths
Erica learns and remembers (especially meaningful information) best with verbal information/language (i.e., listening and speaking) rather than with visual information (i.e., seeing, visualizing)
Visually, Erica does best when she can talk
through visual information (i.e., verbal mediation)
Academically: oral language, reading, does best with structure and predictability, when supported she is hardworking and persists with challenges, enjoys arts (music and dance)
Other strengths/talents: Empathic, friendly, creative, wonderful with younger children and animals, leadership skills, supportive family

35. Erica’s challenges Erica struggled to understand visual information/
things she saw like patterns/problems,
how things go together, etc.
Although Erica is strong verbally, she can struggle to organize and retrieve language (impact of anxiety/perfectionism, processing speed/working memory, executive functioning?)
Processing speed: Erica took longer to work with visual information using a paper and pencil. Her parents report that she is also slower to take in, think about, and express herself *noted to be easily overwhelmed
*other reasons why may be slow? (e.g., anxiety,
perfectionism, OCD?)

36. Erica’s challenges continued
Working memory
Executive functioning: initiation, planning and organization, monitoring performance and behavior, shifting (‘rigid’)
Academically: math, written expression, attention/focus, anxiety about school work and social relationships, hard on herself with perceived challenges and when makes errors, can be resistant to tackling ‘hard stuff’, easily overwhelmed
Emotional: regulation (e.g., 0 to 10 quickly), anxiety, fears
Social: relationships with family, peers (i.e., misreads, rigid/ inflexible, overreacts, etc.)
Behavior: argumentative, blames others, avoidance
Sensory: smells, taste, touch
“Teen hormones”

37. Here’s one way to think about it …}
Other Processes
Executive Functioning 37 37

38. 2nd appointment – 2nd hour
LD is now at the forefront of everyone’s mind
Main concerns, events, feelings and coping are reviewed
Formulation is co-created with family
Goals are created
Integra services are chosen that best address the goals created.
Goals and treatment plan are written, signed and copied

39. How well are these working?
Events
Issues
Feelings
Coping
How well are these working?
Individual Characteristics
Family Characteristics

40. Sister left for university this fall Issues
Events
School refusal Grade 4
Sister left for university this fall
Issues
Struggles with emotion regulation
Not completing school work (last minute)
Conflict at home between parents and Erica
Conflict between Erica and younger sister
Social challenges
Feelings
Frustration
Worry
Overwhelmed
Stress
Shame
Embarrassed
Parents:
frustration
Coping
‘holds it together’ at school
At home:
Meltdowns
Cries
Yells
Avoidance
Rules about school items
Procrastination
‘takes out’ on sister
Yell
Avoid
Seek supports
How well are these working?
Individual Characteristics
Bright Verbally
LD in visual spatial
Executive Functioning Challenges
Anxiety
Artistic
Creative
Family Characteristics
Supportive and loving
Family history of LD’s and anxiety
Older sister struggled with anxiety
Younger sister is high achieving, no LD’s.

41. Erica: Goals and Treatment plan
Priority Concerns: Panic attacks and anxiety, meltdowns at home, yelling and conflict between family members
Goals:
1) Increase Erica’s ability to regulate and cope with her strong emotions, especially anxiety and frustration
2) Increase parents ability to support Erica with her strong emotions
3) Increase Erica and her parents’ understanding of her strengths and challenges

42. Treatment Plan
Individual Therapy: CBT and DBT informed therapy for increasing emotion regulation
Integra Mindfulness Martial Arts: for emotion regulation
Family Therapy to address Erica’s emotion regulation and family dynamics
Psychoeducation for Erica and her parents re: Erica’s Learning Disability

43. Treatment plan Erica is placed on Internal Waiting Lists for:
-Therapy Stream (Family, Individual, Psychoeducation)
-Integra MMA
Parents agree to and sign treatment plan. They take a copy home.

44. Outcomes Anticipated Outcomes: Waitlist Smaller
Wait Times for initial service Shorter
Increased Numbers of Clients for Group Programs

45. Wait List Size

46. Wait Times for Service

47. Increase in # New Clients

48. Increased # Clients Served

49. Efficient Use of Specialized Consultation

50. Unexpected Positive Outcomes
Group Programs have a steady stream of participants (no ebbs and flows).
Clients are taken off the wait list at a consistent rate (min 12 per month)
Clients are streamlined into programs more quickly
Clinicians have less ‘case management’ of clients who are not engaged in therapy

51. Unexpected Positive Outcomes
Clients are assigned with more consideration to Clinicians re: goals, availability
Therapy stream is often shorter and more focused
Improved compliance with timelines for initial documentation

52. Positive Experience
Clients report the system is clear, predictable and provides an innovative and useful service at the beginning (Psych consult)
Clinicians like the daytime hours, manageable rate of service hours, relatively easy documentation requirements

53. Lessons Learned Challenges:
Overlap of old/new system (Psychology time)
Need for communication, ‘ownership’ of case management for program only clients
Change management worked well with:
Transparent Communication
Team Problem Solving
Involvement of Admin staff

54. For More Information
Dr. Marjory Phillips, C.Psych Director, Integra Program Sarah Glover, MSc Clinical Supervisor, Integra Program Dr. Jenifer Scully, C.Psych Psychologist, Integra Program