Dr. Amy Salmon discusses how new mental health guidelines can improve care
People accessing mental health services can find themselves stranded on long waiting lists, treading water until their condition becomes ‘severe enough’ to access care. Dr. Amy Salmon, Advancing Health Associate Director and Clinical Associate Professor at UBC’s School of Population and Public Health, described this common experience: “For many people without access to extended health benefits, a primary care provider, or the means to purchase private services, or who are sitting on long wait lists, it feels like you get nothing, until you have a mental health crisis. Then, you could get access to specialist psychiatry and inpatient service. After which point, you might have some care in the community, but the risk is that this then falls off again to nothing, until the next crisis happens.”
To improve this situation, many organizations across Canada, such as Foundry, have adopted an alternative model, called Stepped Care. This approach seeks to provide a whole toolbox of intervention options at various levels of intensity, including high-intensity supports like crisis care, psychologists, and peer support groups, and lower-intensity supports like self-directed tools that patients can use themselves. It’s called Stepped Care because patients can be stepped ‘up’ or ‘down’ that continuum in response to changing needs. “Stepped Care models are one way of trying to address the problem of bottlenecks that we often see in services where there is a high demand and a resource allocation that doesn’t necessarily fit that demand,” Dr. Salmon explained.
While the model has shown a great deal of promise over the last fifteen years, its organic development has led to a lack of agreement on what it should look like in practice. That lack of consistency can be a problem in any health system but is particularly problematic in ones serving children and youth.
Dr. Salmon and her collaborators decided it was time to fix that. “We said: Let’s bring together all of the people who have an interest in improving mental health and substance use service delivery for young people who are going to the forefront of this field and see if we could develop a consensus statement.”
The results of this work, which was led by Dr. Jai Shah at The Douglas Mental Health University Institute, as well as co-investigators from Memorial University of Newfoundland, McGill University, Stepped Care Solutions, and Foundry, was recently published in Early Intervention in Psychiatry.
Talking it out
To begin to understand the practical requirements for successfully implementing Stepped Care, the team gathered a large group of interdisciplinary experts and sorted them up into panels. These experts included stepped care clinicians, family carers, researchers, policy-makers, and youth with lived experience.
Each panel was given an anonymous survey with statements describing how a Stepped Care model should be implemented. The panels then rated each statement on a five-point scale from strong agreement to strong disagreement. Using this feedback, the statements were re-written and refined over three iterations. This procedure, called the Delphi Methodology, was used to reach consensus among the experts to develop five guiding principles to serve as the gold standard for Stepped Care. “We kept a fairly high threshold in this study for what counted as agreement, because we didn’t want to be glossing over meaningful differences of opinion or differences in practice or style of care.”
The five principles
“We looked from the live perspective of: if you walked in through the front door of a service that operated this way, what would that be like for you? Would you feel like this was a place that you wanted to receive care?”
One: Provide a Wide Breadth of Mental Health Support Options
Stepped Care must provide a wide variety of intervention options provided at a range of intensities and offered with meaningful choice. This aspect is particularly important for young clients who are only just starting to exercise autonomy in decision making. Dr. Salmon explained, “The stepped care model should always be about a person-centered approach and providing people options, not rationing or dictating services.”
Principle #2: Clients Make Informed Decisions That Match Their Personal Goals
Stepped Care should empower patients to make their own health-care decisions. “We are matching people to the best service for them based on a variety of factors, including, importantly, their personal choice and readiness.”
Principle #3: Integrating Services to Improve Continuity and Referral
One of the major weaknesses in current mental health systems is that it is fragmented, where different institutions and organizations are often highly siloed and do not communicate or collaborate. Stepped Care aims to create integrated systems that can easily “move people supportively around the continuum based on their needs and their priorities.”
Principle #4: Track Outcomes and Benefits of Care
“A great deal of the time the experience that people have coming into mental health services is they’re not necessarily provided with a barometer to help have a conversation about how they’re doing now compared to how they were doing in the past, or how they would like to be doing in in the future,” said Dr. Salmon. To address this, patients should receive regular ‘check-ins’ to ensure they’re reaching their goals, and given the option to switch to different kinds of services in response to their changing needs.
Principle #5: Community-Tailored Services
“Communities do really need to be empowered to think about ‘what configuration of services is going to look right for our community’,” Dr. Salmon explained. Whether based in cities or rural environments, communities should be able to adapt their services according to local resources and expertise. “For example, in a rural or remote community, where you might not have access to a lot of hospital-based services, you might have a lot of other really effective community-based supports for mental wellness that aren’t always considered traditional components of government-funded psychiatric services.”
What’s next?
“Our hope now that the standards published and out in the world and available to use is that people who are designing or delivering or just beginning to plan or reorganize mental health and substance use services for children and youth might consider taking a stepped care approach,” said Dr. Salmon. To make that easier, Dr. Salmon’s team is looking to develop an Implementation Guide to help health care organizations adopt the Stepped Care model into their services.
At the same time, more research is needed to evaluate the effectiveness of Stepped Care. “I think there is certainly a need for a lot more research that is specific to diverse groups of children and youth in real world settings, how well these models are serving their communities, and then to take that evidence to understand what adjustments could be made,” she said.
Stepped Care is all about recognizing that mental health needs evolve and change. Dr. Salmon and her team are excited to imagine how the model itself will evolve over the coming years as it is integrated into practice, evaluated, and refined.
