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Bridging Gaps in Accessing Mental Health Care: A Conversation

Masooma Raza · October 30, 2023 · Leave a Comment

We invited 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. Linda is currently Co-chairing the Oversight Committee of the Stepped Care Pilot at the DET OHT. In this discussion, 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.

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

Masooma Raza · October 30, 2023 · 1 Comment

The Barriers to Mental Health Care

This news story is part one of the series on the DET OHT Stepped Care Pilot and highlights 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.

Connecting Care: Emergency Department Outreach Worker Program

Masooma Raza · September 22, 2023 · Leave a Comment

Precarious housing is a mounting crisis in the city, and recently declared an emergency by the Toronto City Council. People experiencing under housing and deep poverty also have difficulties in navigating and accessing social services, such as housing and income support, which directly affect their health.

One in five patients who visits the Emergency Department (ED) at St. Michael’s Hospital is precariously housed. In an effort to support patients with challenges beyond health, the community partners and members of the Community Advisory Council of the Downtown East Toronto Ontario Health Team (DET OHT) have developed the Emergency Department Outreach Worker Program.

With the aim of helping patients facing unstable housing situations achieve stability and long-term support, this program assigns a dedicated outreach worker to each individual in need. The outreach worker’s role includes securing housing, ensuring access to meals, finding sustainable sources of income, and, if required, providing legal assistance. Presently, the program has one outreach worker on staff.

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