On Thursday, December 7th, 2017, a one-day, in-camera “Best Brains Exchange” (BBE) meeting was convened in St. John's on the topic of Alternative Models of Care to Manage Mental Health and Addiction Services in a Diverse Province, hosted by the Canadian Institutes of Health Research (CIHR) in collaboration with the Newfoundland and Labrador Department of Health and Community Services and the Newfoundland and Labrador Centre for Applied Health Research.

Best Brains Exchanges are meetings that bring together key stakeholders, researchers, and policy and decision makers from across federal, provincial and territorial governments with local, national and international experts on a topic that poses significant policy challenges. Participants discuss existing and relevant research evidence on the topic and the applicability of the research to the current Canadian national and provinial contexts. The BBE follows a deliberative dialogue format that is designed to facilitate interaction, exchange and mutual learning on a specific topic, and move a policy forward rather than determine a solution to the policy issue.

Objectives

The Best Brains Exchange allowed participants to:

• Gain an understanding of the existing evidence-base on effective alternative models of care to manage mental health and addiction services while improving access to care, with specific attention paid to a ‘stepped care’ model. This includes:
• examining the best available research evidence on a ‘stepped care’ model, and where gaps in knowledge currently exist; and
• considering best practices and lessons learned from other Canadian and international jurisdictions in implementing an alternative model of care for mental health and addiction service delivery;
• Explore how a ‘stepped care’ (or alternative) model could be effectively implemented within multiple diverse settings and jurisdictions with variable resources and demographics across Newfoundland and Labrador, considering barriers and enablers to implementation.
• Consider and contextualize the best available research and implementation evidence, with the intention of informing the development of a Government of Newfoundland and Labrador implementation plan to adopt a ‘stepped care’ (or alternative) model to managing mental health and addiction services that effectively integrates institutional and community-based care within the province.

Policy Context

In January 2015, the Newfoundland and Labrador (NL) House of Assembly unanimously supported the creation of an all-party committee to review the provincial mental health and addictions system. This committee consulted broadly over a 2-year period to develop an evidence-informed report: “Towards Recovery: A Vision for a Renewed Mental Health and Addictions System”, with 5 broad themes and 54 policy recommendations. One of the key themes that emerged in the all-party committee report was the need for better access to more services in mental healthcare. And, more specifically, one of the key recommendations was the re-design of NL’s mental healthcare services using a ‘stepped care’ approach.

In response, the Government of NL has accepted the committee’s recommendations and has developed an implementation plan and governance structure to apply the findings from the all-party committee’s report. This includes:

• An Executive Committee of Regional Health Authority Chief Executive Officers, chaired by the Deputy Minister (DM) of Health & Community Services and includes DMs from other departments when reviewing progress as part of performance monitoring and evaluation;
• An Implementation Committee with Regional Health Authority Vice Presidents and Regional Directors, a psychiatrist lead and a project manager, chaired by the Provincial Director of Mental Health and Addictions; and
• Eight project teams, each with its own team lead and specific mandate. (Of which, two of the teams – Service Redesign and Provincial Services – will be directly involved in the BBE).

In addition, in an effort to implement the recommendations of the all-party committee report and improve the integration of mental health services, the Government of NL is considering the implementation of the recommended, new province-wide ‘stepped care’ model, to be implemented within its four Regional Health Authorities. The care model would include the following key steps:

• entry-level, community-based prevention and treatment interventions;
• strategies to meet the needs of those who don’t respond to initial interventions (enhanced treatment);
• after-care strategies for those patients who require longer term follow-up and supervision.

Implementing this new model of care across NL’s four Regional Health Authorities will be challenging. To mitigate this reality, the Government of NL seeks research evidence related to the proven effectiveness of a ‘stepped care’ model, with input from experts on the challenges and enablers to implementing such a model, given the diverse communities and distinct provincial and regional contexts across Newfoundland and Labrador.

Identified Need for Evidence

NL’s Department of Health and Community Services is committed to the re-design of the provincial healthcare system but it will implement only those models of care that are supported by scientific evidence, that have been tested elsewhere, and that have proven effective. As such, the evidence for what works (either stepped care, tailored to the needs and capacities of the province, or an alternative model), is critical to implementing the recommendation of the all-party committee’s report regarding the need for better access to a range of mental health services. Because the province seeks to implement this model across four Regional Health Authorities, is seeks evidence to support an implementation plan that would be adaptable across multiple jurisdictions (i.e., what might work in one small clinic may not be feasible when implemented in larger, more diverse care settings). Most importantly, knowing what works well must be complemented by having some indication as to whether or not it will work well within the NL context; as such, attention to local contextual factors will be crucial when assessing the research evidence.

This information will be used to guide the implementation plan for a stepped care model in the province of NL.

Presentations

Shared Collaborative Mental Health Care: The Good, The Bad & The Ugly| Presented by Thomas E. Ungar, MD, M. Ed, CCFP, FCFP, FRCPC, DABPN Psychiatrist-in-Chief, St. Michael’s Hospital
Associate Professor, University of Toronto

Implementing Stepped Care at Scale | Presented by David Richards, PhD, Professor of Mental Health Services Research, NIHR Senior Investigator, University of Exeter Medical School, United Kingdom

Clinical Staging and Stepped Care: Lessons from early psychosis to youth mental | Presented by Dr. Jai Shah, a psychiatrist and researcher at the Program for Prevention and Early Intervention in Psychosis (PEPP-Montréal) at the Douglas Mental Health University Institute and McGill University

Introducing Foundry and Frayme: growing integrated youth services in a stepped | Presented by Dr. Steve MathiasExecutive Director, Foundry, Psychiatrist and Medical Manager, Inner City Youth Program, St. Paul’s Hospital, Clinical Assistant Professor, Department of Psychiatry, Faculty of Medicine, UBC,  Medical Lead, Infant, Child, and Youth Mental Health and Addictions Regional Program, VCH