The Champlain
Client and Family Consultation Project:
Listening to people’s experiences when they return to their communities after mental health or substance use related hospital stays
A report to the Project Advisory Committee for submission to the Champlain Local Health Integration Network
March 30, 2012
Last Updated: July 2012
46 / The Client and Family Experience in Champlain Emergency Rooms and Inpatient Mental Health UnitsAcknowledgements
The Project Team wishes to acknowledge the efforts of the following people:
· Members of the Project Advisory Committee for helping to develop the process for engaging with our community,
· Mental health and addictions service providers, as well as partners such as Wabano Health Centre, for helping to promote the project to clients and family members,
· The Champlain Local Health Integration Network for funding this important project,
And to the clients and family members who so openly shared their stories, and their ideas for improving people’s experiences in the future, we hope that this report reflects, and honours, what you have told us.
46 / The Client and Family Experience in Champlain Emergency Rooms and Inpatient Mental Health UnitsTable of Contents
Executive Summary 6
Process 7
Overview 7
Lessons Learned 8
Context 9
Building on the work in our region 9
Understanding how hospitals are currently being accessed 9
Key Findings and Recommendations 11
Emergency Room Visits 11
Admission to the Inpatient Unit 16
Discharge Process from the Inpatient Unit to Community 17
Some Additional Observations 21
Roadmap 22
Appendix 1: Membership, Advisory Committee 25
Appendix 2: Survey Response Summary 26
Appendix 3: Literature Scan 33
46 / The Client and Family Experience in Champlain Emergency Rooms and Inpatient Mental Health UnitsExecutive Summary
In January 2012, the Champlain mental health and addictions system embarked on an extensive consultation process with clients and family members who had recently used emergency and/or inpatient hospital services. Funded by the Champlain Local Health Integration Network, the two main project goals were to learn about people’s experiences as they were discharged from hospital, and to develop practical and cost-efficient recommendations to help improve these experiences.
Funding was provided to the Pembroke Regional Hospital, who established a representative project advisory committee made up of clients, family and service provider representatives. The advisory committee developed a consultation process that reflected the reality that discharge planning from hospital isn’t an isolated event, but rather an opportunity to promote wellness and prevent return to the hospital or emergency room. The format used for focus groups and surveys included questions around people’s experience with accessing Emergency Rooms for their mental health and addictions issues, their experience of admission to the hospital setting, the inpatient stay, and the discharge planning process.
This report highlights the positive and negative experiences people have had in relation to Emergency Room visits, admission to hospital and discharge processes. The report also brings forward previous work that has been done regionally on discharge planning including the Family Advisory Committee (of the Addictions and Mental Health Network of Champlain) report on discharge planning. Related literature was reviewed and included where appropriate.
People have had the opportunity to participate in focus groups across the region, as well as to complete surveys either online or in hard copy. A total of thirty focus groups have taken place across the region, including two focus groups with service providers (one with community staff and one with inpatient staff and discharge planners), with approximately 250 participants. A total of 74 surveys were submitted online or in hard copy (with about 50% of these participants having also participated in focus groups)
At the outset of the project, the Advisory Committee undertook a literature scan of previous planning exercises and better practices in discharge planning approaches. The LHIN has also provided data with respect to emergency and inpatient utilization by Champlain residents.
This report summarizes findings from the project, together with short, medium and long term implementation steps to address recommendations made by client and family members.
In general, people’s experience with discharge has been that it is rushed, with little information provided. Although we have heard some exceptionally positive stories, in particular for people who have had longer stays in hospital, we have heard that there is limited to no discharge planning taking place (from the client and family perspective). They often feel disengaged with the process, and families have little to no involvement. Similarly, we’ve heard from staff the challenges they face in doing effective discharge planning, particularly for people who are facing housing issues. We have heard the same messages from clients, families, inpatient staff, and staff in the community.
People’s experience in accessing emergency departments for mental health and/or substance use-related reasons is almost uniformly consistent – a lack of information provided both during and after the process, a lack of follow-up options, and that their health needs are not truly urgent nor are they treated as such.
Clients, families, and providers have provided very concrete and constructive suggestions as to how to improve both the discharge planning process, as well as people’s experiences in the emergency room and inpatient services. These include having on-site peer and family support, engaging people in development of Wellness Recovery Action Plans (and using peers to provide the leadership in this), providing staff education in emergency and inpatient settings (on community services available, as well as peer and family experiences), providing clients and families meaningful ways to give hospitals feedback on their experiences, and giving clients and families information packages when they go to emergency and inpatient units.
The Advisory Committee believes that this project presents a real opportunity for our region to take this “snapshot” of information and propel our system to one that focuses on helping people make the connections they need and want to move forward in their personal journey of recovery. The recommendations in this report truly reflect input from clients, families and service providers. The proposed strategies focus on four pillars:
· Information sharing on what resources exist for clients and families
· Development of practical tools that facilitate effective transitions from emergency to hospital and back to community
· Provision of education opportunities for staff on recovery, effective interventions for people in crisis, and innovative practice models
· Creation of innovative peer and family support models
Process
Overview
In addition to this report, there is a companion document that contains copies of the questions used in the focus groups and the surveys, as well as a copy of the flyer used to promote the focus groups, online and hard-copy surveys, website and Facebook page for the project.
A total of thirty focus groups were held across Champlain over a four week period, engaging 203 clients and family participants (in twenty-eight groups), and over 40 service providers in the two groups designated for providers. All client and family participants were offered honoraria or gift cards.
The client and family groups generally lasted from 1.5 to 2 hours, and included:
· Four groups in Renfrew County
· Four groups in the Eastern Counties of Stormont, Dundas and Glengarry, and the United Counties of Prescott-Russell (all available in French and English – one of the groups was conducted only in French)
· One group in Smiths Falls (to reflect the northern portion of the counties of Lanark, Leeds and Grenville)
· Nineteen groups in Ottawa (included two designated francophone groups, two designated groups for people who identify as Aboriginal, and five groups available in French and English)
In general groups were open to both clients and family members, but one group was designated for clients, and one group for family members only.
In addition, the two groups offered for service providers included , one for hospital staff and one for community staff, which were available to staff across the region using televideo. These two groups engaged over 40 staff, working in inpatient units (nursing and discharge planning staff, generally social workers), emergency, and community mental health services including case management, crisis services and assertive community treatment teams.
A total of 74 surveys were submitted by clients and family members: 70 were submitted online, and four by hard copy. Roughly half of people who submitted surveys also participated in the focus groups.
The make-up of the focus groups and survey respondents was as follows:
· Gender: 42% males and 58% females (almost 75% of survey respondents were female)
· Age: 2% under 20 years, 26% 20 – 30 years, 47% 30 – 50 years and 25% older than 50 years (there was a similar age distribution in the survey respondents)
· A total of 21.6% francophone participants (over the 14.8% participation rate in the surveys)
· A total of 18% participants who identified as being Aboriginal (there were no identified participants in the surveys).
Over half of participants requested that they receive copies of this final report. The project website will continue to be maintained, at least for a period of six months so that we can communicate with participants as needed.
Lessons Learned
Recruitment for focus groups was attempted in a number of ways: via community websites, newspaper advertisements, circulation within personal and professional networks, and, most notably, through the work of service providers in reaching out to clients. These strategies appear to have had uneven success in the ease with which we were able to recruit participants in different geographic regions, requiring more careful reflection should such an exercise be undertaken in the future.
The best turnouts tended to be achieved when focus groups could be “added on” to an existing community event , drop-in, or location e.g.peer support drop-in, homeless shelter, Aboriginal cultural evening.
One possibility, as well, is that this was a first opportunity at building a broader network for consultation. While there have been numerous consultations with clients and family members over the years, this project represented one of the largest undertakings to date. Many of the participants we spoke with had not had an opportunity to share their experiences. We were often thanked for listening to their stories.
Next steps from this project should consider how to recruit people’s feedback at the point of service provision; for example, looking at how to promote opportunities to provide feedback in emergency and in inpatient services.
Context
Building on the work in our region
The recommendations related to discharge planning in this report have many similarities to the Addictions and Mental Health Network Family Advisory Committee Discharge Transition Planning Report, 2010 including: making every effort to obtain consent to share information, holding meetings that include family members as part of discharge planning, looking broadly at the needs of individuals when they are preparing to return home (mental, physical, and social), and having common elements in discharge planning at all hospitals.
There have been two initiatives on integrated access to mental health services (two reports were issued by the Champlain Mental Health Network in 2008) and integrated access to addictions services (within the City of Ottawa) in 2010. The integrated access to addictions services is currently being implemented as a two-year pilot project. The work by the CMHN specifically addresses access and discharge issues related to inpatient mental health services.
Ten years ago, the Champlain District Mental Health Implementation Task Force (part of a provincial initiative looking at mental health system reform) produced two tools (2002) that may be useful in looking at next steps from this project: the protocol framework for partnerships between scheduled (hospitals which have mental health units for people with acute needs) and specialized mental health hospitals; and the protocol framework between hospitals and community mental health services, focused on partnerships that would make people’s transition between hospital and community easier. Both frameworks speak specifically to key elements of discharge planning.
Understanding how hospitals are currently being accessed
The Champlain LHIN was able to provide some information about how and when people are accessing inpatient services. The following tables provide some information, more generally related to mental health admissions, about how emergency and hospital services are being used. Table 1 provides a summary of the total number of admissions to designated mental health beds in Champlain in fiscal year 2010 (April 1, 2010 – March 31, 2011). It identifies where the person’s residence is located against which hospital they accessed. This table does not include mental health or substance use-related admissions where people stayed in beds that are not designated for mental health (which was equivalent to 97 beds in 2010/11, and 1,724 discharges).
Table 1. Number of admissions to designated mental health beds, by site and patient residence (2010-11)
Patientresidence
Treatment Site / Ott. / Ren. / SDG / PR / LAN / LG / Other
ON / Out of
Prov / Un-
known / Total
TOH- Civic / 826 / 50 / 13 / 20 / 21 / 9 / 20 / 32 / 41 / 1,032
ROH / 686 / 62 / 42 / 23 / 32 / 13 / 15 / 9 / 31 / 913
TOH- General / 649 / 35 / 12 / 37 / 12 / 13 / 25 / 23 / 40 / 846
Montfort / 421 / <4 / 10 / 148 / <4 / <4 / 10 / 21 / 9 / 625
Pembroke / <4 / 514 / <4 / <4 / 20 / 6 / 11 / 556
Queensway-Carleton / 389 / 26 / 6 / 8 / 32 / 7 / 9 / 8 / 11 / 496
Cornwall / 4 / 325 / <4 / 5 / 23 / 4 / 11 / <4 / 377
Total / 2,977 / 688 / 408 / 238 / 105 / 70 / 103 / 110 / 146 / 4845
Residence abbreviations: Ottawa; Renfrew County; Stormont, Dundas & Glengarry; United Counties of Prescott-Russell; Lanark County; United Counties of Leeds-Grenville; Within Ontario but outside Champlain (Other ON); and outside of Ontario.
Additional data highlights:
· Total length of stay in acute mental health (scheduled) inpatient units was about 16 days, with a range at individual hospitals of about 9.5 days to 25 days.
· Most discharges from designated mental health beds are identified as being planned
· A number of focus group participants felt that you had to be in crisis, or “formed” to be able to access an inpatient bed. According to the available data, over half (53%) of admissions to designated mental health beds in 2010/11 were people on “forms” – these can include an application or order for psychiatric assessment and/or an involuntary admission (Forms 1, 2, 3, or 4).