matryoshka - eenet · systemnhancement e evaluation initiative (seei), the matryoshka project is a...
TRANSCRIPT
the
matryoshkaproject
examining
early intervention
program
development
December 2009
authors
Chiachen Cheng, MD, FRPC(C), MPH
Carolyn S. Dewa, MPH, PhD
Paula Goering, RN, PhD
Desmond Loong
Table of Contentsexecutive summary 2
background 6Introduction�� 6Brief��Description��of��the��Matryoshka��Project�� 7Project��Description�� 8
key findings 10
early intervention in psychosis 12Early��Psychosis��Prevention��and��Intervention��Centre��(EPPIC)�� 13Ontario��Early��Intervention��Program��Development�� 14
overall findings 16Key��Influences�� 16
Regional��Adaptations�� 18Challenges�� 19Successes�� 20Urban��and��Rural��Considerations�� 21
program flow charts 24Muskoka��/��Parry��Sound��Early��Intervention��Program�� 24Toronto��Early��Intervention��Program��(STEPS)�� 26Peterborough��Early��Intervention��Program��(LYNX)�� 28York��Early��Intervention��Program�� 30Windsor��Early��Intervention��Program�� 32Thunder��Bay��Early��Intervention��Program��(First��Place)�� 34
discussion 36
appendices 38APPENDIX��A:��References�� 38APPENDIX��B:��Pre-interview��Questionnaire�� 41APPENDIX��C:��Interview��Guide�� 41APPENDIX��D:��Analysis��Codes�� 43APPENDIX��E:��Acronyms�� 44
acknowledgments 46
heading
[ The Matryoshka Project ] Examining Early Intervention Program Development2
executive summary
In�� 2004/05,�� the�� government�� of�� Ontario�� began�� investing�� significant�� new�� funds�� in�� the��community�� mental�� health�� system.�� Through�� the�� Health�� Accord�� for�� Home�� Care�� federal��initiative,��the��Ministry��of��Health��and��Long��Term��Care��allocated��$117��million��over��a��four-year��period.�� ��Recognizing��the��relationship��between��community��mental��health��services��and��inpatient��care,��the��Ministry��invested��the��funds��in��community��mental��health��services��to��support��intensive��case��management,��Assertive��Community��Treatment��(ACT),��crisis��intervention��and��Early��Intervention��Programs��(EIP).����
[ The Matryoshka Project ] Examining Early Intervention Program Development 3
The��Mental��Health��Systems��Enhancement��Evaluation��Initiative��(SEEI)��is��a��project��funded��by��the��Ontario��Mental��Health��Foundation��and��supported��by��the��Ontario��Ministry��of��Health��and��Long-Term��Care.����The��initiative��is��led��by��members��of��the��Health��Systems��Research��and��Consulting��Unit��at��the��Centre��for��Addiction��and��Mental��Health,��and��draws��upon��the��support��of��an��executive��advisory��committee��composed��of��members��of��stakeholder��groups.����As��part��of��the��System��Enhancement��Evaluation��Initiative��(SEEI),��the��Matryoshka��Project��is��a��3-year��project��looking��at��specific��programs��throughout��the��province.����Its��purpose��is��to��examine��the��effects��of��the��Government’s��new��investments��on��the��continuity��of��care��experienced��by��new��and��ongoing��clients��of��the��system.����The��Matryoshka��Project��focuses��on��two��types��of��specialized��programs:��a)��Early��Intervention��Programs��for��young��people��experiencing��their��first��psychotic��episode,��and��b)��Court��Support��Programs��for��individuals��with��mental��illness��who��are��involved��with��the��justice��system.����This��report��focuses��on��the��factors��that��influenced��how��the��development��and��implementation��of��the��study’s��Early��Intervention��Programs��emerged.
Many��of��the��programs��established��with��the��new��Ontario��funding��were��based��in��community��settings�� with�� an�� emphasis�� on�� outreach�� or�� rural�� service�� provisions.�� �� Prior�� to�� 2004/05,�� the��original��Early��Intervention��Programs��offered��in-house��training��methods��for��new��staff,��such��as��direct��supervision��and��clinical��shadowing.����Since��the��new��funding��roll-out��in��2004/05,��the��number��of��Early��Intervention��Programs��in��Ontario��grew��from��the��original��five��to��over��thirty.����
This��report��focuses��on��the��factors��that��influenced��how��the��study’s��new��Early��Intervention��Programs�� were�� developed�� and�� implemented.�� �� Data�� were�� collected�� using�� semi-structured��qualitative�� interviews�� and�� pre-interview�� questionnaires�� with�� program�� decision-makers�� for��each��of��the��research��sites��for��the��Matryoshka��Project.����During��the��interviews,��the��participants��spoke�� about�� local�� and�� provincial�� EIP�� networks�� as�� being�� very�� important�� with�� respect�� to��program�� development�� and�� implementation�� in�� the�� absence�� of�� Ontario-specific�� guidelines.����Clinical��mentors,��particularly�� from��the��original��five��Early�� Intervention��Programs,��were�� the��most�� influential�� in�� guiding�� new�� Early�� Intervention�� Program�� development.�� �� Most�� program��managers��developed��Early��Intervention��Programs��based��on��their��knowledge�� from��previous��experiences�� with�� other�� types�� of�� community�� mental�� health�� programs,�� in�� addition�� to�� advice��from��established��Early��Intervention��Programs��in��the��Ontario��Network.����The��end��result��was��schematically��unique��programs,��each��with��different��partnerships��that��suited��local��or��regional��needs.
Many��of��the��sites��for��the��Matryoshka��Project��had��rural��components��to��their��service��delivery.����Each��had��mandates��to��service��an��urban��core,��and��most��had��the��mandate��to��provide��outreach��to��rural��areas��as��well.����Initially��the��Matryoshka��Project��sites��adopted��the��hub and spoke��model,��but,��this��quickly��changed��for��practical��reasons.����One��site,��which��had��a��large��rural��component��to��the��program,��adopted��a��network��model��instead,��because��the hub and spoke��notion��was��perceived��
[ The Matryoshka Project ] Examining Early Intervention Program Development4
to��be��too��hierarchical��and��centrally��driven.����They��also��thought��that��the��hub and spoke��model��promoted��top-down��decisions,��rather��than��building��consensus��across��all��sites.����Programs��that��initially��developed��hub��and��spoke��sites��often��changed��to��network��arrangements,��or��eliminated��the�� satellite�� offices�� for�� other�� forms�� of�� rural�� service�� delivery.�� �� Some�� considered�� embedding��EIP�� staff�� within�� other�� general�� mental�� health�� agencies.�� �� However,�� this�� created�� challenges��including��supervisory��difficulties,��scope��of��practice,��and��isolation��issues.����Within��a��single��Early��Intervention��Program,��the��challenges��of��trying��to��balance��the��needs��of��the��hub��and��spoke��were��often��seen��as��a��competition��between��urban��and��rural��needs.����To��this��day,��many��participants��continue��to��struggle��to��deliver��best��practice��EIP��services��to��rural��areas.����
Although�� many�� of�� the�� sites�� in�� the�� study�� faced�� challenges�� around�� not�� having�� Ontario��specific��service��guidelines,��or��EIP��standards,��this��also��may��have��been��beneficial.����Each��program��was��able��to��incorporate��components��of��best��practice��–such��as��early��identification��and��access,��assessment,�� case�� management,�� family�� education/support,�� and�� vocational�� or�� educational��supports–��and��adapt��them��to��their��local��circumstances.����In��fact,��participants��felt��that��some��of��their��successes��included��the��creativity��and��partnerships��that��were��developed��to��provide��EIP��services��in��their��respective��areas.����
[ The Matryoshka Project ] Examining Early Intervention Program Development
heading
[ The Matryoshka Project ] Examining Early Intervention Program Development6
Introduction
In��2002/03,��the��Ministry��of��Health��and��Long-term��Care��reviewed��the��results��of��the��nine��regional��mental��health��reform��taskforces.����The��recommendations��that��arose��from��these��reports��began��to��quantify��the��mental��health��service��needs��throughout��the��province��and��underscored��the��need��for��additional��funding��for��the��mental��health��system.
background
[ The Matryoshka Project ] Examining Early Intervention Program Development 7
In�� 2004/05,�� the�� government�� of�� Ontario�� began�� investing�� significant�� new�� funds�� in�� the��community�� mental�� health�� system.�� Through�� the�� Health�� Accord�� for�� Home�� Care�� federal��initiative,��the��Ministry��of��Health��and��Long��Term��Care��allocated��$117��million��over��a��four-year��period.����Interestingly,��Ontario��was��the��only��province��that��dedicated��Accord��funding��to��mental��health;�� but,�� the�� funding�� had�� important�� restrictions.�� One�� of�� the�� requirements�� for�� funding��was��that��it��had��to��be��earmarked��to��target��the��needs��of��a��population��who��meet��the��criteria��for��homecare,��specifically��those��who��were��discharged��from��hospital��and��could��be��supported��in��the��community.�� ��Recognizing�� the�� relationship��between��community��mental��health�� services��and�� inpatient�� care,�� the�� Ministry�� invested�� the�� funds�� in�� community�� mental�� health�� services��to�� support�� intensive�� case�� management,�� Assertive�� Community�� Treatment�� (ACT),�� crisis��intervention,��and��Early��Intervention��programs.����The��first��allocation��of��$20��million��was��made��in�� the�� summer�� of�� 2004,�� and�� a�� second�� of�� $50�� million�� in�� the�� summer�� of�� 2005.�� �� Additional��allocations��followed��in��2006��and��2007.��
The��Mental��Health��Systems��Enhancement��Evaluation��Initiative��(SEEI)��is��a��project��funded��by��the��Ontario��Mental��Health��Foundation��and��supported��by��the��Ontario��Ministry��of��Health��and�� Long-Term�� Care.�� �� The�� Initiative�� is�� led�� by�� members�� of�� the�� Health�� Systems�� Research��and��Consulting��Unit��at��the��Centre��for��Addiction��and��Mental��Health,��and��draws��upon��the��support��of��an��executive��advisory��committee��composed��of��stakeholder��groups.����The��purpose��of��the��SEEI��is��to��evaluate��and��communicate��the��effects��of��the��Government’s��new��investments.������
Brief Description of the Matryoshka Project
The��Matryoshka��Project��is��part��of��the��System��Enhancement��Evaluation��Initiative��(SEEI).����It��is��a��3-year��project��looking��at��specialized��programs��throughout��the��province.�� ��Its��purpose��is�� to�� examine�� the�� effects�� of�� the�� Government’s�� new�� investments�� on�� the�� continuity�� of�� care��experienced��by��new��and��ongoing��clients��of��the��system.����The��Matryoshka��Project��focuses��on��two��types��of��specialized��programs:��a)��Early��Intervention��Programs��for��young��people��experiencing��their�� first�� psychotic�� episode,�� and�� b)�� Court�� Support�� Programs�� for�� individuals�� with�� mental��illness�� who�� are�� involved�� with�� the�� justice�� system.�� �� This�� report�� focuses�� on�� the�� factors�� that��influenced��how��the��study’s��Early��Intervention��for��Psychosis��(EIP)��Programs��were��developed��and��implemented.
[ The Matryoshka Project ] Examining Early Intervention Program Development8
Project Description
The��purpose��of��this��component��of��the��Matryoshka��Project��was��to��understand��the��processes��in��which��Early��Intervention��Programs��were��planned,��developed,��and��implemented��for��each��region.����The��goals��were��to:
A)��Understand��the��key��influences��of��how��the��Early��Intervention��Program��was��developed��for��their��region��or��program,B)��Identify��the��challenges��and��successes��of��program��development,��andC)��Describe��the��Early��Intervention��Programs��that��emerged.��
Data�� were�� collected�� using�� semi-structured�� qualitative�� interviews�� and�� pre-interview��questionnaires��with��program��decision-makers��for��each��of��the��research��sites��for��the��Matryoshka��Project.�� �� There�� were�� six�� sites�� with�� EIP�� programs�� in�� the�� study.�� �� Representatives�� from�� five��programs��were��successfully��interviewed.����
Prior�� to�� the�� qualitative�� interviews,�� each�� program�� was�� sent�� a�� pre-survey�� to�� collect��program�� information�� about�� staffing�� composition�� and�� their�� target�� populations.�� �� A�� copy�� of��the��questionnaire��can��be��found��in��Appendix��B.�� �� ��An��interview��guide��was��also��developed a priori,��which��can��be��found��in��Appendix��C.����Sampling��for��the��interviews��was��purposeful��and��key��informants��were��identified��using��a��snowball��technique.�� ��All��interviews��were��conducted��by��phone��with��the��written��consent��of��the��interviewees.�� ��The��interviews��were��conducted��in��late�� winter�� of�� 2007�� and�� seven�� interviews�� were�� completed�� with�� eight�� informants�� from�� five��programs.����The��interviews��lasted��between��1-2��hours��and��were��tape-recorded��and��transcribed��verbatim.����Emerging��themes��were��derived��in��an��iterative��process��through��a��series��of��discussions��involving�� two�� coders�� and�� a�� third�� member�� of�� the�� Matryoshka�� Project�� who�� was�� present�� to��provide��an��additional��perspective.����The��codes��that��were��developed��from��this��process��can��be��found��in��Appendix��D.
The��remainder��of��this��report��is��divided��into��three��sections.����The��first��section��summarizes��the��key��themes��that��emerged��when��interviewees��described��their��processes��of��Early��Intervention��Program�� planning,�� implementation,�� and�� development.�� �� The�� second�� section�� illustrates��diagrammatically��each��program,��their��client��flow��through��the��program,��as��well��as��key��successes��and�� challenges�� in�� regards�� to�� program�� development.�� �� The�� last�� section�� is�� a�� discussion�� about��future��implications.
[ The Matryoshka Project ] Examining Early Intervention Program Development
heading
[ The Matryoshka Project ] Examining Early Intervention Program Development10
The��purpose��of��this��report��is��to��describe��some��of��the��Early��Intervention��Programs��in��Ontario��and��to��examine��the��factors��that��shaped��the��new��program��service��models.����The��following��key��messages��were��observed.
key findings
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Key��Finding#1:
Program��developments��for��the��new��Early��Intervention��Programs��in��Ontario��were��significantly��influenced��by��the��provincial��EIP��Network,��local��champions,��and��clinical��mentors.����Program��decision-makers��often��relied��on��each��other��within��their��provincial��Network��for��guidance��about��program��implementation��and��development.����Programs��had��to��adapt��their��EIP��models��according��to��funding��and��local��service��characteristics,��in��the��absence��of��Ontario��specific��guidelines.
Key��Finding#2:
Although��the��research��evidence��assisted��program��decision-makers��to��develop��an��ideal��EIP��model��for��their��region,��implementation��of��the��ideal��was��often��shaped��by��funding��constraints.����
Key��Finding#3:
The��lack��of��specific��guidelines��may��have��allowed��innovation;��this��creativity��and��diversity��is��consistent��with��EIP��research��evidence.����
Key��Finding#4:
Despite��the��challenges��related��to��geography��and��staffing,��programs��experienced��important��successes��such��as��partnerships��across��sectors,��quality��clinical��service,��and��the��ability��to��engage��hard-to-serve��clientele��and��families.����
Key��Finding��#5:
Programs��were��passionate��about��serving��people��with��EIP��and��firmly��believed��that��their��services��provided��better��long-term��outcomes��to��individuals��with��severe��mental��illness.��
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heading
Over��the��past��fifteen��years,��early��intervention��for��psychosis��received��international��attention.����Emerging��research��indicates����EIP��may��improve��outcomes��for��young��people��experiencing��severe��mental�� illness��early�� in��their�� lives.1,2�� �� In��Ontario,�� the��first��Early��Intervention��Programs��were��established��in��1992��in��Hamilton��and��Toronto.����London��soon��followed��in��1997,��then��Ottawa��and�� Kingston�� in�� 2001.3�� �� All�� five�� programs�� were�� based�� in�� tertiary,�� urban�� academic�� centres.����The�� EIP�� models�� adopted�� by�� these�� clinical�� programs�� were�� based�� on�� pioneers�� in�� the�� field,��including��the��Early��Psychosis��Prevention��and��Intervention��Centre��(EPPIC)��from��Melbourne,��Australia.����
early intervention in psychosis
[ The Matryoshka Project ] Examining Early Intervention Program Development 13
Early Psychosis Prevention and Intervention Centre (EPPIC)
EPPIC�� is�� a�� specialized�� clinical�� program�� that�� aims�� “to�� facilitate�� early�� identification�� and��treatment��of��psychosis��and��therefore��reduce��the��disruption��to��the��young��person’s��functioning��and��psychosocial��development”.4,5����It��was��established��in��1992��as��a��“second��generation��model”��with��two��purposes:��a)��“to��identify��patients��at��the��earliest��stage��from��onset��of��psychosis”,��and��b)��“to��provide��intensive��phase��specific��treatment��for��up��to��2��years��thereafter”.6����Key��program��areas��identified��by��EPPIC��include:��assessment��and��community��treatment��team;��assertive��case��management;��inpatient��unit;��family��work;��cognitive��based��psychotherapy;��early��assessment��team;�� systematic�� treatment��of��persistent��positive�� symptoms;��group��and��day��programming;��brief��cognitive��therapy��for��acute��high-risk��suicide;��evaluation;��and��follow��up��of��prodromal��cases.7,8��An��illustration��of��the��EPPIC��service��model��is��shown��in��Figure��1.�� ��EPPIC��is��now��a��program��within��ORYGEN��Youth��Health��in��Melbourne,��Australia.����
��
��
Figure��1:��EPPIC��Service��Model9
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Through�� the�� work�� of�� EPPIC�� and�� other�� international�� EIP�� leaders,�� international�� best��practices�� for�� EIP�� were�� developed�� and�� components�� of�� best�� practice�� have�� been�� defined�� as:��public��education�� in��settings��that��are��youth-focused;��early�� identification��and��access�� to��care;����comprehensive�� assessment�� and�� case�� management;�� low�� dose�� neuroleptic�� treatment�� and��close�� ongoing�� monitoring;�� family�� education�� and�� support;�� group�� programming�� for�� various��psychosocial��treatment��modalities��such��as��cognitive��therapies;��occupational��and��educational��supports;��intensive��psychosocial��rehabilitation;��underlying��program��values��of��client-centred��services;��hope;��and��recovery.10
Ontario Early Intervention Program Development
Despite��the��accumulating��evidence��for��the��effectiveness��of��EIP,��there��is��still��relatively��little��research��on��which��to��base��operational��planning��and��implementation��of��EIP��in��either��rural��regions��or��community��settings.11,12����Many��of��the��programs��established��with��the��new��Ontario��funding�� were�� based�� in�� community�� settings�� with�� an�� emphasis�� on�� outreach�� or�� rural�� service��provisions.����Given��that��the��EIP��field��is��relatively��new��and��highly��specialized,��the��new��programs��were��charged��with��the��task��of��hiring��new��staff��who��needed��to��develop��specialized��EIP��skills��on��the��job.����Prior��to��2004/05,��the��original��Early��Intervention��Programs��offered��in-house��training��methods��for��new��staff,��such��as��direct��supervision��and��clinical��shadowing.�� ��Programs��found��this��to��be��manageable��because��staff��were��often��hired��in��small��numbers.����Since��the��new��funding��roll-out��in��2004/05,��the��number��of��Early��Intervention��Programs��in��Ontario��grew��from��the��original��five��to��over��thirty.����The��opportunities��and��challenges��associated��with��the��rapid��Early��Intervention��Program��expansion��in��Ontario��provided��a��unique��opportunity��to��examine��the��factors��that��shaped��service��models��for��the��new��programs.
[ The Matryoshka Project ] Examining Early Intervention Program Development
[ The Matryoshka Project ] Examining Early Intervention Program Development16
headingoverall findings
Key Influences
In��Ontario,��front��line��staff��observations��about��gaps��in��the��mental��health��system,��coupled��with��grass��roots��advocacy��groups’��actions,��helped��to��keep��EIP��on��the��agenda��with��decision��makers��and��funders.����For��example,��transitional��age��youth��between��the��ages��of��16��and��20��were��observed�� to�� be�� falling�� through�� the�� cracks�� between�� the�� adult�� and�� children’s�� mental�� health��systems.����In��response,��one��local��champion��started��to��service��this��age��group,��and��also��became��active��in��applying��for��funding��to��support��this��previously��unpaid��work.������For��a��subset��of��EIP��
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sites,��they��organized��themselves��prior��to��funding��decisions��and��submitted��proposals.����Local��leaders��and��champions��were��often��staff��from��existing��mental��health��service��organizations��who��galvanized��support��to��create��local��EIP��working��groups��or��community��advisory��committees��to��steer��the��funding��proposals.����Part��of��the��momentum��was��founded��on��the��belief��that��people��with��severe��mental��illness��could��achieve��better��long-term��outcomes��than��traditionally��believed.����
We were very persistent and kind of patient and we did a lot of different things along that way and lobbying while we were waiting
and building a ground of interest and support locally.
Many��people�� involved�� in��the��grass��roots��movement�� joined��the��provincial��EIP��Network.����This��provincial��Network��was��created��by��the��original��five��Ontario��Early��Intervention��Programs��that��were��based��in��tertiary��academic��centres.����The��Network’s��activities��also��kept��EIP��on��the��policy��agenda.�� ��For��example,�� the��group��conducted��outcomes��research��that��pointed��toward��the��positive��results��associated��with��Early��Intervention��Programs.13,14����Local��research��evidence,��coupled�� with�� discussions�� with�� various�� decision-makers�� and�� politicians�� from�� all�� political��parties��helped��to��shape��the��Health��Accord��funding��decisions��in��Ontario.����These��decisions��led��to��community��mental��health��agencies��across��Ontario,��including��those��that��did��not��participate��in��submitting��initial��funding��proposals,��to��receive��funding��for��EIP��services.����
Many��of��these��community��agencies��had��little��or��no��previous��experience��in��providing��clinical��EIP�� services.�� �� For�� guidance,�� they�� turned�� to�� practice�� guidelines�� and�� standards.�� �� With�� the��absence��of��Ontario-specific��guidelines,��the��participants��spoke��about��local��and��provincial��EIP��networks��as��being��very��important��with��respect��to��program��development��and��implementation.����Clinical��mentors,��particularly��from��the��original��five��Early��Intervention��Programs,��were��the��most��influential��in��guiding��new��Early��Intervention��Program��development.����Overall,��clinical��mentors��and��other��perceived��experts��were��found��to��be��more��influential��than��research��evidence��during��the��development��of��the��new��programs.��������
What I found myself doing of course and like other EIP managers is calling one another. Luckily we had the [provincial Network] … and so
through there I had mentors…
The�� program�� decision-makers�� who�� were�� charged�� with�� implementing�� the�� new�� Early��Intervention��Programs��often��relied��on��each��other��for��guidance��and��direction.����This��Network��was�� also�� more�� influential�� than�� published�� research�� evidence�� and�� direction�� from�� local��policy-makers.����
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The��values��associated��with��EIP��internationally��(from��EPPIC��and��others)��were��adopted��by��some��EIP��staff��wholeheartedly.����Staff��were��committed��not��only��to��the��EIP��service��philosophy,��but��also��to��the��EIP��work��ethic.
Well read, well informed, good regular supervision, flexible, smart, heaps of energy, good problem solver, passionate, likes young people.
NOT a control freak and NOT lazy.��15
It��is��important��to��note��as��well��that��some��staff��worked��in��conditions��that��others��may��not��have��tolerated.����For��example,��part��time��positions��doing��EIP��case��management��in��addition��to�� a�� regular�� case�� load,�� solo�� EIP�� clinicians�� with�� a�� wide�� scope�� of�� practice�� extending�� beyond��clinical��competencies,��and��unpaid��administrative��or��management��duties.
[Worker] joined the program as a public education and family support worker … she continued to be employed by SSO…In fact she continued to
act as the regional coordinator like the local director, she kept her old job … [she] just added on the EIP part.
Regional Adaptations
Early��Intervention��Programs��around��the��world��were��growing��at��a��rapid��rate.����As��program��managers��attempted��to��implement��new��EIP��service��models,��they��faced��the��tension��of��creating��new��services��based��on��research��evidence,��and��adapting��these��models��to��meet��local��service��needs.����Interviewees��have��expressed��frustration��with��the��lack��of��Ontario-specific��guidelines.�� ��Some��found��it��was��very��difficult��to��develop��new��programs��without��specific��guidelines��or��standards��to��follow.������And��the��guidance��that��interviewees��received��from��local��policy-makers��were��found��to��be��unhelpful.����Interviewees��believed��that��the��recommendations��that��were��given��were��either��too��restrictive��or��irrelevant��for��local��conditions.����In��hindsight,��some��participants��recognized��that��EIP��was��too��new��and��unfamiliar,��with��many��of��the��local��policy-makers��lacking��experience��and/or��knowledge��with��EIP��service��development.��
Overall,��most��program��managers��developed��Early��Intervention��Programs��based��on��their��knowledge�� from�� previous�� work�� experiences�� as�� well�� as�� on�� advice�� from�� established�� Early��Intervention��Programs��in��their��provincial��Network.����The��end��result��was��schematically��unique��
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[ The Matryoshka Project ] Examining Early Intervention Program Development 19
programs,��each��with��different��partnerships��that��suited��local��or��regional��needs.����(Please��refer��to��the��Program��Flow��Charts��section��for��further��discussion��on��program��models).
One��of��the��many��challenges��that��program��decision��makers��faced��was��having��to��first��adapt��original�� visions�� to�� emulate�� best�� practice�� models,�� such�� as�� EPPIC,�� and�� then�� adapting�� their��service��model�� to��address�� local�� influences��and��needs.�� ��Program��decision��makers�� spoke��with��pride��about��these��creative��adaptations��and��collaborations��across��sectors��to��deliver��EIP��services.����
I think one of the things that has really shifted is around the staff complement…and that had to do with funding…It was very limited and
there were all sorts of different things that money had to pay for…so while the proposal might have called for 2 nurses, more social workers, OT’s…
The agency has gone with more generic kind of case managers…in making the money spread a little wider.
We don’t have any vocational assessment or resources on site…we go with established [services that] we have great connection with… employment
agencies in the community who are not necessarily geared towards people with major mental illnesses but who are so receptive…they’ve been really,
really excellent with our clients. What’s been great about them [,] they’ve actually found placements for our clients, but even before the placements
they have structured 2 week employment opportunity like they are getting ready for employment…[and] they get to know our clients really well…
The��participants��believed��that��they��positively��changed��the��existing��mental��health��system��by�� providing�� services�� where�� there�� were�� perceived�� gaps,�� specifically�� services�� for�� transitional��age��youth,��homeless��youth,��and��youth��in��trouble��with��the��law.����Early��identification��and��early��intervention��for��severe��mental��illness��were��also��provided.
Challenges
Although�� some�� of�� the�� themes�� identified�� under�� Regional�� Adaptations�� were�� cited�� as��challenges,�� the�� basic�� challenge�� voiced�� by�� all�� of�� the�� program�� decision-makers�� was�� the�� lack��of�� Ontario�� specific�� service�� guidelines.�� �� Some�� found�� that�� the�� restrictive�� nature�� of�� the�� early��
”“
”“
[ The Matryoshka Project ] Examining Early Intervention Program Development20
funding,��coupled��with��lack��of��guidelines,��prevented��them��from��implementing��their��ideal��EIP��service��based��on��international��best��practice��guidelines.
the first thing that happened to the dollars was they were cut in half… So naturally everybody had to kind of squeeze into their implementation[.] So instead of a worker it was .5 of a worker… the money squeaked out
of the envelope year by year… It’s difficult because then you are trying to implement half of everything. It really compromised us.
Those�� who�� were�� new�� to�� delivering�� services�� that�� were�� traditionally�� hospital-based��faced��challenges��in��providing��these��services��in��the��community��setting.�� ��For��instance,��access��to��psychiatrists��and��family��physicians��decreased��as��services��branched��out��from��urban��hospital��centres�� to��community-based��or�� rural��programs.�� �� Interviewees�� spoke��about��difficulties��with��providing��aspects��of��the��clinical��service��such��as��prescribing��highly��regulated��medications��and��monitoring��potentially��harmful��side-effects.����This��was��also��compounded��by��the��lack��of��skilled��EIP��service��providers,��including��psychiatrists��trained��in��EIP.
P: We have one psychiatrist now who comes up from Toronto usually one day a week sometimes 2 days a week…But, but he works for the whole agency so
he is not specific to EIP at all…And he won’t prescribe[.] then we also have… videoconferencing….
I: So what do you do when you need to admit someone [to the hospital to manage their symptoms]?
P: [long pause] We are quiet here because that is a huge problem.
Successes
The��program��decision��makers��were��very��proud��of��the��successes��that��they��believed��they��had��achieved.����Partnerships��across��sectors��and��between��local��and��provincial��providers��were��things��they��believed��were��their��greatest��accomplishments.����
”
”“
“
[ The Matryoshka Project ] Examining Early Intervention Program Development 21
They��developed��service��partnerships��with��schools,��employment��agencies,��child��and��youth��mental��health��agencies,��youth��shelters,��youth��programs,��housing��and��hospitals.����
We have also been able to maintain some of our clients in the school system... we’ve been impressed with the level of co-cooperativeness they have
shown us with working with us and our clients, [For example] they’ve decreased [clients’] work load, they have provided rooms where they can
[have] stimulation to do their work…You know, a more protective setting during lunch....we’ve found them very, very cooperative.
The�� participants�� attributed�� their�� collaborations�� with�� other�� agencies�� to�� providing��better��clinical��services,��particularly��with��hard-to-serve��clientele;��and��in��turn,��achieving��greater��successes��in��client��outcomes,��staff��commitment,��and��client/family��satisfaction.����
I think the success is the family work we have been able to do and the families themselves have really helped us to be successful in intervening
in the lives of the youth.
They��also��believed��they��were��able��to��shift��the��mental��health��system��by��decreasing��resistance��to��the��EIP��model��and��change��through��education.����
I think that the public education, while we may not have had one person dedicated to it, we all of us have done a really great job of that.
And I think that we’re known in the community.”
The��program��decision��makers��attributed��their��ability��to��overcome��challenges��in��program��and�� service�� development�� to�� very�� collegial,�� coherent,�� and�� enthusiastic�� clinical�� teams.�� �� They��celebrated��their��successes��by��mutual��support��through��local��and��provincial��EIP��networks.��
Urban and Rural Considerations
Many��of��the��sites��for��the��Matryoshka��Project��had��rural��components��to��their��service��delivery.����Each��had��mandates��to��service��an��urban��core,��and��most��had��the��mandate��to��provide��outreach��to��
”“
”“
”“
[ The Matryoshka Project ] Examining Early Intervention Program Development22
rural��areas��as��well.����The��EPPIC†��hub and spoke‡��model��to��deliver��services��to��rural��areas��has��been��adopted��by��many��programs��internationally.����Initially��the��Matryoshka��Project��sites��adopted��the��hub and spoke��model,��however,��this��quickly��changed��for��a��variety��of��practical��reasons.����One��site,��which��had��a��large��rural��component��to��the��program,��adopted��a��network��model��instead,��because��the��hub and spoke��notion��was��perceived��to��be��a��too��hierarchical��and��centrally��driven.����They��also��thought��that��the��hub and spoke��model��promoted��top-down��decisions,��rather��than��building��consensus��across��all��sites.����They��believed��that��the��hub and spoke��service��model��skewed��services��to��urban��areas,��rather��than��balancing��services��across��the��whole��region.����Programs��that��initially��developed��hub and spoke��sites��often��changed��to��network��arrangements,��or��eliminated��the�� satellite�� offices�� for�� other�� forms�� of�� rural�� service�� delivery.�� �� Some�� considered�� embedding��EIP��staff��within��other��general��mental��health��agencies.����Unfortunately,��this��created��challenges��including��supervisory��difficulties,��scope��of��practice,��and��isolation��issues.����Although��some��of��the��challenges��mentioned��earlier��were��accentuated��in��rural��areas,��there��was��a��severe��shortage��and�� lack��of��medical�� support.�� ��Videoconferencing��proved��to��be��a��very��useful�� tool,�� and��this��was��especially��true��in��hub��centres,��but��less��so��in��rural��areas��because��of��the��lack��of��IT��support��and��equipment.�� �� ��Within��a�� single��Early�� Intervention��Program,�� the��challenges��of��balancing��the��needs��of��the��hub��and��spoke��were��often��seen��as��a��competition��between��urban��and��rural��needs.����Many��participants��continue��to��struggle��with��delivering��best��practice��EIP��services��to��rural��areas.����
Many��of��the��programs��that��covered��large��geographies��faced��challenges��providing��services��to�� low�� population�� density�� areas.�� �� In�� some�� cases,�� a�� program�� would�� cover�� a�� vast�� geography��with��widely��differing��needs,��all��within��the��same��region��and��program.����Staff��travel��costs��and��regional��planning��complexities��were��some��of��the��unexpected��problems��that��surface��from��low��population��density��service��delivery.
†��EPPIC��was��one��of��the��first��Early��Intervention��Programs��internationally��to��publish��research��evidence��about��servicing��rural��areas.����
‡��Hub��and��spoke��refers��to��service��provision��that��resembles��the��hub��and��spoke��of��a��wheel.����The��hub��is��usually��located��in��a��central,��urban��area,��with��a��full��complement��of��EIP��service��provision,��including��family��education,��psychiatric��assessment��and��medical��care,��nursing��care��and��follow��up,��recovery��and��psychosocial��rehabilitation.����The��spokes��are��satellite��sites��of��EIP��service��with��access��and��clinical��support��from��the��hub,��but��specialist��EIP��service��is��delivered��within��a��generalist��agency��or��model.
[ The Matryoshka Project ] Examining Early Intervention Program Development
[ The Matryoshka Project ] Examining Early Intervention Program Development24
heading
Muskoka / Parry Sound Early Intervention Program
The��Muskoka/Parry��Sound��site��is��the��only��Matryoshka��study��site��that��could��be��considered��a�� spoke�� in�� the�� hub and spoke�� model.�� �� The�� central�� coordinating�� hub�� is�� based�� in�� North�� Bay,��which��does��not��provide��any��direct��clinical��EIP��service.����There��are��multiple��spokes,��each��with��1��to��2��EIP��case��managers��who��provide��all��the��direct��service��components��of��EIP.����Within��the��Muskoka/Parry��Sound��Early��Intervention��Program,��there��are��three��sites,��each��staffed��with��one��part-time��EIP��case��manager.����The��EIP��program��is��embedded��within��a��general��mental��health��
program flow charts
[ The Matryoshka Project ] Examining Early Intervention Program Development 25
agency��which��supports��the��lone��EIP��worker��clinically��and��administratively.������The��case��managers��are�� responsible�� for�� all�� EIP,�� including�� assessment,�� engagement,�� psychosocial�� intervention,��vocational��support,��and��family��support.����Case��managers��rely��on��the��hub��to��provide��education��and��training��opportunities,��clinical��assessment,��and��screening��scales.����Clients��typically��stay��for��up��to��3��years.����
EIP
wo
rk
Er
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t o
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cy
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m;
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aws
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el
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tral A
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y In
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IP H
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GRAM
(SPO
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Ref
erra
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= E
IP T
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IP t
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ansi
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P
The�� Muskoka/Parry��Sound�� site�� participants��felt��that��they��experienced��successes�� through��their�� innovation�� in��developing�� a�� program,��while�� working�� within��limited�� resources�� and��a�� large�� rural�� geography��to��service.�� ��Their��largest��challenge�� continues��to�� be�� finding�� medical��or�� psychiatric�� backup��for�� their�� EIP�� service��provision.������
[ The Matryoshka Project ] Examining Early Intervention Program Development26
Toronto Early Intervention Program (STEPS)
The�� STEPS�� program�� is�� somewhat�� unique�� in�� a�� number�� of�� ways�� compared�� to�� other��Matryoshka�� Project�� sites.�� �� This�� program�� mainly�� services�� homeless,�� inner-city�� youth�� of��transitional��age,��16-24��years��old.����Given��that��the��clients��are��homeless,��there��is��very��little��family��involvement.�� �� Individuals�� from�� this�� population�� typically�� have�� significant�� legal�� problems��and��concurrent��substance��use��disorders.�� ��Clients��of�� this��program��are��referred��by��a��number��of�� sources,�� including�� inpatient�� units,�� youth�� shelters,�� youth�� justice�� programs,�� and�� general��practitioners.����Although��public��education��events��have��been��held��in��schools,��not��many��referrals��are��through��the��educational��system.����Intakes,��however,��are��completed��centrally��through��one��team�� member,�� who�� also�� completes�� the�� initial�� assessments�� and�� engagement�� of�� the�� client.����Psychiatric�� assessment�� referrals�� are�� made�� by�� the�� same�� nurse�� case�� manager�� when�� necessary.����Afterwards,��clients��are��assigned��to��a��case��manager��(from��occupational��therapy��or��social��work��disciplines)��who��coordinates��the��treatment��of��psychosis,��as��well��as��other��basic��aspects��such��as��housing,��disability��insurance,��and��reaching��vocational��goals.����Clients��typically��stay��with��the��program��until��they��reach��24��years��of��age,��at��which��point��they��will��transition��to��other��adult��mental��health��services.����The��STEPS��program��also��has��important��collaborations��with��family��medicine��residency��programs��and��youth��shelters��to��address��medical��and��housing��issues.
The�� STEPS�� program�� is�� uniquely�� part�� of�� a�� downtown�� hospital’s�� community�� outreach��program��and��it��is��one��of��five��programs��along��a��continuum��of��community��programs��providing��services��to��clients��with��severe��mental��illness.����The��main��challenge��faced��by��STEPS��was��program��development��without��established��guidelines��or��standards��for��EIP��in��Ontario.�� ��The��funding��restrictions��and��incremental��increases��also��made��it��a��challenge��to��plan��for��physical��space,��hiring��the��appropriate��number��of��staff,��compensating��for��the��lack��of��funding��for��psychiatry,��and��the��training��for��new��staff.����But��despite��the��challenges,��STEPS��was��successful��in��shifting��an��existing��mental��health��system��to��accommodate��and��provide��services��for��hard-to-serve��transitional��age��youth.����The��STEPS��team��is��very��collegial��and��cohesive,��and��has��attracted��learners��to��train��in��EIP.
[ The Matryoshka Project ] Examining Early Intervention Program Development 27
co
lleg
ial
tea
m;
eng
ag
ing h
ar
d t
o s
erve
yo
uth
;fi
llin
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ts;
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[ The Matryoshka Project ] Examining Early Intervention Program Development28
Peterborough Early Intervention Program (LYNX)
Like�� the��other�� sites,�� the��LYNX��program�� is�� located�� in��a�� rural��part��of�� the��Province,��with��the�� mandate�� to�� provide�� services�� in�� a�� smaller�� urban�� centre�� and�� outreach�� to�� multiple�� rural��communities.����LYNX��is��unique��because��it��is��an��eight��agency��collaboration��across��four��counties.����There��is��a��central��Joint��Management��Committee��that��provides��coordination��and��management��decisions.�� ��The��Committee��also��works��closely��with��the��community��advisory��group��and��the��program��paymaster-lead��agency,��from��which��funding��is��flowed��through��to��each��site.����Referrals��to�� the�� program�� can�� be�� made�� from�� families,�� schools,�� other�� community�� agencies,�� hospitals,��general�� practitioners,�� and�� from�� clients�� themselves.�� �� Once�� a�� referral�� has�� been�� made,�� the��nearest/local��case��manager��completes��the��comprehensive��assessment,��assertive��outreach,��and��engagement.����The��case��manager��then��coordinates��other��referrals��for��psychiatric��consultation,��family��support,��and��education.����The��local��case��manager��also��manages��all��of��the��EIP��treatment,��such��as��medical��investigations,��school��or��vocational��support,��psychosocial��rehabilitation,��and��any��ongoing��medical��follow-up��required.��On��average,��clients��usually��stay��in��the��program��for��2��to��5��years��and��graduate��into��an��Alumni��Program��that��involves��three��scheduled��appointments��with�� a�� case�� manager�� and�� psychiatrist,�� as�� well�� as�� alumni�� peer�� supports.�� �� Clients�� may�� also��progress��into��other��community��mental��health��programs��or��even��achieve��independent��living��under��the��care��of��a��general��practitioner.
The��challenges��faced��by��LYNX’s��program��development��were��in��delivering��services��across��four��counties��with��only��half��the��funding��and��resources��that��they��applied��for.����The��incremental��increases��in��funding��over��four��years��created��difficulties��in��delivering��services.����It��was��only��when��LYNX��reached��the��full�� funding��complement��were��they��able��to��overcome��their��obstacles��–��three��years��after��the��start��of��the��program.����The��main��successes��of��the��LYNX��program��were��the��collaborations�� and�� partnerships�� established�� among�� the�� eight�� agencies�� across�� four�� counties.����These��partnerships��were��instrumental��in��delivering��quality��clinical��services��with��a��high��degree��of��early��identification��and��prevention��of��hospital��admissions.
[ The Matryoshka Project ] Examining Early Intervention Program Development 29
Ref
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ls w
ithin
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m
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ls t
o/f
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m
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[ The Matryoshka Project ] Examining Early Intervention Program Development30
York Early Intervention Program
Like�� many�� of�� the�� other�� Matryoshka�� sites,�� the�� York�� Region�� Early�� Intervention�� Program��accepts�� referrals�� from�� many�� sources�� including�� families,�� hospital�� units,�� client�� self-referrals,��community��agencies,��and��general��practitioners.����Consistent��with��published��literature,��public��education�� efforts�� increased�� the�� number�� of�� referrals�� following�� an�� education�� event.16,17,18,19����Preliminary��screening��is��completed��to��determine��appropriate��fit��into��the��Early��Intervention��Program.����If��a��client��fulfills��the��intake��criteria,��a��full��assessment��is��completed��by��the��program��manager��and��one��front-line��staff.����Following��this��assessment,��a��case��manager��(from��any��one��of��the��disciplines:��social��work,��nursing,��peer��support,��occupational��therapy)��will��service��the��client.����The��York��Region��program��has��established��partnerships��with��schools,��employment��support��agencies,��housing��programs,��and��other��youth��services��to��provide��psychosocial��rehabilitation��and��recovery��support.����The��York��program��started��implementing��the��hub and spoke��model��by��initially��establishing��a��satellite��site��in��the��rural��portion��of��their��region.����However,��over��the��first��few��years��following��the��opening��of��services,��the��York��program��decided��to��close��their��satellite��site��and��operate��all��of��their��services��from��a��central��site��in��Aurora.
The��main��challenges��faced��by��the��York��Early��Intervention��Program��were��providing��adequate��training��for��new��staff,��compensating��for��the��lack��of��funding��for��psychiatry,��recruiting��additional��psychiatry��time,��and��balancing��the��needs��of��both��urban��and��rural��regions��in��one��program.����The��main��successes��were��the��partnerships��and��positive��community��presence��that��they��established.����This�� was�� in�� part�� due�� to�� public�� education�� efforts,�� family�� education,�� and�� support�� groups�� –��including��those��provided��for��clients.
[ The Matryoshka Project ] Examining Early Intervention Program Development 31
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CLI
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LOW
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effe
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par
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Ref
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[ The Matryoshka Project ] Examining Early Intervention Program Development32
Windsor Early Intervention Program
The��Windsor��Region��Early��Intervention��Program��is��one��of��a��handful��of��EIP��services�� in��Ontario��accepting��individuals��less��than��16��years��of��age.����The��actual��intake��criteria��for��Windsor’s��EIP��program��are��clients��between��the��ages��of��14��and��35��years.����Referrals��to��this��program��can��be�� made�� from�� inpatient�� units,�� families,�� school�� officials,�� community�� agencies,�� and�� clients��themselves.�� �� Like�� many�� other�� mental�� health�� services,�� preliminary�� screening�� is�� conducted��to�� assess�� appropriate�� fit�� to�� the�� EIP�� services�� available.�� �� If�� appropriate,�� a�� full�� consultation�� is��completed�� with�� a�� program�� psychiatrist�� and�� family�� educator.�� �� Ongoing�� case�� management��involving��mental��health��education,�� symptom��management,��coping��skills��development,��and��advocacy,��are��performed��by��registered��nurses.����Other��services��such��as��psychiatric/medical��care,��family��education��and��support,��housing��and��vocational��support��are��also��available��to��complement��case�� management�� services.�� �� However,�� the�� enrolment�� time�� is�� limited�� to�� a�� maximum�� of�� 2��years,��after��which,��individuals��are��discharged��from��the��program��when��they��have��either��been��transitioned��to��another��level��of��service,��or��when��their��service��goals��have��been��completed.��The��Early��Intervention��Program��has��also��developed��a��community��partnership��with��City��Centre��Health�� Care�� located�� at�� the�� Canadian�� Mental�� Health�� Association�� Windsor-Essex�� County��Branch��office.����Services��that��are��provided��include��a��dietician,��a��nurse��practitioner,��therapists,��a��chiropodist,��a��health��promoter,��psychiatrists,��and��general��practitioners.��
The��main��successes��from��Windsor’s��Early��Intervention��Program��were��the��establishment��of��community��partnerships��and��a��positive��community��presence.��As��part��of��the��family��support��offered��in��the��Early��Intervention��Program,��Multi-Family��Groups��are��utilized.����These��groups��are�� intended�� for�� both�� the�� clients�� of�� the�� Early�� Intervention�� Programs�� and�� the�� people�� who��are�� identified�� as�� ‘family’�� by�� the�� client.�� �� Group�� meetings�� are�� held�� bi-weekly�� and�� about�� 90��minutes��per�� session.�� ��The��focus��of�� the��group�� is�� for��participants�� to��gain��support�� from��their��peers,�� as�� well�� as�� to�� increase�� communication,�� problem-solving,�� and�� coping�� skills�� in�� dealing��with�� symptoms�� that�� are�� reported.�� �� Group�� meetings�� typically�� begin�� with�� a�� few�� minutes�� of��informal��socialization,��followed��by��a��check-in��where��all��participants��indicate��“something��that��has��gone��well��since��the��last��group��and��something��that��they��wish��had��gone��better”.����From��the��“things��that��could��have��gone��better”,��the��facilitators��choose��one��of��the��situations��to��problem��solve.����With��the��permission��of��the��client��and��family,��the��facilitators��then��lead��the��group��in��a��problem��solving��exercise.����This��results��in��the��client��and��family��leaving��the��group��with��a��plan��to��begin��solving��their��problem.����A��copy��of��the��plan��is��provided��to��the��client’s��case��manager,��and��at��the��following��session,��the��facilitators��check��back��with��the��family��and��client��to��inquire��if��the��plan��was��successful.����One��of��the��challenges��experienced��by��this��program��was��the��continued��need��for��services��and��the��straining��of��limited��resources.
[ The Matryoshka Project ] Examining Early Intervention Program Development 33
Windsor
CLI
EN
T F
LOW
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ART
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ls w
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[ The Matryoshka Project ] Examining Early Intervention Program Development34
Thunder Bay Early Intervention Program (First Place)
The��First��Place��Clinic��&��Resource��Centre��in��Thunder��Bay��accepts��adolescents��and��adults��between��the��ages��of��14��and��35��years.����Younger��clients��are��also��routinely��accepted.����Individuals��are�� typically�� referred�� by�� a�� variety�� of�� sources�� including�� hospital�� inpatient�� units,�� addiction��services,��family��practitioners,��psychiatrists,��housing,��schools/education��sector,��child��welfare,��aboriginal��mental��health,��and��other��community/social��services.����Referrals��are��screened��initially��by��a��senior��clinician.����If��early��psychosis��is��suspected,��an��assessment��consultation��is��provided��by��a��psychiatrist,��nurse��case��manager,��family��educator,��and��recovery��care��coordinator.����After��the��initial��appointment,��a��decision��is��made��to��provide��short-term��extended��consultation,��or��long-term��treatment��and��recovery.����The��time��limit��registered��in��the��program��is��dependent��on��individual��needs.����At��times��care��is��transitioned��to��ACT��or��other��intensive��case��management��services,�� such�� as�� housing,�� employment/vocational�� support,�� and�� other�� community�� mental��health��services.����Individuals��who��achieve��their��recovery��goals��are��then��enrolled��in��an��Alumni��Program��where��they��have��annual��follow��up��with��the��Early��Intervention��Program,��but,��First��Place��maintains��a��shared��care��model��with��the��individual’s��family��physician��or��general��practitioner.����A��key��accomplishment��in��the��program��was��the��development��of��important��partnerships��with��regional��aboriginal��mental��health��services,��hospitals,��other��adult��and��children’s��mental��health��services,��and��recreational/leisure��facilities.
The��challenges��in��program��development��at��First��Place��included��servicing��a��vast��geography��with��varying��stakeholder��needs.����The��challenges��of��balancing��needs��in��Thunder��Bay��with��the��service��needs��in��the��region��were��illustrated��by��the��demand��for��services��before��the��clinical��team��was��appropriately��trained.����Staff��were��asked��to��develop��a��wide��range��of��clinical��skills,��servicing��clients�� ranging�� from��children��to��adults.�� �� Important�� successes��of�� this��program��included��the��partnerships��established��with��local��and��regional��mental��health��providers.����First��Place��also��has��a��skilled��and��collegial��team��that��has��engaged��youth��and��families��to��achieve��clinical��goals.
[ The Matryoshka Project ] Examining Early Intervention Program Development 35n
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[ The Matryoshka Project ] Examining Early Intervention Program Development36
heading
In��some��ways,��funding��for��EIP��services��was��a��risk��to��funders��because��EIP��was��an��innovative,��specialized,��and��revolutionary��approach��to��treating��psychotic��disorders��such��as��schizophrenia.5����
In�� Ontario,�� the�� EIP�� services�� began�� in�� the�� early�� 1990’s�� when�� EIP�� was�� being�� established��internationally.�� �� Over�� twelve�� years,�� a�� collaborative�� provincial�� Network�� was�� created�� which��connected�� with�� the�� grassroots�� movement�� in�� the�� early�� 2000’s�� and�� also�� coincided�� with�� new��funding��for��EIP.��������
Interviewees��for��this��study��were��obviously��passionate��about��EIP,��and��firmly��endorsed��EIP��as��
discussion
[ The Matryoshka Project ] Examining Early Intervention Program Development 37
making��a��difference��for��clients��of��the��mental��health��system��who��were��previously��not��identified��or��treated��early,��causing��much��suffering��and��expense.����They��emphasized��the��message��that��EIP��was��worth��the��risk��to��funders.
Although�� many�� of�� the�� sites�� in�� the�� study�� faced�� challenges�� related�� to�� not�� having�� Ontario��specific��service��guidelines,��or��EIP��standards,��this��also��may��have��been��a��benefit.����As��illustrated��in�� the�� program�� client�� flow�� charts,�� each�� program�� appears�� unique,�� but�� each�� has�� adapted��the�� components�� of�� best�� practice,�� such�� as�� early�� identification�� and�� access,�� assessment,�� case��management,��family��education/support,��and��vocational��or��educational��supports.����Variations��were��seen��in��the��number��of��staff��and��program��sites,��the��disciplines��of��case��managers��(i.e.��social��work,��nursing,��occupational��therapist),��and��the��type��of��partnerships��developed.����
Interviewees��were��anxious��to��receive��feedback��about��whether��they��were��“doing��a��good��job”.����Part��of��this��may��have��been��to��show��funders��that��EIP��and��community��mental��health��was��worth��the�� investment.�� ��Perhaps�� the��ability�� to��gauge�� success��would��have��been��easier��by��measuring��themselves�� against�� provincial�� standards;�� however,�� in�� the�� absence�� of�� standards�� in�� Ontario,��the��programs��were��each��able��to��adapt��and��mould��their��EIP��service��to��local��conditions,��while��meeting��best��practices.����Experts��in��the��field��have��always��advocated��for��ingenuity��and��creativity��in��Early��Intervention��Programs��development.
An early psychosis service can be developed in many different ways. Diversity and creativity are to be encouraged, and services should be developed in ways
that are congruent and synergistic with the local setting.��20����
Certainly,�� the��participants�� felt�� that��some��of��their��successes��were��the��creativity��and��partnerships��developed��to��provide��EIP��service��in��their��area.�� ��Each��service��model��proved��to��be��quite��dynamic,��with��services��changing��depending��on��local��client��needs��and��learning��from��experience.����The��program��flow��charts��are��a��snapshot��in��time��and��have��shifted��–��even��as��this��report��is��being��written.����
Given��the��contextual��nature��of��much��of��this��report,��it��is��important��to��view��the��results��in��the��broader��context��of��all��the��results��in��the��Matryoshka��Project,��and��even��the��SEEI.����Qualitative��data��in��this��report��is��able��to��provide��the��program��and��systems’��context��of��other��outcomes��data��and,��ultimately,��the��effects��of��the��new��investments��made��by��the��Ontario��Ministry��of��Health��and��Long-Term��Care.
”“
[ The Matryoshka Project ] Examining Early Intervention Program Development38
[APPENDICES]
APPENDIX A: References
(1)���� Malla��AK,��Norman��RM,��Joober��R.����(2005).����First-episode��psychosis,��early��intervention,��and��outcome:��what��have��we��learned?����Canadian��Journal��of��Psychiatry��-��Revue��Canadienne��de��Psychiatrie,��50(14),��881-891.
(2)���� Marshall��M,��Rathbone��J.����(2006).����Early��Intervention��for��Psychosis.��Cochrane��Database��of��Systematic��Reviews,��(4).
(3)���� Lhines,��Elizabeth.����(2001).����A��guide��to��Canadian��early��psychosis��initiatives.����Canadian��Mental��Health��Association.��
appendices
[ The Matryoshka Project ] Examining Early Intervention Program Development
[APPENDICES]
(4)���� Early��Pyschosis��Prevention��and��Intervention��Centre.����(2004).����About��EPPIC.����Retrieved��June��1,��2009,��from��www.eppic.org.au/contentpage.asp?pageCode=ABOUT
(5)���� Edwards��J,��McGorry��PD.����(2002).����Implementing��Early��Intervention��in��Psychosis:����A��guide��to��establishing��early��psychosis��services.��London:��Martin��Dunitz��Ltd.
(6)���� McGorry��P,��Edwards��J,��Mihalapoulos��C,��Harrigan��SM,��Jackson��HJ.����(1996).����EPPIC:��an��evolving��system��of��early��detection��and��optimal��management.����Schizophrenia��Bulletin,��22(2),��309.
(7)���� McGorry��P,��Edwards��J,��Mihalapoulos��C,��Harrigan��SM,��Jackson��HJ.����(1996).����EPPIC:��an��evolving��system��of��early��detection��and��optimal��management.����Schizophrenia��Bulletin,��22(2),��305-326.
(8)���� McGorry��P,��Edwards��J.����(1998).����The��feasibility��and��effectiveness��of��early��intervention��in��psychotic��disorders:��The��Australian��experience.����International��Clinical��Psychopharmacology,��13��(Supplement��1),��S47-S52.
(9)���� Edwards��J,��McGorry��PD.����(2002).����“The��EPPIC��Service��Model”.��Implementing��Early��Intervention��in��Psychosis:����A��guide��to��establishing��early��psychosis��services.����London,��Martin��Dunitz��Ltd,��67.
(10)����International��Early��Psychosis��Association��Writing��Group.����(2005).����International��clinical��practice��guidelines��for��early��psychosis.����British��Journal��of��Psychiatry,��187(48),��120-124.
(11)����Welch��M,��Welch��T.����(2007).����Early��Psychosis��in��Rural��Areas.����Australian��and��New��Zealand��Journal��of��Psychiatry,��41(6),��485-494.
(12)����Welch��M,��Garland��G.����(2000).����The��safe��way��to��early��intervention:��An��account��of��the��SAFE��(Southern��Area��First��Episode)��Project.����Australasian��Psychiatry,��8(3),��243-248.
(13)����Archie��S,��Rush��BR,��khtar-Danesh��N,��Norman��R,��Malla��A,��Roy��P��et��al.������(2007).����Substance��use��and��abuse��in��first-episode��psychosis:��prevalence��before��and��after��early��intervention.����Schizophrenia��Bulletin,��33(6),��1354-1363.
(14)����Malla��A,��Schmitz��N,��Norman��R,��Archie��S,��Windell��D,��Roy��P��et��al.����(2007).����A��multisite��Canadian��study��of��outcome��of��first-episode��psychosis��treated��in��publicly��funded��early��intervention��services.����Canadian��Journal��of��Psychiatry��-��Revue��Canadienne��de��Psychiatrie,��52(9),��563-571.
(15)����Sainsbury��Centre��for��Mental��Health.����(2003).����A��window��of��opportunity:��A��practical��guide��for��developing��early��intervention��for��psychosis��services.����London:��Sainsbury��
[ The Matryoshka Project ] Examining Early Intervention Program Development40
[APPENDICES]
Centre��for��Mental��Health.
(16)����Krstev��H,��Carbone��S,��Harrigan��SM,��Curry��C,��Elkins��K,��McGorry��PD.����(2004).����Early��intervention��in��first-episode��psychosis--the��impact��of��a��community��development��campaign.����Social��Psychiatry��&��Psychiatric��Epidemiology,��39(9),��711-719.
(17)����Joa��I,��Johannessen��JO,��Auestad��B,��Friis��S,��McGlashan��T,��Melle��I��et��al.����(2008).����The��key��to��reducing��duration��of��untreated��first��psychosis:��information��campaigns.����Schizophrenia��Bulletin,��34(3),��466-472.
(18)����Johannessen��JO,��Larsen��TK,��Joa��I,��Melle��I,��Friis��S,��Opjordsmoen��S��et��al.����(2005).����Pathways��to��care��for��first-episode��psychosis��in��an��early��detection��healthcare��sector.����British��Journal��of��Psychiatry,��187(48),��24-28.
(19)����Cassidy��CM,��Schmitz��N,��Norman��R,��Manchanda��R,��Malla��A.����(2008).����Long-term��effects��of��a��community��intervention��for��early��identification��of��first-episode��psychosis.����Acta��Psychiatrica��Scandinavica,��117(6),��440-448.
(20)����Edwards��J,��McGorry��P.����(2002).����Developing��an��early��psychosis��service��-��‘nuts��and��bolts’.����Implementing��Early��Intervention��in��Psychosis:��A��guide��to��establishing��early��psychosis��services.����London:��Martin��Dunitz��Ltd,��85-106.
[ The Matryoshka Project ] Examining Early Intervention Program Development 41
[APPENDICES][APPENDICES]
APPENDIX B: Pre-interview questionnaire
•�� Program��Characteristics :����Year��program��began,��Staff��members
•�� Client��demographics:����Average��age��(yrs),��%��Male
•�� Clients’��special��characteristics
•�� Intake��criteria
•�� Enrolment��time��limit��(yrs)
•�� Average��length��of��enrolment��in��program��for��clients��(yrs)
•�� Psychiatry:����Source��of��Funding��for��Psychiatrist,��Type��of��Funding��for��Psychiatry,��Amount��of��FTE��time��for��psychiatry,��Is��Psychiatry��position��filled?
•�� Formal��links��with��other��programs��that��help��provide��services
APPENDIX C: Interview guide
Program��Planning/Development
1.���� Compared��to��your��implementation��plans��and��proposals,��how��have��you��actually��spent������ the��money��over��the��three��phases��of��EIP��funding?�� a.��What��accounts��for��the��differences?
2.���� Some��of��the��core��features��of��EIP��include:��facilitating��access��and��early��identification,������ comprehensive��assessment,��case��management,��psychosocial��support,��family���� ���� education��and��support��…�� a.�� Did��your��program��incorporate��any��or��all��of��these��features?�� b.�� What��was��the��rationale��and��why��did��you��change��or��adapt��these��core��features?�� c.�� Can��you��describe,��or��walk��through,��how��you��might��service��an��18��year��old������ �� client��from��referral��to��discharge��from��the��program?������ d.�� What��does��your��program��look��like��in��accordance��to��this��prototype�� e.�� Is��there��a��clinical��model��for��your��program?�� f.�� If��so,��what��is��it,��or��what��does��it��look��like?�� g.�� How��did��you��pick��or��decide��on��your��model?
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[APPENDICES]
3.���� Did��you��have��to��make��accommodations��to��fit��the��needs��of��your��service��area?�� a.�� If��so,��how?�� b.���� Did��the��geography��or��population��of��your��service��area��influence��changes/���� �� accommodations��made?���� �� i.���� Provide��examples.
4.�� To��what��extent��has��your��intake��criteria��changed?
5.�� What��have��been��the��particular��challenges��in��implementing��your��program?
6.���� What��do��you��think��are��the��important��successes��of��your��program?
Key��Influences
7.���� Who��or��what��were��the��important��influences��that��directed��how��you��went��about������ developing��your��Early��Intervention��Program?
8.�� What��kind��of��direction��and��support��did��the��decision-makers��provide��with��regards��to��the���� �� implementation��and��design��of��the��program?�� a.�� Did��the��ministry��provided��any��standards��or��guidelines?
9.�� Are��you,��or��members��of��your��program,��part��of��the��provincial��EIP��network?�� a.�� Have��you��seen��the��standards��for��EIP��set��by��the��Ontario��provincial������ �� government?�� b.�� Have��you��seen��any��international��clinical��guidelines��for��EIP?�� c.�� Did��the��standards��(by��Ontario,��or��internationally)��have��any��influence��in��how������ �� you��designed��or��implemented��your��program?�� d.�� Did��they��have��to��be��modified��to��fit��your��geography��and��region?
10.�� Did��participation��in��the��provincial��EIP��network,��the��conference��help��you��in���� planning,��implementing��or��managing��your��program?
Other
12.�� What��advice��would��you��pass��onto��someone��else��starting��a��similar��program?��
13.�� Is��there��anyone��else��in��your��program��that��I��should,��or��need��to��talk��with?
[ The Matryoshka Project ] Examining Early Intervention Program Development 43
[APPENDICES]
APPENDIX D: Analysis codes���� 1�� (1)��/Key��Influences�� 2�� (1��1)��/Key��Influences/OWG�� 3�� (1��1��1)��/Key��Influences/OWG/Other��EIP��network�� 4�� (1��1��2)��/Key��Influences/OWG/Conferences�� 5�� (1��2)��/Key��Influences/Ministry�� 6�� (1��2��1)��/Key��Influences/Ministry/lack��of��direction�� 7�� (1��2��2)��/Key��Influences/Ministry/clear��direction�� 8�� (1��3)��/Key��Influences/Expert~Senior�� 9�� (1��3��1)��/Key��Influences/Expert~Senior/Clinician�� 10�� (1��3��2)��/Key��Influences/Expert~Senior/Program�� 11�� (1��3��3)��/Key��Influences/Expert~Senior/Leader�� 12�� (1��3��4)��/Key��Influences/Expert~Senior/Agency�� 13�� (1��4)��/Key��Influences/Front-Line��Observations�� 14�� (1��4��1)��/Key��Influences/Front-Line��Observations/lack��of��existing��service�� 15�� (1��5)��/Key��Influences/Research�� 16�� (1��6)��/Key��Influences/Funding�� 17�� (1��7)��/Key��Influences/Inter-Agency��Partnerships�� 18�� (1��8)��/Key��Influences/Stakeholders�� 19�� (1��8��1)��/Key��Influences/Stakeholders/grassroots��initiative�� 20�� (2)��/Regional��Adaptations�� 21�� (2��1)��/Regional��Adaptations/Population��Characteristics�� 22�� (2��2)��/Regional��Adaptations/Local��Agency�� 23�� (2��3)��/Regional��Adaptations/Stakeholders�� 24�� (2��4)��/Regional��Adaptations/Staffing��Needs�� 25�� (2��5)��/Regional��Adaptations/Geography�� 26�� (3)��/EIP��Model�� 27�� (3��1)��/EIP��Model/Characteristics�� 28�� (3��1��1)��/EIP��Model/Characteristics/Referral~Intake�� 29�� (3��1��2)��/EIP��Model/Characteristics/Case��Management��Model�� 30�� (3��1��3)��/EIP��Model/Characteristics/Discharge�� 31�� (3��2)��/EIP��Model/Challenges�� 32�� (3��3)��/EIP��Model/Successes�� 33�� (3��4)��/EIP��Model/Recommendations�� 34�� (3��5)��/EIP��Model/Psychiatry�� 35�� (4)��/Mental��Health��System�� 36�� (4��1)��/Mental��Health��System/Reform�� 37�� (4��2)��/Mental��Health��System/Effecting��Change
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[APPENDICES]
APPENDIX E: Acronyms/Abbreviations
ACT Assertive��Community��TreatmentCM Case��ManagerEIP Early��Intervention��PsychosisEPPIC Early��Psychosis��Prevention��and��Intervention��CentreFTE Full��Time��EquivalentGP General��PractitionersInpt InpatientLYNX Peterborough��EIP��programOT Occupational��TherapistRN Registered��NurseSEEI Systems��Enhancement��Evaluation��InitiativeSSO Schizophrenia��Society��of��OntarioSTEPS Toronto��EIP��ProgramSW Social��WorkerYR York��Region
��
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[APPENDICES]
During��the��time��of��this��project,��Dr.��Cheng��was��a��fellow��in��the��Research��in��Addictions��and��Mental��Health��Policy��&��Services��Program��(a��Canadian��Institutes��of��Health��Research��funded��Strategic��Training��Program).�� ��Dr.��Cheng��would�� like�� to��acknowledge�� the��Canadian��Mental��Health��Association-Thunder��Bay��Branch��and��St.��Joseph’s��Care��Group��-��Thunder��Bay��for��their��support.����The��Matryoshka��Project��is��funded��by��the��the��Ontario��Mental��Health��Foundation.����
acknowledgments
[ The Matryoshka Project ] Examining Early Intervention Program Development 47
[APPENDICES]
Principal InvestigatorCarolyn��S.��Dewa,��MPH,��PhD
Co-InvestigatorsJames��Dunn,��PhDJanet��Durbin,��PhDPaula��Goering,��RN,��PhDNora��Jacobson,��PhDElizabeth��Lin,��PhDJoan��Nandlal,��PhDRoss��Norman,��PhDGeorge��Tolomiczenko,��PhD,��MBA,��MPHRobert��Zipursky,��MD
The Matryoshka Coordinating CentreKathlyn��Babaran-HenfryNancy��Chau,��MStatWayne��deRuiter,��MScAlexander��KnibbDesmond��Loong��Kenneth��LeeAngela��YipNatalia��Zaslavska,��MA,��MPH
Research FellowsDiego��Bassani,��MPH,��PhDChiachen��Cheng,��MD,��MPH
CAMH RegionalAlan��Cudmore��(Hamilton)Mark��Erdelyan��(Windsor)Kim��Karioja��(Thunder��Bay)Brian��Mitchell��(Peterborough)Suzanne��Witt-Foley��(Parry��Sound)
Funded by:The��Ontario��Mental��Health��Foundation
Program PartnersCMHA��HamiltonMuskoka��Parry��Sound��Community��Mental��Health��ServicesThe��Lynx��Early��Intervention��Psychosis��Program,��PeterboroughCMHA��PeterboroughCMHA��Thunder��BayCMHA��TorontoCMHA��YorkCMHA��WindsorSt.��Michael’s��Hospital,��Toronto
SEEI PartnersMinistry��of��Health��and��Long-Term��CareCentre��for��Addiction��and��Mental��Health��Canadian��Mental��Health��Association��–��OntarioOntario��Federation��of��Community��Mental��Health��and��Addiction��Programs
SITE INTERVIEWERS and Program SupportsMichele��Caveen,��MScChiachen��Cheng,��MD,��MPH