Mod oderator: Bonita Varga, Mental Health Commission of Canada Pan - - PowerPoint PPT Presentation

Panel Discussion:

Emerging Topics in the Implementation of e-Mental Health Services in Canada

Mod

• derator:

Bonita Varga, Mental Health Commission of Canada Pan aneli lists:

• Dr. Danielle Impey, Mental Health Commission of Canada;

Elisabeth Smitko, Health Quality Ontario;

• Dr. Allison Bichel, Alberta Health Services

Presented on April 12th, 2019 CADTH Symposium, Edmonton

e-Mental health (e-MH)

“...mental health services and information delivered or enhanced through the Internet and related technologies.”

Christensen H, Griffiths KM, Evans K. (2002). e-Mental Health in Australia: Implications of the Internet and Related Technologies for Policy. ISC Discussion Paper No 3.

Examples of e-MH services

Why e-Mental health?

• Access to mental health services

continues to be a significant barrier to people getting the help they need

• E-mental health services are an

effective and complimentary option

• Currently underused in Canada

• The MHCC has been hosting meetings to raise awareness about

e-MH, share promising practices and dialogue about barriers and

• pportunities.
• The 8th annual e-MH Conference: New Generations, New

Services: Shifting Mental Health to the Digital Age

• The event focused on implementation strategies for tailoring e-

MH services. Several key themes emerged as a representation of the e-MH landscape in Canada.

Convening Roundtable Discussions

e-Mental Health in Canada – A Briefing Document

Briefing recommendations

Person-centered care Scalability Quality assurance Research Knowledge translation & exchange Integration with health services Integration with wider health and tech framework Sustainability Privacy and security

Source: E-Mental Health in Canada: Transforming the Mental Health System Using Technology (MHCC, 2014)

Mental Health, Technology and You – A Companion Product

Mental Health, Technology and You – A Companion Product

Advancing research

• The 8th annual e-MH Conference: New Generations,

New Services: Shifting Mental Health to the Digital Age

• Several key themes emerged as a representation of

where Canada is at and where we need to go in the implementation of e-MH

Convening Roundtable Discussions

 Empowering clients and families with information; Our true North;  Valuing co-creation with end users and engaging people with lived experience; Fostering active partnerships  Paying attention to context  Pursuing “radical transparency” within mental health care: establishing value and trust

Key Emerging Themes

 Empowering clients and families with information and valuing data — especially client-generated data  Recognizing that better outcomes require better data  Deciding how we should think about early warning systems, big data and the promise of A.I.  Keeping it simple without oversimplifying

Key Emerging Themes

 Implementing quality e-MH: the challenge of delivering compassionate mental health care through technology  E-MH as a platform for change and care integration: providing access where it is absent  Charting a new course collectively to provide quality access to care for those who need it most

Key Emerging Themes

Purpose:

To provide a framework tool to support informed decision-making when evaluating, using, or recommending e-mental health apps.

Mental Health Apps: How to Make an Informed Choice

Purpose: To accelerate the awareness, uptake and

implementation of e-MH among practitioners

e-MH Implementation Toolkit

e-MH Implementation Toolkit

RE-AIM Framework R E A I M

Bridges the gap between research and practice by specifying the key steps involved in successfully applying programs and policies in real-world settings.

Innovation to Implementation Guide

Objectives:

 Challenge prevailing myths about what clients think about eMH  Identify practitioner role and impact on client engagement  Understand stages of client engagement and how to support clients in using eMH

Module IV: Engaging Clients in eMH

Module 4: Engaging Clients in eMH

Key take away: Co-design is key

Contact : dimpey@mentalhealthcommission.ca bvarga@mentalhealthcommission.ca Visit our eMH webpage on the MHCC website: https://www.mentalhealthcommission.ca/English/ what-we-do/e-mental-health

Thank you!

Internet-Delivered Cognitive Behavioural Therapy for Major Depressive Disorder and Anxiety Disorders: A Health Technology Assessment

ELISABETH SMITKO, LIAISON OFFICER, HEALTH QUALITY ONTARIO APRIL 15, 2019

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Disclosures

• HQO funded by Ontario Ministry of Health and Long-

Term Care.

• CADTH Funded by federal, provincial, and territorial

ministries of health.

• Application fees for three CADTH programs:

– CADTH Common Drug Review (CDR) – CADTH pan-Canadian Oncology Drug Review (pCODR) – CADTH Scientific Advice

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Authorship

Presentation authors: Elisabeth Smitko Presentation based on:

–Internet-delivered cognitive behavioural therapy for major depressive disorder and anxiety disorders: patient’s experiences and perspectives, implementation, and ethical issues. Ottawa: CADTH; 2019

• Feb. (CADTH Optimal use report; vol. 8, no. 2b). Available from: http://www.cadth.ca/icbt

–Health Quality Ontario. Internet-delivered cognitive behavioural therapy for major depression and anxiety disorders: Health Quality Ontario recommendation [Internet]. Toronto (ON): Queen’s Printer for Ontario; 2019 February. 4 pp. Available from: http://www.hqontario.ca/evidencetoimprove- care/recommendations-and-reports/OHTAC/internet-delivered-CBT

CADTH adheres to the authorship and contribution guidelines established by the International Committee of Medical Journal Editors (ICMJE).

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Acknowledgments

CADTH Team Lesley Dunfield, Project Owner Teo Quay, Manager, Program Development Bert Dolcine, Program Development Officer Laura Weeks, Manager, Scientific Affairs Kaitryn Campbell, Research Information Specialist David Kaunelis, Research Information Specialist Methods Clinical Review Calvin Young, Clinical Research Officer Alison Sinclair, Scientific Advisor Economics Review Bernice Tsoi, Manager, Health Economics Cody Black, Health Economics Research Officer Patients’ Perspective and Experiences Review Tamara Rader, Patient Engagement Officer David Nicolas (external contractor) Elijah Herington, Qualitative Research Officer Implementation Review Dinsie Williams, Clinical Research Officer Calvin Young, Clinical Research Officer Eftyhia Helis, Knowledge Mobilization Officer Ethics Review Maxwell Smith (external contractor) HQO Team Nancy Sikich, HTA Director Merissa Mohamed, Senior Business Analyst Melissa Walter, Medical Librarian Andrée Mitchell, Manager, Operations Claude Soulodre, Project Manager Clinical Review Sarah McDowell, Manager, Clinical Reviews Kristen McMartin, Clinical Epidemiologist Amanda Manoharan, Clinical Epidemiologist Economics Review Olga Gajic-Veljanoski, Health Economist Xuanqian (Shawn) Xie, Health Economist Vivian Ng, Manager, Economic Evaluations Patients’ Perspective and Experiences Review David Wells, Patient, Caregiver and Public Engagement Arshia Ali, Patient, Caregiver and Public Engagement

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Objective

• Discuss the role of evidence and how evidence based

reports and resources, including health technology assessment, can inform the implementation of e-Mental Health initiatives.

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The Role of Health Technology Assessment (HTA)

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Health Quality Ontario & CADTH HTA’s

• Health Technology Assessment

– Systematically examines short-and long-term consequences of the use of a health care treatments to inform policy decision- making. – Systematic review of the clinical evidence; a cost effectiveness analysis; patient preferences and values review, implementation review, a review of the legal, social, and ethical issues. – Provides guidance by including recommendations from experts

• n the use of a technology and funding.

– Allows for evidence based decision making. – Provides context and insights on feasibility.

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HTA Implementation Support

• Environmental Scan

– Provides jurisdictional insights, identify barriers and facilitators.

• Pan Canadian Lens

– CADTH Liaison Officers connected within jurisdictions and can provide further insights and connections across the country. – Pan-Canadian HTA collaborative.

• Tools and Resources

– Develop resources to support implementation of a technology.

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Liaison Officers across the Country

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Overview - iCBT Health Technology Assessment

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Background and Context

• A wide variety of iCBT programs are currently available

in Canada. However, the effectiveness of iCBT is not well-established.

• iCBT not currently funded in a systematic way in

Canada.

• Concrete frameworks for implementation and integration
• f iCBT into clinical practice have not yet been

established.

• iCBT may offer ways for some people to overcome

barriers to accessing timely and effective therapy.

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Findings

• Clinical Effectiveness and Safety

– Compared with waiting list, guided iCBT improves symptoms of mild-to-moderate major depression and select anxiety disorders.

• Cost-Effectiveness and Budget Impact Analyses

– Guided iCBT represents the most economical option for the short-term treatment of adults with mild to moderate major depression or anxiety disorders in Ontario.

• Patient Preferences and Values

– People with anxiety or depression with whom we spoke viewed iCBT as an effective treatment option.

• Ethical Analysis

– Considerations included equity and access, trust and the therapeutic alliance, privacy and confidentiality.

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Findings cont’d

• Implementation

– Barriers

• Financial costs for establishing required infrastructure.
• Data security, privacy and confidentiality risks and concerns.
• Lack of awareness or training.
• Gaps in technical capability.
• Legal restrictions to offering cross province service.

– Opportunities

• Engagement of multiple stakeholders in the development of

strategies and standards for integrating iCBT into clinical care pathways may facilitate implementation and increase access to iCBT in Canada.

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ICBT Recommendations

• HQO OHTAC Recommendation

– Health Quality Ontario, under the guidance of the Ontario Health Technology Advisory Committee, recommends publicly funding guided internet-delivered cognitive behavioural therapy for mild to moderate major depression and anxiety disorders.

• CADTH HTERP Recommendation

– HTERP recommends that guided Internet-delivered cognitive behavioural therapy be offered to adults with mild to moderate major depressive disorder and/or anxiety disorders.

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How to Leverage the iCBT HTA to Support Implementation

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Implementation Support

• Leverage HTA findings and resources to establish a

strategy to integrate iCBT into your clinical care pathway.

• CADTH Environmental Scan.
• CADTH In Brief.
• HQO Anxiety Disorders Quality Standard - Draft –

Evidence informed implementation vehicle to reduce variation in practice.

• Connect with Liaison Officer in your jurisdiction for

further support from CADTH.

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Liaison Officers across the Country

Elisabeth.Smitko@hqontario.ca

Planning for Scale: eMental Health

eMental Health

Planning for Scale

April 2019

David Johnson & Allison Bichel

Planning for Scale: eMental Health

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Agenda

• Research Design &

Business Case

• Technology

Assessment & Procurement

• Youth engagement
• Indigenous co-

design

• Implementation
• Benefits Realization
• Implications

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Planning for Scale: eMental Health

CREATE AN INTEGRATED VIRTUAL SYSTEM OF MENTAL HEALTH CARE

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Planning for Scale: eMental Health

The Challenge

POPULATION

Internet Delivered

• Screening &

Assessment

• Peer-to-Peer & Family

Support

• Cognitive Behavioral

Therapy

• Brief intervention for

substance misuse

INTERVENTION

Youth and Young Adults

• Substance Misuse
• Anxiety
• Depression

OUTCOMES

70%

• f mental

illness has their onset during childhood or adolescence 5 out of 6 of children and youth will not receive needed treatment

1 in 5

children & youth will experience some form of mental health problem

20,000 Albertans

under the age of 25 presented to the ED with a Mental Health or Substance Problem

56% increase in mental health ED visits 47% increase in Hospitalizations

2007 – 2015

63% of youth point to stigma as the

most likely reason to not seek help

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Planning for Scale: eMental Health

Leverage internationally recognized research Innovative Clinical Trial Research Scale & Spread

• Procure evidence-

based tools, applications & resources

• Multiple baseline, nested

prospective cohort trial design

• Theoretical Domains

Framework; Longitudinal Case Study

• Sex and Gender Based

Analysis

• Rural and Remote
• Indigenous
• Address institutional

barriers to integrate e-mental health into service delivery

• Demonstrate

benefits to the health system – access, appropriate service use, cost

• Enhance and sustain

quality and

• utcomes

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Planning for Scale: eMental Health

Scope and Approach

POPULATION

Internet Delivered

• Screening &

Assessment

• Peer-to-Peer & Family

Support

• Cognitive Behavioral

Therapy

• Brief intervention for

substance misuse

• Penetrance: adoption
• f e-mental health as a

proportion of health service use

• Effectiveness: Quality
• f life, Anxiety,

substance mis-use, depression scores

INTERVENTION

Youth and Young Adults

• Substance Misuse
• Anxiety
• Depression

OUTCOMES

Planning for Scale: eMental Health

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• Contract Procurement and Supply

Management: research vs request for proposals

• Health Technology Assessment:
• AHS: process for determining best of breed Apps
• CADTH
• Option Analysis:

1. Newfoundland & MHCC model: outcome measurement feasibility 2. Made in Alberta: Host Evidence Based Apps etc on a website 3. Australia InnoWell Partnership

Intervention Selection

Planning for Scale: eMental Health

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• Relevance
• Pathway Integration
• Evidence of Effectiveness
• User Experience
• Safety/Security
• Technology Considerations
• Cost
• Implementation and Feasibility

Selection Criteria

Planning for Scale: eMental Health

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• Research partnership to support the first Canadian trial
• f Innowell Platform
• Platform: promotes mental wellness, and act as a first

point of contact for mental health support including screening, assessment and integrated, tailored e- interventions

• Community activation model: co-design provincial

model, tailor integration into the local context and AMH pathways

• www.innowell.org

Intervention

Planning for Scale: eMental Health

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Intervention

• Referrals to eMH platform made

through PCNs, AHS AMH Centres and contracted services, and Schools

• eMH platform: conduct assessment

and use algorithm to assign most appropriate management App.

• Integrate eMH with AHS/community services: referral
• f patients with poor response to eMH apps to face-to-

face mental health providers

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Planning for Scale: eMental Health

INNO THRIVE INNO CARE

App: ReCharge Website: E-Couch Depression Texting Service: Text4Mood App: Sleep Better App: My Fitness Pal App: MyStudyLife

*Co-Design Specific Apps incorporated into the provincial platform (year 1)

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Planning for Scale: eMental Health

Research Design

Pre-intervention phase in Intervention Communities, and entire study period for Control Communities Post-intervention phase in Intervention Communities Data retrieval, cleaning, study analysis

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Planning for Scale: eMental Health

Intervention & Control Communities

Planning for Scale: eMental Health

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Research Outcomes

Planning for Scale: eMental Health

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Patient and Community Engagement Research (PaCER)

• Cohort of youth, young adults, family members with lived

experience

• Certificate program through the University of Calgary, Cumming

School of Medicine

• Recruit youth and Young Adults from participating communities
• Training: 1 Year
• Co-design the intervention/platform, social media &

communications campaign

• Conduct peer to peer research
• Provincial & local youth councils

Youth Engagement

Planning for Scale: eMental Health

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• Co-design of Research Questions
• Ownership, Control, Access, Possession

(OCAP principles)

• Consultation with Indigenous Communities
• Indigenous Populations with Study

Communities

• Indigenous Populations On-Reserve

Indigenous Research Design

Planning for Scale: eMental Health

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Identified two outcomes to ‘define success’:

• Number of youth on the

platform

• Improvement in Mental

Health ‘Functioning’

Benefits Realization

Clinical Improvement Plan Study Inflow & Outflow Sample Size on Clinic Roster Community Y/YA Population in Need CLINICAL IMPROVEMENT PLAN (i.e. Outcome/ performance statistics to be monitored in near-real time using the Innowell platform)

Estimated Number of Youth with MH Issues who have signed up to use (i.e. enrolled to use) the e- Synergy Platform at the end of the month (J - see Enrollment Plan) (Note 18) Estimated Average Mental Health Score if Client had not been enrolled on Platform (0- 10; Lower- the-better) (S) (Note 19) Total Client- Score (i.e. J x S), assuming Clients had not been enrolled on the Platform (T = J x S) Estimated Average Mental Health Score for Clients

• n the

Platform (U) (NOTE: Assume Initial Score Upon Enrollment was 10) (Note 20) Total Client- Score (i.e. J x S), for Clients enrolled on the Platform (V = J x U) Estimated Improvemen t in Mental Health Score (U = 1 - T / S) (Note 21)

8.00 10.00 80.00 9.50 76.00 5.00% 15.76 10.00 157.60 9.31 146.73 6.90% 23.29 10.00 232.87 9.12 212.47 8.76% 30.59 10.00 305.89 8.94 273.50 10.59%

Scale & Spread Payback Model Gain

Planning for Scale: eMental Health

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What policy direction can inform investment direction and decision making? What investment approaches best support integration of eMH?

Collaborate: Wicked Questions

Feasibility, strategy and infrastructure for a national approach to Health Technology Assessment How to support national learning and collaboration to ideally benefit from leading, promising and emerging practice? What are the issues &

• pportunities related to

procurement and supply chain innovation?

Planning for Scale: eMental Health

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What are approaches/key considerations related to decision making models, analysis?

Collaborate: Wicked Questions

How to engage Indigenous peoples in co-design? How do we share learnings and implications? How to ensure people with lived experience are engaged in design and decision making? How do we define benefits realized from eMH? What is the health economic case to be made?

Planning for Scale: eMental Health

Questions & Discussion

Allison Bichel, PhD

Senior Provincial Director Addiction & Mental Health Maternal Newborn Child and Youth Strategic Clinical Networks TM Alberta Health Services

allison.bichel@ahs.ca

• Dr. David Johnson

Senior Medical Director Maternal Newborn Child and Youth Strategic Clinical Network TM Alberta Health Services

david.johnson@ahs.ca

Panel Discussion:

Emerging Topics in the Implementation of e-Mental Health Services in Canada

Mod

• derator:

Bonita Varga, Mental Health Commission of Canada Pan aneli lists:

• Dr. Danielle Impey, Mental Health Commission of Canada;

Elisabeth Smitko, Health Quality Ontario;

• Dr. Allison Bichel, Alberta Health Services

Presented on April 12th, 2019 CADTH Symposium, Edmonton