Presentation by Dr. Vicky Stergiopoulos on the CATCH

Coordinating Access to Care for
Frequent Users of Emergency Departments
March 27, 2014
Vicky Stergiopoulos, MSc, MD, MHSc, FRCPC
Scientist, Centre for Research on Inner City Health, St. Michael’s Hospital
Director, Division of Adult Psychiatry and Health Systems
Associate Professor, University of Toronto
Coordinating Access to Care for
Frequent ED Users
• People with mental illness and addictions are over-represented among frequent
ED users
• TC-LHIN Frequent Users Advisory Committee, 2012
o Review patterns of ED utilization
o Identify approaches to decrease ED use and improve health outcomes
• CATCH-ED was implemented in 2012, sponsored by the TC-LHIN and the MHA
Acute Care Alliance
o The program is an adaptation of a Critical Time Intervention Model, developed to support
transitions of care for vulnerable populations
The Target Population
• People with mental health and addictions problems who make frequent use of
o 2% (about 400 individuals) made 21+ visits in 2010/11
o Accounted for 20% of all ED visits by people visiting at least once for a MHA-related visit
• Patient profile:
o More likely to be male, middle-aged
o Have depression and anxiety with or without substance use problems
o Visit multiple EDs, non-emergent by CTAS score, not frequently admitted
o Have variable primary care connections
• Target population: people with 5+ visits in a single ED
CATCH-ED Partners and Roles
Referral Sources
Primary Care / Mental Health
and Addictions Counseling
Peer Outreach /
Project Management
and Coordination
6 Toronto Hospitals Emergency
3 Community Mental Health Agencies
4 Community Health Centres
1 Community Support Service Agency
Toronto Mental Health and Addictions Acute Care Alliance
St. Michael’s Hospital
St. Michael’s
When the Patient is the System….
Social integration
Hospital based care
Legal support
Front line, specialized and
intensive services
Minister’s Advisory Group, Respect, Recovery, Resilience: Recommendations for Ontario’s Mental Health and Addictions Strategy
Facilitating Transitions Building Continuity of Care
• Grounded on inter-agency and inter-sectoral collaboration to address system
• Frequent users are given immediate access to primary care, mental health and
addictions counseling and peer support
• Program hypotheses:
o Frequent users are not connected to primary care and mental health supports and services
o Continuity of care will improve acute care utilization and health outcomes
Transitional Case Management
• TCMs work with participants for approximately 16 weeks focusing on addressing
immediate needs and connecting to long term supports
• Small case loads (1 TCM to 12-15 participants)
• Intervention has 3 phases:
o Engagement and Goal setting (Months 1-2)
 Frequent contact, crisis intervention, needs assessment, working alliance
o Bridging and Connecting to Community Resources (Months 2-3)
 Referrals to community, practical needs assistance
o Transitioning and Transfer of Care (Months 3-4)
 Less frequent contact, warm hand-off to long term supports, open door policy
Program Evaluation
Implementation Evaluation
Qualitative evaluation assessing barriers and facilitators to program implementation and
service delivery
42 stakeholder interviews and one focus group
Mixed Methods Outcome Evaluation
Randomized Controlled Trial measuring health service utilization, mental health and
substance use, quality of life and service satisfaction 12 months after enrollment
167 participants randomized to CATCH-ED or usual care
Qualitative Evaluation to assess program’s key ingredients, areas for improvement and
service satisfaction
13 key informant interviews, 20 participant interviews, focus group of service providers
Implementation Evaluation
42 in-depth stakeholder interviews and one focus group conducted to explore
factors that helped or hindered program implementation:
26 key informants
6 service providers (primary care physicians and case managers)
10 consumer participants
What has worked well with the program?
What are the areas for improvement?
Implementation Evaluation:
What has worked well?
Inter-sectoral, multi-agency partnerships and partner commitment
4 TCMs and peer support drawn from existing resources
4 CHC based counselors funded by the TC-LHIN
Opportunity to bridge the gap between hospitals and community agencies
Individualized service provision and low access barriers
Implementation Evaluation:
Challenges to Implementation
Multi-agency structure
Lack of clinical leadership
Inadequate training of frontline providers
Lack of central supervision / variable quality of supervision
Not integrated psychiatric care and counseling/therapy
Referrals from Emergency Departments
Identifying frequent users (lists, automated flagging systems)
Referring frequent users (low program profile, “complex” referral process)
Hand offs to long-term supports
Lack of high quality community-based MHA services and lengthy waitlists
Implementation Evaluation:
Changes made to the Program
Multi-agency structure
Referrals from Emergency Departments
Additional TCM training on the CTI model
Program manager to provide some central supervision and program cohesion
Process measures to assess continuity of care and facilitate ongoing quality improvement
Simplified referral process (single page, invitation script)
Automated flagging system instituted at most hospitals
“Champions” at each hospital, both at the frontline and administrative levels
Routine presence of research team at hospital rounds
Hand off to long term supports
Communication to the TC-LHIN
Implementation Evaluation:
Lessons Learned
Ensure a standardized frequent user identification system is in place
Need for dedicated ED staff to promote front-line buy in and facilitate the
connection of frequent users to ongoing care
Simple referral process / low access barriers
A centralized program structure and process measures to provide consistency/
quality in service delivery
Case managers and counselors with the right skill mix and training
Outcome Evaluation:
Quantitative Component
• 167 participants randomized to CATCH-ED or usual care and followed for 12
• The research questions are:
Is a brief, case-management intervention effective in reducing ED visits for frequent ED users 12
months after program enrolment?
Is the intervention effective in improving health outcomes for frequent ED users 12 months after
program enrolment?
• An economic evaluation will also be pursued to assess programs costs and cost
• Data collection continues until October 2014
o Excellent follow up rates
Qualitative Evaluation
• 13 key informant interviews, focus group of service providers, 20 consumer
participant interviews
• The research questions are:
o What are community stakeholder, frontline provider and consumer perspectives on the
o What are the program’s key ingredients and theory of change?
• Data collection completed
• Data analysis underway
Qualitative Evaluation:
Emerging Findings
The users
• Frequent users have variable service connections, from “unconnected” to “highly
• Many frequent ED users have primary care support, but the majority are not
connected to high quality multidisciplinary community mental health and
addictions services
• The emotional and social support provided by the Transitional Case Managers is
viewed by participants as a key element of the program
Qualitative Evaluation:
Emerging Findings
The service providers
• Transitional case managers are called on to play a complex role with little training
or supervision
• Transitional case managers and participants have different views on service
provider roles and service expectations highlighting the need for service
standards and workforce development
• The service period of 12-16 weeks may be too short to establish a strong working
alliance and provide warm hand off to long term services
Recommendations to Planners
• Program monitoring and implementation evaluation have an important role to
play in program improvement
• Integrated care models that draw from multiple agencies require appropriate
organizational structures
• Service standards, training and technical assistance to frontline providers are
needed to ensure high quality services
• Frequent ED users with mental health and addictions problems have complex
health needs requiring specialized multidisciplinary community based teams
Toronto Mental Health and Addictions Acute Care Alliance
Centre for Research on Inner City Health, St. Michael’s Hospital
Research Team
• Co-Investigators:
Zuhair Alsharafi, Tim Guimond, Stephen Hwang, Meldon Kahan, Paul Kurdyak, Molyn
Leszcz, Pat O’Campo, Howard Ovens, Julie Spence, Peter Voore, Don Wasylenki
• Research Staff:
Deborah Wise Harris, Daniel Pauly and Caroline Patterson
Your questions?
Contact: Vicky Stergiopoulos
Tel: 416-864-6060 x 6415
[email protected]

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