Health System-Level Evaluation of Tele-Mental Health Services Among Children and Adolescents in Ontario, Canada.

OBJECTIVE: To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. METHOD: Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. RESULTS: In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P < 0.001)]. In the second cohort (n = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up. CONCLUSIONS: Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

The Transition of Academic Mental Health Clinics to Telehealth During the COVID-19 Pandemic.

OBJECTIVE: A consortium of 8 academic child and adolescent psychiatry programs in the United States and Canada examined their pivot from in-person, clinic-based services to home-based telehealth during the COVID-19 pandemic. The aims were to document the transition across diverse sites and to present recommendations for future telehealth service planning. METHOD: Consortium sites completed a Qualtrics survey assessing site characteristics, telehealth practices, service use, and barriers to and facilitators of telehealth service delivery prior to (pre) and during the early stages of (post) the COVID-19 pandemic. The design is descriptive. RESULTS: All sites pivoted from in-person services to home-based telehealth within 2 weeks. Some sites experienced delays in conducting new intakes, and most experienced delays establishing tele-group therapy. No-show rates and use of telephony versus videoconferencing varied by site. Changes in telehealth practices (eg, documentation requirements, safety protocols) and perceived barriers to telehealth service delivery (eg, regulatory limitations, inability to bill) occurred pre-/post-COVID-19. CONCLUSION: A rapid pivot from in-person services to home-based telehealth occurred at 8 diverse academic programs in the context of a global health crisis. To promote ongoing use of home-based telehealth during future crises and usual care, academic programs should continue documenting the successes and barriers to telehealth practice to promote equitable and sustainable telehealth service delivery in the future.

Home-Based Telemental Health: A Proposed Privacy and Safety Protocol and Tool.

Objectives: To describe the development of a protocol and practical tool for the safe delivery of telemental health (TMH) services to the home. The COVID-19 pandemic forced providers to rapidly transition their outpatient practices to home-based TMH (HB-TMH) without existing protocols or tools to guide them. This experience underscored the need for a standardized privacy and safety tool as HB-TMH is expected to continue as a resource during future crises as well as to become a component of the routine mental health care landscape. Methods: The authors represent a subset of the Child and Adolescent Psychiatry Telemental Health Consortium. They met weekly through videoconferencing to review published safety standards of care, existing TMH guidelines for clinic-based and home-based services, and their own institutional protocols. They agreed on three domains foundational to the delivery of HB-TMH: environmental safety, clinical safety, and disposition planning. Through multiple iterations, they agreed upon a final Privacy and Safety Protocol for HB-TMH. The protocol was then operationalized into the Privacy and Safety Assessment Tool (PSA Tool) based on two keystone medical safety constructs: the World Health Organization (WHO) Surgical Safety Checklist/Time-Out and the Checklist Manifesto.Results: The PSA Tool comprised four modules: (1) Screening for Safety for HB-TMH; (2) Assessment for Safety During the HB-TMH Initial Visit; (3) End of the Initial Visit and Disposition Planning; and (4) the TMH Time-Out and Reassessment during subsequent visits. A sample workflow guides implementation. Conclusions: The Privacy and Safety Protocol and PSA Tool aim to prepare providers for the private and safe delivery of HB-TMH. Its modular format can be adapted to each site's resources. Going forward, the PSA Tool should help to facilitate the integration of HB-TMH into the routine mental health care landscape.

Case Report: Defining Applicant Attributes to Be Prioritized in the Selection of Child and Adolescent Psychiatry Subspecialty Residents at the University of Toronto.

Background/Objectives: The child and adolescent psychiatry (CAP) subspecialty training program at the University of Toronto was among the first fully accredited CAP programs in Canada. As one of Canada's largest CAP subspecialty programs, we attract many excellent applicants annually. While objectivity and transparency in the selection of candidates have been valued, it was unclear which applicant attributes should be prioritized. This quality improvement project was undertaken to identify the key applicant attributes that should be prioritized for admission to the program. Materials/Methods: An initial list of attributes was compiled by project team members and feedback solicited. Through iterative design, this list was categorized into "end products," "branding attributes" and "generic attributes." The "end products" were removed as these represented outputs of training rather than attributes on which applicant selection should be based. Subsequent steps involved only the "branding" and "generic" attributes. A consensus-building exercise led to the creation of two short-lists of five attributes within each category. Finally, a paired-comparison forced choice methodology was used to determine the ranking of these attributes in order of importance when assessing applicants. Results: The final lists of "generic" and "branding" attributes developed through a consensus-building exercise are presented in rank order based on the paired-comparison methodology. The overall response rate for the forced choice electronic survey was 49% of faculty and learners. Conclusions/Discussion: This project used an iterative process of consensus building & pairwise comparison to prioritize key attributes for assessing trainee selection to the program. Going forward, these attributes will be incorporated into the file review and interview portions of our admissions process. In addition to emphasizing these priority attributes in admissions, there are implications for other aspects of the program including curriculum and faculty development, as well as guiding the overall mission and vision for the Division. A similar process could be undertaken by other training programs seeking to identify priority attributes for admission to their programs.

Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity. METHODS: Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April-June 2020. Data were analyzed using constant comparative analysis. RESULTS: Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions. CONCLUSION: These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty's role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.

From Pandemic to Progression: An Educational Framework for the Implementation of Virtual Mental Healthcare for Children and Youth as a Response to COVID-19.

COVID-19 restrictions have necessitated child/youth mental health providers to shift towards virtually delivering services to patients' homes rather than hospitals and community mental health clinics. There is scant guidance available for clinicians on how to address unique considerations for the virtual mental healthcare of children and youth as clinicians rapidly shift their practices away from in-person care in the context of the COVID-19 pandemic. Therefore, we bridge this gap by discussing a six-pillar framework developed at Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada, for delivering direct to patient virtual mental healthcare to children, youth and their families. We also offer a discussion of the advantages, disadvantages, and future implications of such services.

Lost in Transition: Examining Transitions in Psychotherapy Training.

OBJECTIVE: Disruptions are inevitable during psychiatry residency training and can affect resident learning and patient care. This exploratory study examined the nature and impact of transitions in psychotherapy training. METHODS: PGY2-5 residents (45/150; 30% response rate) and psychotherapy supervisors (46/247; 18.6% response rate) were surveyed about transitional events during residency training in psychotherapy. RESULTS: Supervisors and residents ranked the frequency of occurrence of transitional events and their impact very similarly, as well as the "feed forward" items when transitioning to a new supervisor. Residents feeling confused or overwhelmed with the balancing of learning differing models with differing levels of comfort or knowledge was ranked as the issue that occurred most frequently by both supervisors and residents. CONCLUSIONS: This study highlights issues that arise at transitions during psychotherapy training in psychiatry residency. Strategies for managing these periods are discussed, with a focus on resident learning and improved continuity of patient care.