Innovations in Telemedicine: Addiction Services of Thames Valley s TeleWithdrawal and Crisis Support Program

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1 Innovations in Telemedicine: Addiction Services of Thames Valley s TeleWithdrawal and Crisis Support Program Background In 2010, as part of the provincial government s Open Ontario plan, 191 full time nursing positions were created to provide clinical telemedicine across the province. As of 2012, four of these nurses - Michelle Faoro, Kelly Mitchell, Barbra Kasule, and Judy Wakem have found a home at Addiction Services of Thames Valley (ADSTV). In ADSTV s innovative new TeleWithdrawal and Crisis Support Program, this highly qualified nursing team provides community-based addictions and mental health services to clients across London-Middlesex, Elgin, and Oxford counties using telemedicine. In doing so, they are blazing the trail for community-based addictions and mental health care, using technology to enhance service access for residents in remote and rural locations, and building capacity for specialized medical care delivery in community settings. Program Details Telemedicine involves the use of the telephone and videoconferencing (in this instance, via the Ontario Telemedicine Network, OTN) to deliver services remotely. Using this approach, ADSTV s TeleWithdrawal and Crisis Support Program aims to provide comprehensive addiction and mental health screening and assessment, offer early point-ofaccess care, and identify appropriate community resources and referrals for residents of Thames Valley who are experiencing withdrawal or crisis. The program has two streams: (1) Community withdrawal management. ADSTV s nursing team provides care tailored to address the client s specific withdrawal needs, meeting them where they are in their personal journey, and aiming to minimize disruption in the client s life. (2) Crisis support. The nurses also offer support to individuals experiencing crises relating to either addiction or mental health concerns. They provide supportive interventions to minimize risks and promote well-being. The program serves individuals 16 years and over and living in London-Middlesex, Elgin, and Oxford counties. So far, the nurses have supported clients up to approximately 65 years old, with a wide range of substance use and mental health issues.

2 ADSTV accepts referrals for their TeleWithdrawal and Crisis Support Program through selfreferrals or referrals from any service provider in Thames Valley who feel that a client would benefit from crisis support or community withdrawal management services. To date, referral sources have included primary care physicians, family health teams, hospitals, crisis teams, and community agencies. Since July 2013, the team of nurses at ADSTV has been collaborating with a local physician. This general practitioner acts as a key resource for the team, brainstorming with them surrounding specific cases. The hope is that this physician eventually will provide comprehensive assessments to the program s clients. The nurses also meet twice a month with a local consulting psychiatrist to get advice and guidance on challenging cases. The psychiatrist will also meet with the client if needed. Program history and development Development of the TeleWithdrawal and Crisis Support Program started in May 2012 and the nursing team has been delivering services since November The team currently consists of three registered nurses who provide telemedical care Michelle Faoro, Kelly Mitchell, and Barbra Kasule, plus a program coordinator, Judy Wakem, also a registered nurse. The team works under the vision and guidance of ADSTV s 2 2 Left to Right: ADSTV Executive Director Linda Sibley, nurse Michelle Faoro, nurse Kelly Mitchell, program coordinator Judy Wakem, and nurse Barbra Kasule. management team, including a clinical manager and Executive Director Linda Sibley. The team at ADSTV built their new program from the ground up, guided by several key priorities of the Ministry of Health and Long Term Care and the South West Local Health Integration Network (SWLHIN). These priorities include: improved access to both primary care and specialty care in the community, decreased unnecessary emergency department visits and hospitalizations, and improved access to care for rural and remote communities. Extensive work went into defining the program elements and establishing practice protocols. To ground their program in evidence and build on existing expertise in the field, Michelle Faoro, the first nurse hired, began by reviewing the literature on community withdrawal and crisis support for addictions and mental health. She

3 examined best practice guidelines from both the College of Nurses of Ontario (CNO) and the Registered Nurses Association of Ontario (RNAO). The program was also informed by the literature on nursing protocols for withdrawal management from Australia and New South Wales, as well as guidelines for physicians and nurses developed by the Centre for Addiction and Mental Health (CAMH). The team also consulted with agencies running or developing similar programs across the province, including Halton s Alcohol, Drug and Gambling Assessment, Prevention and Treatment Services (ADAPT), Centre of Hope Withdrawal Management Services in London, Fourcast (Peterborough and other areas), Pinewood Centre in Oshawa, and Choices for Change Alcohol, Drug and Gambling Counselling Centre in Stratford. In developing the program, ADSTV s team worked closely with an advisory group of community partners from the mental health and addictions sector and the SWLHIN to receive feedback, input, and support. They continue to meet with this group to receive advice on an ongoing basis. To develop the program, the team: created a policy and protocol manual; developed a program flow map for the two 3 3 ADSTV s TeleWithdrawal and Crisis Support team in their private telemedicine office. Seated: Judy Wakem. Standing Left to Right: Barbra Kasule, Kelly Mitchell, and Michelle Faoro. program streams, to help map the pathways that different clients might take; developed program forms; defined protocols for dealing with clients who use specific drugs or alcohol, drawing on guidelines published by CAMH and reviewed by a physician to ensure that they are in line with current best practice standards; adapted assessment tools for ease of use over telephone and OTN; and created an orientation package for new staff. Connections and partnerships are one key to success It was also important to the team that they establish direct connections with psychiatrists, to enhance their capacity to provide specialized

4 medical care in the community. In this regard, their program is very unique. We have a Memorandum of Understanding with Regional Mental Health Care London to provide psychiatric services to us, which is a local innovation that we hope becomes a template for other agencies to collaborate with their hospital partners, says ADSTV s Executive Director Linda Sibley. Historically, community agencies have not shared access to psychiatrists, but there just aren t enough to go around, she notes. So, as a LHIN-wide community, we pooled resources, we have a shared budget, and ADSTV s portion of that enables us to consult with a psychiatrist twice a month. Plus, because we want to groom the next generation of psychiatrists to want to work in community-based agencies, the consulting psychiatrist brings residents during consultations, so there is a teaching capability and a nextgeneration potential built into the process. The nursing team also works closely with crisis teams, to ensure that they are coordinating efforts rather than duplicating work. They are in the process of defining protocols with crisis teams throughout Thames Valley, including, for instance, guidelines for sharing clients crisis plans. This will help ADSTV and crisis teams provide consistent, coordinated care to clients who tend to rely on both services. Measuring progress Another important feature of the program is the team s commitment to ongoing program evaluation. As one measure of their progress, they document whether they are meeting targets identified by their own agency and by the SWLHIN. They also distribute satisfaction surveys to clients, ADSTV staff, and community stakeholders, to determine whether there are opportunities to further improve the program. So far, the feedback from these surveys has been very positive. People are really excited about the program because it is such a unique service that hasn t been available in the community until now. Clients report that they are happy to have somebody to call who they know they can trust to provide them with the help they need when they are going through a difficult time, explains nurse Michelle Faoro. The ability to provide support to clients during withdrawal resonates powerfully with the team. The need to have a supportive voice is a main reason people access the program, Ms. Faoro notes. They re experiencing withdrawal, they may be having symptoms they ve never felt before, so it s very helpful for them to have somebody to talk to, to say to them, This is normal, this is something that goes along with withdrawal, and we re here to listen to you. It s so important to be able to offer them that support 4 4

5 and provide them with some strategies that they can use to help them get through their crisis or manage their withdrawal. Challenges, lessons learned, and opportunities Developing and running such an innovative program has not been without its challenges. The team has had to work through the kinds of barriers that might be expected when delivering telemedicine services, such as audio-visual issues. For instance, if OTN equipment off-site is located in a large room, there can be an echo that disrupts the nurses ability to properly assess and communicate with the client. As with any new program that takes a nontraditional approach to treatment, it has been challenging to engage service providers to refer clients. The team is still working on building an understanding in the community about what the program can offer other service providers clients by delivering presentations and nurturing collaborations. The program also has been somewhat slower getting off the ground than the team had initially anticipated, but, as Linda Sibley explains, that time commitment is critical for ensuring program quality. It takes a long time for protocols to go live. To write the protocols, to have them vetted by a physician, to experience them, to revise them as we go that takes a lot of work, a lot of time, a lot of careful preparation. As soon as you go live with a program, you re dealing with real live people, so it was incredibly important for us to be very methodical in developing our protocols. Every step has been researched, planned, and reviewed carefully. We are moving slowly, because we have to do it right. Despite the challenges they ve faced along the way, the team is making great strides in establishing its place in the local system of care. Team members are excited to be building their client base and meeting a distinct community need through innovative use of technology. With their novel program, they are working to redefine standards of care for withdrawal management across Ontario, explains Linda Sibley. There s a real need for community withdrawal management, she notes. Because of our nurses professional capabilities, they ve been able to bring medical withdrawal management to a community-based protocol. Traditionally, community-based withdrawal management is not medical. Because of this and other initiatives, the possibility has been opened for creating a new level of services in the Provincial Standards of Withdrawal Management that exists between the current levels of withdrawal management - hospital-based services on the one hand, and community-based withdrawal management that 5 5

6 does not involve a medical professional on the other hand, she says. They re also building capacity beyond their agency. For example, they are helping service providers in other sectors, such as women s shelters, learn how to use OTN to connect clients to ADSTV s withdrawal management services. In doing so, they are able to reach individuals who might otherwise experience unmet needs during withdrawal or crisis. Overall, by making community-based addiction and mental health care more accessible in Thames Valley, ADSTV s TeleWithdrawal and Crisis Support Program is setting an important example of how technology can be used to improve client care. This Promising Practice represents an innovative model of care that is contributing to the evolution of addiction and mental health service delivery in Ontario. To learn more about ADSTV s TeleWithdrawal and Crisis Support Program, contact the Program Coordinator Judy Wakem at jwakem@adstv.on.ca. Author: Andrea Flynn 6