In this section :
Team lead: Brad Pollman
Patient/family representative: Nora Lilligreen
Senior officer/director: Cheryl Dowden, Executive Director
ANKORS, a local harm reduction agency serving Nelson, British Columbia, partnered with technology firm SMRT1 to increase accessibility to harm reduction supplies, support and resources. The SMRT1 Pod provides interactive touchscreen vending technologies that increase point of care access for substance use and harm reduction services. By adding a 24/7 access “SMRT1 POD (Personalized On-Demand)” at ANKORS, the organization has increased access to the service’s existing content, resources and related services by providing on-demand, self-service locations in the community. Real-time measurement and reporting can be generated through anonymous data collection accessed by both clients and providers, which increases population reach and program effectiveness. Interaction points are at the large format touchscreen located at ANKORS and through personal devices such as cell phones, tablets or computers, which can provide continuity of care simultaneously.
Team lead: Jennifer Kuntz, Project Facilitator
Patient/family representative: Kerri Conner
Senior officers/directors: Avril Deegan; Andrea Perri
The Child and Adolescent Addiction, Mental Health and Psychiatry Program (CAAMHPP) aims to improve the transition from psychiatric emergency department/urgent care to community care for children and youth who have experienced trauma. The service pathway created through this project connected Calgary families with mental health and psychiatry outreach support and helped in developing a crisis plan. The service also coordinated a case conference for the child, youth and family’s informal and formal supports (including primary care teams, education, government agencies and other health professionals). An important component of the pathway was regular reviews of the intervention/support plan as well as follow-up with the client, family and services providers.
Team lead: Bronagh Morgan, Executive Director
Patient/family representative: Denise Ludrigan
Senior officer/director: Bronagh Morgan
In this project, the Bereaved Families of Ontario: Southwest Region served children, youth and young adults who had experienced the death of a close family member by offering services and programs with safe spaces and peer support. The team designed programs to target children aged 5 to 9 and youth aged 10 to 17, and worked on scoping additional support to better address the needs of First Nations and LGBTQ+ communities facing societal barriers. The team also evaluated programs and services to determine opportunities for improvement and ensure programs are engaging, inclusive and effective in supporting their targeted groups.
Team lead: Sonia Seguin, Executive Director, Body Brave
Patient/family representative: Becca Bishop
Senior officer/director: Shaleen Jones, Executive Director, Eating Disorders Nova Scotia
Eating Disorders University was a social learning e-platform designed by and for organizations across Canada that support individuals impacted by eating disorders. Through this platform, those impacted by eating disorders could access educational modules, peer support groups, workshops and treatment delivered by community organizations and treatment providers from across Canada. The individual looking for support was truly in the driver’s seat, able to create their own support network. By removing geographic and other barriers to care, the e-platform addressed existing inequalities that impact those in rural and under-served areas. From live classrooms to discussion forums, individuals had options to connect with healthcare providers and trained peer supporters. The e-platform served as a community space, knowledge hub and service delivery tool – increasing access to mental health care.
Connect: @bodybravecanada, @nsedrecovery
Team lead: Jackie Aufricht, Program Manager
Patient/family representative: Farah Anastas
Senior officer/director: Allison Fielding
A joint initiative between the Calgary Foothills Primary Care Network and Alberta Health Services, the Case Collaborative Model has been tested as a method for better coordinating care for individuals challenged by mental health and addictions issues. The Case Collaboratives support patients in successfully navigating mental health and addiction services by immediately connecting them to the most appropriate services in their community based on their needs. The model brings together providers from multiple organizations to problem-solve complex patient situations and improve continuity of care.
Team lead: Karen Leung
Patient/family representative: Shane Hooshmand
Senior officer/director: Ashley Hogue
BounceBack: Reclaim Your Life is a skill-building program designed to help adults and youth 15+ manage low mood, depression and anxiety, stress or worry. In this project the team created improvements, using quality improvement methodologies, to improve wait-times to service, from date of screening through to the date of the participant’s first coaching session. The team also focused on reducing the number of participants that become unreachable before an assessment, to impact the wait-time.
Team lead: Cyndy Forsyth
Patient/family representative: Mary Boersma
Senior officer/director: Krista Sibbilin
Youth wellness hubs are designed to provide youth with the right services, at the right time, in the right place. Youth wellness hubs provide centralized service at a single site in a geographic area, thus reducing barriers in accessing care. In Wellington County and the city of Guelph, the Integrated Youth Services Network planned to create seven sites: four in Guelph and three in rural Wellington County. The project’s goal was to make it easy for youth to access youth related services, and for them to be involved in all stages of development. Reflecting the collaborative model on which youth wellness hubs are designed, the project was led by the Rotary Club of Guelph, with partners including the Canadian Mental Health Association Waterloo Wellington, the Guelph YMCA/YWCA, the University of Guelph, Shelldale Family Gateway, Big Brothers Big Sisters of Centre Wellington, Minto Mental Health, East Wellington Community Services and the Guelph Community Foundation.
Team lead: Christine Tomori
Patient/family representative: Joanne Finnegan
Senior officer/director: Doctor Joanna Cheek
The CBT Skills Group program is an eight-week, publicly-funded, evidence-based intervention for adults with mild to moderate symptoms of anxiety or depression. Designed by psychiatrists and taught by physicians, this course integrates neuroscience, mindfulness and cognitive behavioural therapy skills and concepts. In groups of 15 patients, this trans-diagnostic program teaches patients self-management skills and practical tools to recognize, understand and manage patterns of feeling, thinking and behaving. They learn to be conscious of their choices as they respond to life stressors, and explore options for living a fuller, richer life, more aligned with what they value most. To adapt to these unprecedented times and to support the mental wellness of the communities it serves, the program has successfully moved online with hundreds of patients being served at any given time through virtual groups.
Learn more: CBT Skills Groups
Team lead: Captain Anna Harpe
Patient/family representative: Colonel Heather Morrison
Senior officer/director: Major Health Robson
This study investigated the impact of social support networks, and system wide education and awareness initiatives, on CAF members initiating and maintaining recovery from addiction. It examined perceptions and attitudes toward mental health and addictions aftercare services and the related effects on individuals’ recovery capital, engagement and overall well-being. Participants used aftercare services in two settings, CFB Edmonton (the experimental group) and CFB Petawawa (the control group), and completed a questionnaire to compare pre- and post-project attitudes and perceptions about addiction and the Aftercare program.
Team lead: Dakota Drouillard, Licensed Practical Nurse
Patient/family representative: April Bullchild
Senior officer/director: Shelby Young
Through environmental scanning and distribution of surveys, Indigo Harm Reduction compared the population of Albertans who identify personal challenges with mental health and addictions to utilization of services, as reported by Statistics Canada. The aim of the project was to unite programs in such a way that referral of services is easier and clients know the criteria for utilizing services – to create a way in which individuals can find appropriate services that match their needs almost fully.
Learn more: Indigo Harm Reduction
Team lead: Bila Sabra, PHAST Charge Nurse
Patient/family representative: Lynn Gallagher
Senior officer/director: Cheryl Gustafson
Joseph Brant Hospital has led the development of a multi-agency Mental Health and Addictions (MH&A) model in Burlington called PHAST (Prioritizing Health through Acute Stabilization and Transition). PHAST is an innovative, system-wide integrative ’hub and spoke’ service delivery model. Its goal is to provide the most appropriate urgent MH&A care through timely access, assessment and intervention while preventing unnecessary emergency room visits and hospital admissions. The stabilizing interventions will help to reduce recidivism to the emergency department while the warm transfers, i.e. those transfers occurring from service to service, are designed to improve an individual’s initiation into community treatment, particularly for more complex situations.
Team lead: Rossana Astracio-Morice
Patient/family representative: Rebecca McDermott
Senior officer/director: Analyn Einarson
KIDTHINK offers clinical and outreach services that aim to improve mental health services, with a focus on early intervention and prevention for children aged 12 and under. KIDTHINK leverages technology to remove geographical barriers to accessing timely services, by offering services through a rapid screening process without requiring a diagnosis. The program offers additional supports to improve childrens’ access to treatment, including financial aid, home visits to meet families or communities, and partnerships with public schools to facilitate referrals from school psychologists and guidance counsellors. Using InterRAI’s Child and Youth Mental Health Screener (ChYMH-S) and Child and Youth Mental Health Community Based Assessment Form (ChYMH), clients are directed to the appropriate treatment stream within a corresponding timeframe according to the urgency of their presenting concerns.
Learn more: KIDTHINK
Team lead: Ryan Andres, High Risk Therapist
Patient/family representative: Sarah Cannon
Senior officer/director: Bill Helmeczi, Director of Strategic Initiatives, Standards and Practices
Pathstone Mental Health’s High Risk program provides mental health assessment and therapy for children and youth who have been identified as being at an elevated risk to harm themselves or others. Often these children and youth are identified and referred to Pathstone by community partners including police, schools, hospitals or child welfare. They are provided with intensive individualized services designed to reduce the imminent risk they pose to themselves or others. Once risk has been reduced, the individual is referred to a more appropriate and less intense service or program. T
he team participated in the Quest Continuous Quality Improvement Program with a goal of improving care pathways into the High Risk program. Using Six Sigma QI methodology, the team reviewed and worked to improve the Violence Threat Risk Assessment (VTRA) care pathway. They also aimed to establish ongoing quality improvement initiatives that improve all care pathways into the High Risk program (for example, hospital admission referral to High Risk program).
Learn more: Pathstone Mental Health’s High Risk Services
Team lead: Tacie McNeil, Clinical Nurse Educator
Patient/family representative: Jesse Dobson
Senior officer/director: Lois Ward, Senior Operating Officer
With the aim of developing strong evidence-informed medical treatment to support individuals with reducing or stopping stimulant use at the Peter Lougheed Hospital, the team implemented Contingency Management (CM) to support individuals experiencing a stimulant use disorder. Stimulants can have profound effects on mental and physical health, thereby contributing to increased visits to emergency departments and admissions to hospital. Stimulant use also makes it difficult for some patients to remain in hospital for the full course of their medical treatment, which contributes to multiple presentations for the same and worsening health problems.
The CM group created opportunities for people who use stimulants to make positive changes including reducing or stopping their use of the substance, participating in addiction treatment and attending to their health and social needs.
While CM has been evaluated in the outpatient setting, it had not been implemented and formally studied in Alberta in an inpatient setting and in the context of wraparound supports from an addiction medicine consult service. Using patient-centered objectives, rather than simply abstinence-focused outcomes, enabled additional important and meaningful outcomes to be evaluated.
Team lead: Alex Gosselin, MSW, RSW, RYT, Clinical Manager
Patient/family representatives: Lucie Langford; Samantha Ledamun
Senior officer/director: Nzinga Walker, Director of Program Operations
This evidence-based program run at Stella’s Place identifies and teaches young adults aged 16 to 29 skills in distress tolerance, emotion regulation and recovery. The 14-week program has a group component one day a week for two hours, along with one session of individual counselling per week. In each cycle of the program, 12 participants are registered. Clinicians and peer supporters facilitate the DBT Skills groups. DBT has been shown to be effective for individuals living with a borderline personality disorder diagnosis, and has also been proven effective in treating self-harming behaviors, suicidal behaviors, post-traumatic stress and depression. Stella’s Place has been offering the program in person since 2017 and online since May 2020. A co-design focus group with young adults and a survey with participants who received in-person and virtual services through Stella's Place help with better understanding how each mode of service delivery makes an impact, and what can be improved.
Learn more: Stella’s Place
Team lead: Roula Markoulakis, Research and Evaluation Lead
Patient/family representative: Julie Cowan
Senior officer/director: Sugy Kodeeswaran
Sunnybrook’s Family Navigation Project (FNP) is a non-profit, free-of-charge service for youth aged 13 to 26 with Mental Health and Addictions (MHA) concerns. It is designed to guide patients through care plans and reduce barriers to timely access and transition of services. Services are designed to be responsive and accessible. Upon initial intake through a screening assessment, cases are assigned to Navigators. These are graduate-level clinicians in mental health and/or addictions care, social work, psychology, child development, Parent Advocates with Lived Experience (PAL) and psychiatrists, who work one-on-one by phone or email with patients and/or their families to assist in untangling the web of the MHA system and design care plans around the youth’s medical, social and family goals. The model is designed to reduce barriers to access by creating meaningful relationships with families to engage them throughout the care process, and in some cases, working with families where youth are not motivated to access care or are unwilling to engage in care.
Team lead: Andrew Reyes, Project Coordinator
Patient/family representative: Community Engagement Advisory Network (CEAN)
Senior officer/director: Monica McAlduf
Kelty’s Key is a free online psychotherapy platform that enables therapists to incorporate Therapist Assisted Internet-Cognitive Behavioural Therapy (TAI-CBT) into their practice. TAI-CBT is as effective as face-to-face therapy and gives clients added flexibility. Kelty’s Key can help therapists treat more clients and reach individuals who may otherwise be unable to access treatment. The program is based on email therapy and online courses. The modules are evidence-informed and developed by clinical CBT experts at Vancouver Coastal Health and Providence Health Care. Courses offered include: Anxiety, Chronic Pain, Complicated Grief, Depression, Insomnia, Panic and Substance Use.
Learn more: Kelty’s Key
Team lead: Monty Ghosh
Patient/family representative: Rebecca Morris-Miller
Senior officer/director: Kim Ritchie
The Virtual Overdose Response Line (now National Overdose Response Service) provides peer-supported supervision for individuals who use substances alone. Clients call a phone number to have a peer supervise them virtually. If the client becomes unresponsive, the peer calls 911 to send an ambulance to the client. Physical supervised consumption sites reduce mortality rates to a maximum of 500 meters around them, but the majority of overdoses (80-95%) occur outside of this therapeutic radius, in suburban communities and rural communities, where individuals often use substances alone. The goal is to support clients who use substances alone, and refuse to utilize services like supervised consumption sites due to fear of being seen or stigma, to use with remote supervision. The overall goal is to reduce mortality outcomes (especially rates) among these individuals as well as reduce morbidity outcomes. In addition, the service provides clients with access to community-based resources that treat addiction and mental health concerns.
Team lead: Claire Doherty
Patient/family representative: Irene Toy, Providence Health Care’s Care Experience Advisory Committee; Lyn Brooks, Patient Voices Network;
Mario Gregorio, Providence Health Care’s Care Experience Advisory Committee (
note: one additional patient partner did not wish to be identified)
Senior officer/director: Margot Wilson
In the Vancouver City Centre area, there is limited access to adult psychiatry for non-acute mental health concerns, but significant need and long wait times. Many people with moderate mental health conditions cannot access a psychiatrist at all, resulting in family physicians providing all of their mental health care without advice from a specialist. This project aimed to improve access to psychiatric care for Vancouver residents aged 19 to 64. The team developed a shared care model of managing non-acute cases virtually on an outpatient basis in conjunction with primary care providers, so psychiatrists could provide patients with efficient short-term care without assuming ongoing responsibility for care or utilizing office space. Access improvements were assessed on an ongoing basis by comparing the median wait time from referral to first appointment for the virtual psychiatry prototype, versus existing psychiatry models of care in British Columbia. The team also evaluated patient-reported health outcomes. VPC2 was an initiative of Providence Health Care, supported with funding from the Shared Care Committee.
Learn more: Patient Voices Network
Team lead: Nicole Schween
Patient/family representative: Sarah Precious
Senior officer/director: Flora Ennis
Woodview in the Square is a one-stop Youth Hub offering multiple services under one roof to youth aged 12 to 25. We aim to offer the right service, at the right time, in the right place. This is made possible through our partnerships and integrated services with multiple sectors including Education, Mental Health and Addictions, Youth Justice, Indigenous Services, Public Health, Recreation, Social Services, the City and Municipality, and non-profit organizations. Woodview goes above and beyond to engage individuals and families by providing high quality mental health and autism services and supports that inspire hope and strengthen lives.
Learn more: Woodview in the Square
Team lead: David O’Brien
Patient/family representative: Keon Reid-Charles
Senior officer/director: David O’Brien
Yorktown Family Services operates the West Toronto Youth Hub. The Hub is an integrated youth services site for youth 12 to 29, with an interdisciplinary team that provides rapid and seamless access to mental health, social service and primary health support. The team facilitates the care pathway navigation to increase access to services and enable wraparound support. The outcomes for youth are strengthened mental health functioning, increased social participation and support in acquiring the social determinants of health so they can live healthy lives.
Learn more: Yorktown Family Services