LHSC Based Services
The new adult eating disorder program has made significant strides in the last year, according to Physician Leader, Dr. Robbie Campbell. We have moved into our new location at 111 Waterloo Street. There is a consistent assessment plan for all referred patients and those that agree to continue in the program and have a diagnosis of eating disorder are assigned a case manager to support them moving through the program. Seriously low weight patients are streamed into a more intensive tract which includes more frequent medical monitoring pending inpatient treatment in another facility if weight gains cannot be made in an out-patient setting. Patients are offered an outpatient psychoeducational group which runs 2 hours per week for 4 weeks. Family and friends are encouraged to attend a daylong workshop to learn about eating disorders which is offered approximately every 2 months.
Once patient psychoeducation is completed, patients are offered an 8 session Motivation Enhancement Group to prepare them to explore their readiness for recovery oriented treatment. On completion, if the patient expresses the desire to seek more intensive treatment we have them enter our Readiness Program which is once a week for 4-1/2 hours. This includes an orientation to the Dialectical Behavior Therapy philosophy, a supported lunch, goal setting, and basic distress management skills.
In May 2013 we opened our day treatment service which is 3 days per week 10am to 6:15pm. This program is Dialectical Behavior Therapy infused and offers a supported lunch and dinner each day, along with multiple groups that focus on goal-setting, mindfulness, emotion regulation, interpersonal effectiveness skills, and exploring other aspects of their eating disorder. By the end of September 2013 the Day Treatment Service will be expanded by another day which will allow for more in vivo experience.
Also in September a transition/step down program will be beginning 2 days per week for 4-6 hours per day. This program is offered to patients who have completed our Day Treatment Service or have successfully completed and are returning from another treatment program. Longer term follow-up will be offered in a 90 minute weekly group in the late afternoon.
In conjunction with WOTCH, we will have a fully staffed apartment opening at the end of September, 2013. This will provide 24/7 emotional and nutritional support for up to 4 patients while they are attending our Day Treatment Service. Our longer term goal is to have a setting that will allow for the whole program to be housed under one roof, thus offering much improved continuity of care. We are also hopeful that we can provide a small inpatient program at LHSC devoted to patients with eating disorders that are low weight or have more complex medical needs. This would allow us to provide the full spectrum of eating disorder care for patients in Southwestern Ontario.
Emergency assessments are conducted in the emergency room by a team consisting of psychiatrists, residents, social worker and students, with nurse case managers. We work in collaboration with community partners including mental health agencies and family physicians in an effort to best serve our patients. Service Leader, Dr. Dan Lefcoe states, “There has been further evolution of CEPS services in the ER in the past year. CEPS nurse case managers are performing screens ahead of ER physicians to advise on disposition. Enhanced protocols have evolved for management of patients brought by police, with a new waiting area. New staff is expected this year, with the arrival of Dr. Georges Loba Gutierrez.”
Consultation-Liaison Psychiatry is a specialized service that deals with the overlap of physical health and mental health care issues. The primary mandate is to provide timely psychiatric consultation to adult patients admitted to medical/surgical units at the University Hospital and Victoria Hospital sites. Accomplishments in the last year include: successfully working with Critical Care Colleagues to implement structured delirium screening in the ICU, regular formal teaching to ICU fellows and juniors on delirium, Mental Health Act education to non-psychiatric colleagues, enhanced educational opportunities for off-service residents and elective medical students through rotation development.
The past year has reflected many changes within the Consultation Liaison team. Dr. Rebecca King was welcomed as our much needed third Consultation Liaison psychiatrist, and has launched a very exciting outpatient practice with a focus in neuropsychiatric diseases and traumatic brain injury. We also welcomed a new psychologist, Dr. Ian Nicholson, and a new acting nurse case manager, Judy Wilson.
According to Service Leader, Dr. Jennifer Barr, goals for the upcoming year include: development of a Psychosomatic Medicine Continuing Professional Development module, working further with our Critical Care Colleagues at both an academic and clinical level to enhance the early recognition and management of ICU delirium including implementation of delirium management protocols, ongoing service focus on education of psychiatric residents, off-service residents, medical students, and our medical colleagues. Another important goal is to work with existing outpatient mental health resources to facilitate pathways to care for bedded medical and surgical patients.
FEMAP provides ambulatory psychiatric services for youth aged 16-25 experiencing the recent onset of mood and/or anxiety symptoms with or without secondary substance use; FEMAP conducts clinical research on the same population. There are exclusion criteria for youth with prolonged histories of psychiatric problems, primary substance abuse/dependence, and significant cognitive deficits.
FEMAP clinicians conducted 2815 patient visits and FEMAP psychiatrists conducted 138 new intakes from July 2012 to June 2013. On November 18, 2012, FEMAP had reached clinical capacity and had to temporarily suspend taking on new patients. Due to funds raised from generous supporters, FEMAP was able to reopen to new patients in May 2013. A part-time psychologist and family therapist will be added to the team shortly, also thanks to these donations.
Research activities at FEMAP include:
1. Functional brain imaging into the pathophysiology of mood disorders, marijuana use, self-injury and other aspects involving the neurocircuitry of reward-processing.
2. Systems evaluation research for the model of FEMAP as a clinically, and cost-effective paradigm.
3. Clinical evaluations of individual aspects of treatment at FEMAP such as the group therapy program that evolved from the trauma program group at Victoria Hospital.
4. Collaborative research related to the use of smart technology to facilitate clinical needs.
Physician Leader, Dr. Beth Osuch states that the goals for the next few years are to secure funding for the essential roles of: full-time reception, full-time intake and assessment, two days per week of the psychologist, two days per week for the addictions therapist, and one day per week for the family therapist. These personnel are crucial to the functioning of FEMAP to meet patients’ needs. More publications on completed research, and more grant applications, will be submitted related to research in brain imaging and service evaluation.
In keeping with the overarching principle of right patient, right service, right time, the General Adult, the largest ambulatory service in the Division, GAAMHS provides a variety of outpatient based services for patients and their families in the London-Middlesex County area. Ambulatory Service will continue its primary focus on access to treatment and flow of patients from the three primary areas of referral, inpatients, community, and emergency department. Clinically, the service will try to prevent barriers to treatment by maintaining broad-based inclusion criteria. In addition to individual assessments and pharmacological treatment, group psychotherapy streams exist for CBT and DBT. GAAMHS also provides specified groups in a Track to Wellness format: Stabilization skills, Activation skills, and Managing Emotions skills. This helps to further identify subsequent treatment streams patients may move on to, as well as assist in transitioning patients from hospital. ECT assessment and treatment are also provided. Expanding our services further, we are now involved in shared care at The Centre of Hope. We have also added an ongoing post-residency fellowship to our Program. The latter three initiatives mentioned having been all spearheaded by Physician Leader, Dr. Richard Owen.
Crisis and short-term inpatient treatment for adults is the focus of this service of 74 beds located at the Victoria Hospital B-Tower Level 7. The inpatient service provides care to adults who present with mental health difficulties that embrace the entire spectrum of mental illness such as mood disorders, suicidal behaviour, anxiety disorders, schizophrenia and other psychotic disorders, mental disorders of aging, concurrent substance abuse problems, and acute symptoms of distress related to family or personal crisis. It is also the site where much of our department’s educational and training activities take place.
According to Service Leader, Dr. Volker Hocke, during the year 2012/2013 the process of implementing more therapeutic options was very successful. After having started skills training groups with support by OT and a motivational group for addictions with support from nursing management and refining the group processes several more new open groups were conceptualized and implemented. Information groups about community resources with representatives from the agencies take place on a monthly basis, groups about emotion regulation, depression management, and relaxation are also very well regarded by patients and treatment teams.
The start of a medical directive mandating a metabolic screening for each admitted patient staying longer than 3 days has been a first major step in improving the physical health of our patient population. This project was initiated and championed by Dr. Kamini Vasudev.
We are expecting the HUGO (Healthcare Undergoing Optimization – electronic health record system) project to improve our documentation system to a new level.
The inpatient unit is chronically challenged with high patient volumes and high admission rates. A major focus of the program is on improving patient flow, access and facilitating discharge. In collaboration with WOTCH we now have transitional case managers (TCMs) available. This new project has been a great success and is highly appreciated by patients, treatment teams and families. In turn, these same TCMs are part of a larger project funded by the Council of Academic Hospitals of Ontario (CAHO), Adopting Research to Improve Care (ARTIC) Program, entitled “Implementing the Transitional Discharge Model”, which also incorporates peer-support workers. Further steps in improving the discharge process are on its way.
Program Highlights of PEPP, Physician Leader, Dr. Lena Palaniyappan.
The program held a successful retreat in the fall of 2012. Working groups on screening and assessment, group interventions and case management were formed based on feedback. Each group developed recommendations for quality improvement which have since been adapted.
PEPP has formed a partnership with Wheable Secondary School that has resulted in a number of clients successfully entering a variety of apprenticeship programs.
We hired a patient with a background in web design to lead our website development committee in an effort to make the PEPP website more client and family friendly. A number of family members and another client also participated in this committee.
Our new psychometrist/teacher initiated the Duke of Edinburgh Award at PEPP. This award allows individuals to build leadership skills while learning new activities, maintaining an active lifestyle and volunteering. She has started a PEPP book club.
Five members of the team attended the International Early Psychosis conference in San Francisco. Three staff members, two clients and a family member attended the Ontario Early Psychosis Conference in Toronto. Several presentations were delivered in various secondary and post-secondary class rooms in addition to other community venues.
A successful partnership was formed with WOTCH. An experienced WOTCH case manager has been assigned to work with some of our post-PEPP clients.
PEPP held its Creative Minds Art Show in October of 2012.
At PEPP we continue to have a strong belief in patient and family centered care. PEPP managed to maintain a no-wait list policy despite a record number of new admissions. We currently have approximately 20 client volunteers who are actively involved in various aspects of the program. We have a number of PEPP parents who also help out. Recently a retired teacher has started to provide tutoring in math for a number of students.
Our regional outreach program continues to function well. PEPP provides a variety of supports including monthly education sessions on best practices for early psychosis intervention.
Research in PEPP within the past year has primarily focused on continuing analysis of the results of our five year follow-up of clients as well as planning for our ten year follow-up study. Ethics approval for the latter has just been received. In addition, PEPP researchers continue to be involved in research on the stigma of mental illness and collaborative translational research concerning standards for early intervention programs for psychotic disorders. During the past year 10 publications have come out of PEPP and one manuscript is currently under review.
For patients who have experienced acts of violence, emotional, physical and/or sexual abuse, severe neglect, catastrophic events such as motor vehicle accidents, natural disasters, or war-related trauma, a phase-oriented approach utilizing individual and group therapies, along with tailored pharmacotherapy is offered. Dr. Kamini Vasudev continues to provide medical/psychiatric support to the service.
A second area of service is our assessment and treatment unit affiliated with clients referred from the Workplace Safety and Insurance Board (WSIB). Strong links exist between the service and our neuroimaging research program in trauma.
The mandate of the UCS is to provide a timely response to patients in need of urgent ambulatory mental health assessment whether referred by family physicians, the Emergency Departments at LHSC, and SJHC Urgent Care Clinic. Psychiatrists, Dr. Dan Lefcoe and Dr. Charlie Chamberlaine work together with nurse case managers and trainees, seeing all new referrals within 72 hours of notification.
According to Service Leader, Dr. Lefcoe, goals over the next year are “to continue to meet high demand and acuity, whilst maintaining service integration with intra-program services and external care providers."