What is the system challenge?

Youth with complex mental health and/or addiction needs often do not receive the information or assistance needed to successfully transition from youth to adult services.

As a result, TAY and their family members may not find the right mental health and addiction services in the adult system. Or they simply may be unable to bridge the gap to adult care and discontinue services altogether. For the Sudbury-Manitoulin Service Collaborative, this presented an important challenge – how could their system ensure consistent, appropriate, and successful transitions between youth and adult mental health and addiction services?

Evidence:

Research tells us that services can be organized and delivered in specific ways to best support transitions from youth to adult services. Specifically, continuity of care is highlighted as a key factor in effective transitions. Continuity of care helps bridge the gap between youth and adult services. It ensures that youth and families have the information and guidance they need to effectively move into the adult sector.

According to recommendations from the TRACK study, a multi-site project that looked at youth to adult sector transitions across the United Kingdom, the critical components of continuity of care include:

Information Continuity: Effective information transfer
Relational Continuity: A period of parallel care and joint working between services
Cross Boundary and Team Continuity: Transition planning with at least one meeting including the young person, parent/caregiver, youth service provider, adult service provider, and other services
Care Continuity: Connection between the youth and adult sector service providers after the transition is complete (for at least three months after the transition)

Singh, S.P. Paul, M., Islam, Z., Weaver, T., et. al. (2010). Transition from CAMHS to Adult Mental Health Services (TRACK): A Study of Service Organisation, Policies, Process and User and Carer Perspectives. Report for the British National Institute for Health Research Service Delivery and Organisation programme. Queen’s Printer and Controller.

Find more evidence

With the support of the Provincial System Support Program at the Centre for Addiction and Mental Health (CAMH), the Sudbury-Manitoulin Service Collaborative developed the TAY Protocol – a defined set of procedures for helping youth with mental health and/or addictions issues move seamlessly into adult services. This protocol is based on evidence provided by Dr. Swaran Singh’s TRACK Study.

The TAY Protocol is a step-by-step process that service providers use to plan transitions for youth ages 14-24 from child/adolescent mental health services to the appropriate adult mental health and addictions services.The TAY Protocol helps improve the service experience for these youth and can help them achieve better outcomes.

The Service Collaborative also developed a local version of the Be Safe mobile app, which was based on the work of the London Service Collaborative. Be Safe supports youth to safety reach out to appropriate community resources when they are in need. Specifically, Be Safe:

allows the user to create a digital safety plan;
informs the user about mental health and addiction resources in their local community;
directs users to the best options fortheir needs though a decision-making aid;
creates a personal ‘get help script’that helps users find the words to reach out; and
empowers the user to reach out safely.

Exploration
Installation
Initial Implementation
Full Implementation

?What's this?

Exploration

The Sudbury-Manitoulin Service Collaborative analyzed the data focusing on the needs of TAY within local communities and decided to develop and implement a protocol based on the TRACK study from the UK.

To support this work, the Service Collaborative partnered with CAMH’s Youth System Innovation Group to host a workshop entitled “Putting the Youth in Youth-Focused Services." Fifty-eight community stakeholders from a variety of sectors from across the region considered ways to build youth-friendliness into their agencies with the goal of improving services to better meet the needs of TAY; discussed ways to facilitate smoother and more successful transitions for youth from the child to the adult system; and planned changes in practice to better meet the needs of TAY.

Installation

The Service Collaborative Implementation Team (SCIT) developed the TAY Protocol and accompanying resources for providers, including:

Protocol, Roadmap, Checklist and Transition Summary and the Ready, Set, Go online data entry form.

Youth resources include:

The Ready Set Go passport, the Youth FAQ and the Youth in Transition video.

Also for youth, a local version of the Be Safe mobile app was designed for youth in crisis. The app informs the user about mental health and addiction resources in their local community.

A small number of agencies were identified as 'protocol pilots' and developed tailored agency-level action plans to assist with implementation

Initial Implementation

Pilot agencies received training to familiarize them with the Protocol and its associated resources. Agencies met regularly throughout initial implementation of the TAY Protocol to share and discuss their experiences.

Jordan Barr, a Health Sciences North Summer student, was hired to promote the Be Safe app in schools and at community agencies. Jordan presented to over 370 youth, visited seven schools, and ensured that post-secondary students had access to the app through ‘Frosh Week’ kits at Laurentian University. He also presented to approximately 500 service providers from a variety of sectors, including primary care, education, health, justice, and child services. He also reached out to the LGBTIQ, First Nations, Inuit, Métis and Francophone communities.

Student Jordan Barr ensures access to Be Safe mobile app in Northeastern Ontario

Full Implementation

At the end of the pilot phase, the pilot agencies shared their learning about using the protocol and resources. The number of agencies in Sudbury and Manitoulin districts using the protocol was then broadened. All agencies using the protocol met regularly to discuss the best way to implement and sustain the process.

Webinar: Supporting youth through their transition to adult services

Voir la vidéo

How do we know it works?

I’m doing better… I have been more out in the open, more open with new things. I’ve been happier because I’ve been going out more. Life’s good.
— Youth, TAY video

4

communities in the Sudbury-Manitoulin district are using the TAY protocol (Sudbury, Manitoulin Island, Chapleau and Espanola)

15

sites from the following agencies: CMHA Sudbury Manitoulin, Child and Family Centre, Turning Point Décisif, Children’s Community Network and Mnaamodzawin Health Services are using the TAY Protocol

I had a client that I recently transferred. The referral was quick & done over the phone. The transition meeting was scheduled within a week & the whole process took no more than 3 weeks
— Staff from the Child and Family Centre

Who is involved?

The Service Collaborative brought together 30 community members, including agency representatives from across six ministries and three communities - Sudbury, Manitoulin and Chapleau. 183 youth and 67 family members were consulted and their voices were included in the development and planning of the Protocol and its resources.

Resources

Download the resource and click on the pin to access the embedded documents.

Youth in Transition in Sudbury and Manitoulin Districts

Voir la vidéo

The importance of involving youth in planning youth services

Voir la vidéo

For More Information, Please Contact:

Heather Haynes, Clinical Manager, Child and Family Centre

Sudbury, Ontario
(705) 675-1195 ext. 78331
shandy.vandeligt@camh.ca

Sandra Watson, Regional Implementation Coordinator

Sudbury, Ontario
(705) 675-1195 ext. 78327
sandra.watson@camh.ca

CAMH PSSP

Improving Services for Transition Aged Youth

What is the system challenge?

What are we doing about it?

Exploration

Installation

Initial Implementation

Full Implementation

How do we know it works?

Who is involved?

Resources

For More Information, Please Contact:

Heather Haynes, Clinical Manager, Child and Family Centre

Sandra Watson, Regional Implementation Coordinator

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