Repairing the broken bridge between youth and adult mental health services in Canterbury
With all the pressures of becoming an adult, turning 18 can be an anxious time for young people. For those who need ongoing support from mental health services beyond the age of 18, the prospect of transitioning from specialist youth to general adult mental health services can add to this anxiety and increase the risk of disengagement at a time where support should be at its most robust.
With this in mind, Canterbury District Health Board, Te Poari Hauora ō Waitaha (CDHB) chose to focus on the youth to adult mental health services transition as part of the Health Quality & Safety Commission’s (the Commission’s) Connecting care: Improving service transitions – Te tūhono i ngā manaakitanga, te whakapai ake i ngā whakawhitinga ratonga project.
With the support of the Commission and a focus on co-design (an approach to designing services that actively involves all stakeholders), CDHB developed and implemented a new process aiming to promote safety and continuity of care by making this transition less risky, more collaborative and generally less stressful for young people and their whānau.
Preventing young people from falling through the cracks
The project group was made up of clinicians, leaders, consumer advisors and whānau advisors from both youth and adult speciality services. They applied a ‘repairing a broken bridge’ analogy to the project, quality improvement advisor and project lead Liam McKenny said.
‘There was a strong sense that the current transition process was associated with a greater risk of young people unnecessarily falling through the cracks. A young person’s care and treatment should not be negatively impacted by service-imposed demarcations, particularly at such an uncertain point in their lives when they may already be encountering other transitions, such as leaving home, leaving school or entering tertiary education or the workforce,’ he said.
Planets aligning through Connecting care
CDHB’s specialist mental health service team felt strongly about this issue and jumped at the opportunity to address it through the Connecting care project.
‘The planets all aligned,’ said Liam. ‘I happened to be undertaking the Commission’s quality improvement facilitator (QIF) training programme [sponsored by the Commission] at the same time as the Connecting care project was launched. QIF programme participants were expected to undertake a project that aimed to improve transitions of care. For mental health care settings, three possible focus areas were identified: DHB adult inpatient specialist services to DHB adult community services, DHB services to primary care and DHB youth community services to DHB adult community services.
‘In reality we could have focused on any one of these areas as they all present challenges and opportunities for improvement. However, the youth to adult services transition was one that stakeholders felt most strongly about. We ultimately chose to focus on this transition because we know the consequences and emerging risks associated with poor transition processes are significant and far-reaching. Poor transitions can, for example, lead to vulnerable consumers completely disengaging from services or presenting an increased risk of self-harm or suicide.’
To keep the emphasis on co-design, the project group collected feedback from young people, whānau and clinicians about their experiences of transitioning to adult services. Those who had a negative experience used words like ‘anxious’, ‘overwhelmed’, ‘unwanted’, ‘abandoned’, ‘fear’, ‘disorientated’, ‘no-control’ and ‘confused’. Conversely, those who described positive experiences used words like ‘respected’, ‘listened to’, ‘believed’ and ‘informed.’
‘Analysing this feedback helped us understand what good looks like,’ Liam said. ‘We also drew on case studies of previous transitions as well as complaints and incident reviews to increase our understanding.’
Transfer of care checklist for case managers
Mapping the transition process helped the project group appreciate and better understand the complexity and variation of the transition. They quickly learned there could not be a ‘one size fits all’. Creating a transfer of care checklist slowly emerged as a way of combining several of the ideas for improvement the group had identified during their exploration into a single, elegant solution.
‘The co-design process helped us identify what the “core” elements of “good” transitions are. Adopting a checklist format allowed us to capture these essential elements in the same place,’ Liam said. ‘The challenge with the checklist approach was balancing a methodical approach with the need for some flexibility so the transition process can be tailored to the unique needs of the young person.
‘It’s a tool to help clinicians to support the young person and their whānau through a successful transition; it also promotes a safer, more positive experience while fostering an increasingly collaborative process between services.’
Another theme described by young people and their whānau about the transition was a fear of the unknown. This led to an idea to develop a youth-friendly information package to help young people and their whānau think ahead about the transition, formulate questions and address common concerns.
The content of the package was created in direct response to issues raised during the co-design process. The final iteration of the package contains lots of essential information written in clear, concise language, for example, how the adult service will be different from the youth service and what will be the same. It also outlines what will happen during the transition and what a young person can expect from their first appointment with the adult team.
‘The relatively small number of direct youth to adult mental health services transitions that occur at CDHB makes evaluation of these changes challenging in the short-term. However, those transitions that have occurred since the new tools were introduced have had positive outcomes. Particularly when looking at whether young people remained engaged with adult services after the transition,’ Liam said.
Feedback from clinicians has also been positive. ‘Some youth case managers had never overseen a transition from youth to adult services before and, for those who had, it wasn’t unusual to just “wing it”,’ Liam said. ‘Clinicians who have worked with the new process seem to really value the structure and clarity it provides.
‘I am hopeful that meaningful benefits to young people and whānau will be revealed over time through a reduction in complaints or serious events occurring where the quality of the transition is a contributing factor,’ Liam said.
Tools now available for use
The project is now complete and the tools are available for use. The message about them is also getting out to clinicians and teams.
The CDHB quality team will continue to monitor progress to ensure improvements are embedded and sustained.
‘Transitions in health care are complex and this was a challenging piece of work. I am so pleased we saw it through to the end and remained focused on the goal.’ Liam said.
For more information on the Connecting care project see:
Connecting care: Improving service transitions – Top tips | Te tūhono i ngā manaakitanga, te whakapai ake i ngā whakawhitinga ratonga (hqsc.govt.nz)