Transforming youth mental health services in a large urban centre: ACCESS Open Minds Edmonton

Abstract Aim This paper outlines the transformation of youth mental health services in Edmonton, Alberta, a large city in Western Canada. We describe the processes and challenges involved in restructuring how services and care are delivered to youth (11‐25 years old) with mental health needs based on the objectives of the pan‐Canadian ACCESS Open Minds network. Methods We provide a narrative review of how youth mental health services have developed since our engagement with the ACCESS Open Minds initiative, based on its five central objectives of early identification, rapid access, appropriate care, continuity of care, and youth and family engagement. Results Building on an initial community mapping exercise, a service network has been developed; teams that were previously age‐oriented have been integrated together to seamlessly cover the age 11 to 25 range; early identification has thus far focused on high‐school populations; and an actual drop‐in space facilitates rapid access and linkages to appropriate care within the 30‐day benchmark. Conclusions Initial aspects of the transformation have relied on restructuring and partnerships that have generated early successes. However, further transformation over the longer term will depend on data demonstrating how this has impacted clinical outcomes and service utilization. Ultimately, sustainability in a large urban centre will likely involve scaling up to a network of similar services to cover the entire population of the city.

insufficient . Encouragingly, youth-friendly interventions at early stages of need offer long-term benefits for outcomes (Clark & Unruh, 2009). It is in this context that the ACCESS Open Minds (ACCESS OM) initiative has facilitated service transformation around five common objectives in different contexts across Canada . Here, we describe how efforts towards these objectives have manifested in service and system transformation in a large urban centre in Edmonton, Alberta. The city has a population of 1.32 million, 31% of which is under the age of 25 along with the second largest urban Indigenous population in Canada and a large homeless population (estimated at 1700), mostly young adults (Statistics Canada, 2016). Edmonton's city centre, where its ACCESS OM program is located, has a population of 17 000 youth aged 10-24 and a relatively high level of unemployment, with one-third of individuals having no income (Statistics Canada, 2016). Thus, the Edmonton ACCESS OM program serves a local population with complex needs, amidst a young, diverse and growing city.
Mental health services in Alberta are primarily provided by Alberta Health Services (AHS) and organized according to geographic zones, one of which is Edmonton and its surrounding regions. Prior to joining ACCESS OM, the Edmonton Zone Addiction and Mental Health program had historically provided a continuum of specialized care options for youth experiencing mental health and/or substance use concerns (Table 1). However, despite initial attempts at integration (e.g., the creation of a young adult portfolio specifically for youth aged 16-25), this age group remained at risk for poor outcomes due to the system's age-bounded service delivery model, the lack of engagement in effective and appropriate care options and a disorganized or poorly supported transition processes (Alberta Health Services, 2017). Rapid access to care was limited except for those who met criteria for early psychosis, services were fragmented with little continuity across teams, and there was no active follow-up for acute patients who did not meet specific Diagnostic and Statistical Manual (DSM) diagnostic criteria. Consequently, service providers were likely to miss opportunities for early identification and intervention.
These service gaps became an important reason for partnership when the Edmonton Zone was approached to join the ACCESS OM initiative. Building on this, the Edmonton Young Adult Addiction and Mental Health Services team organized a multidisciplinary ACCESS OM steering committee with representation across child, youth and family services, young adult and cross level (recovery through employment, education, housing and peer support) services, research and evaluation and decision support and analytics that highlighted areas of the service delivery system that ACCESS OM Edmonton should focus on.

| COMMUNITY MAPPING
Prior to joining ACCESS OM, community mental health services for youth in Edmonton were sharply divided based on age. Children below the age of 18 attended child and adolescent mental health services (CAMHS), while those between 18 and 65 years of age attended general adult psychiatry. Although transfer of care from CAMHS to general adult services was typically initiated by the time the youth was 18 years old, this model lacked adequate continuity of care: 80% of youth (aged 16-25) discontinued seeing their primary service provider in adult services after three visits and without a planned discharge (Alberta Health Services, 2018). Furthermore, despite utilizing high-intensity services at high rates (with 30% of all psychiatric intensive care admissions being for those under 25 years old), individuals least likely to engage in appropriate care were those who were close to aging out of the service at their first contact (e.g., 17 years old); or who did not have adequate supports in navigating the access point (e.g., homeless youth, individuals who were unable to ask for help from their parents or guardians, or who had parents with mental health and substance use issues) (Alberta Health Services, 2018).   A significant investment has also been made in the ACCESS Clinician role and developing skills in motivational interviewing, behavioural activation, harm reduction approaches and strengths-based models of care. To support successful implementation of this role, the AHS clinical informatics team was able to create an "Engagement" ACCESS Clinicians are also regular attendees at agencies serving youth throughout the Edmonton area, many of which have established drop-in spaces as a means to engage vulnerable groups.

| ACCESS CLINICIANS
Prior to ACCESS OM, these agencies could identify young people who were experiencing mental health difficulties, but had few ways to facilitate access to appropriate mental health evaluations and services.
The newfound relationship with ACCESS Clinicians provides agencies with a clear pathway to accessing services-without needing to wait until a threshold for emergency or urgent care is met. Thus, individuals, families and caregivers are now seen based on need rather than whether they meet a minimum threshold or stage of illness.

| RAPID ACCESS
In addition to the mobile and flexible availability of ACCESS Clinicians, another facilitator of rapid access to care has been the development and opening of a physical ACCESS OM site. Prior to joining ACCESS OM, there was no "walk-in clinic" for young adults with mental health needs in this large urbal centre. The ability to provide services in a drop-in format matches the urgency expressed by youth (age 11-25) to address their needs (Clark & Unruh, 2009  Thus, the model of service integration informed by data has allowed multiple needs of youth to be progressively addressed in an iterative manner over time (Hetrick et al., 2017).

| CONTINUITY OF CARE BEYOND AGE 18
The transformation of continuity of care across the age 18 threshold began prior to ACCESS OM, when two programs spanning these age clusters (under 18 and over 18) together developed a shared vision.
Initially, however, individuals accessing services outside of the young adult programs were still required to be referred to an entirely separate adult service when "aging out" of child/adolescent care-creating a jarring and potentially disengaging transition point.
In joining ACCESS OM, the multidisciplinary steering committee recognized that designing a transformation to phase out the notion of "aging out" involved issues such as improved understanding of mature

| CHALLENGES AND SUSTAINABILITY
Although some early identification programming has been undertaken, the complexity of opening a single clinic with limited resources in a large city has meant that a more thorough, multi-pronged outreach effort is required. In this regard, the Edmonton Zone has an addiction and mental health prevention and promotion team whose mandate is to provide public education, student education and general prevention and promotion materials in our community. In the coming year, ACCESS OM Edmonton plans to liaise with this team to design and plan further outreach activities. An associated challenge is that stronger outreach work will likely draw in more youth in need of care, whereas the current clinic site is already outgrowing its space.
Clinically, many of the connections between a help-seeking youth and an appropriate service provider (e.g., social worker, addiction counsellor, mental health therapist for short-term therapy, recreation therapy) are made within the first 7 to 10 days. For more intensive care options (e.g., specialty care with a psychologist or specialist psychiatric service), there can be challenges to meeting the target timeline due to limited resources, occasional lack of appropriate care options even within this larger system of care, and continuing gaps in service. And although it is uncommon for youth under 14 to present to the ACCESS OM clinic, well-developed clinical programming and specialist services for this age range exist elsewhere in Edmonton: in order to conduct initial assessments and ensure connection to the appropriate service, a dedicated child and adolescent psychiatrist is now located on site.
Additional practical challenges include: Moving forward, the increasing integration of services from a number of sectors/jurisdictions to address the common goal areas of young people and their families accessing services should assist in consistent matching of an individual's needs to available service options. Evaluating this will ensure that services provided can be optimized to meet desired outcomes, and that they are effective and acceptable to young people.
As an outgrowth of ACCESS OM, the AHS-Edmonton Zone team plans to develop, implement and evaluate a growing number of interventions that will provide more options through which services and treatment plans can be individualized. This has converged around the ACCESS OM framework and facilitated by administrative and psychiatry leadership within the Edmonton Zone Addictions and Mental Health portfolio, who are together working to provide a developmentally relevant continuum of services specifically for this transition-age group of individuals. Associated with this, the local Mental Health Foundation has been an impactful convener and advocate for commitment to systems change.
Having now firmly established the ACCESS OM site in Edmonton, the service's sustainability is well-supported by AHS Edmonton Zone, which has allocated operational funds of approximately $1 million/year to increase the capacity of ACCESS OM Edmonton-including case management and psychotherapy interventions, occupational therapy, and partnerships that will further populate the integration of service options.
Finally, a major area of current focus is the scaling up of the single ACCESS OM clinic to a network of integrated youth hubs in the Edmonton Zone. A functional plan has been put forward for a centralized clinical services building and five walk-in clinic sites to be geographically embedded across Edmonton. This work is developing in consultation with the Mental Health Foundation, with the hope that such an approach will expand across the province of Alberta.