Transforming youth mental health care in a semi‐urban and rural region of Canada: A service description of ACCESS Open Minds Chatham‐Kent

Abstract Aim This study describes how mental health services for youth are being transformed within the context of a semi‐urban and rural region of Canada (Chatham‐Kent, Ontario), based on the framework of ACCESS Open Minds (ACCESS OM), a pan‐Canadian youth mental health research and evaluation network. Methods Transformation has focused on the five key objectives of ACCESS OM, namely early identification, rapid access, appropriate care, continuity of care, and youth and family engagement. A community mapping process was conducted at the beginning of the transformation to help develop a comprehensive inventory of services, identify challenges and optimize partnerships to address the five key objectives. Results The following strategies represent key elements in the transformation: coordination and partnerships between hospital, community and voluntary organizations, as well as different sectors of the community (e.g., Child and Youth Services, Education, Community Safety and Correctional Services, CSCS); working with local champions (e.g., Youth Diversion Officer and the Mental Health and Addictions Nurse in the school sectors); establishing a youth‐friendly space in a central part of the community, where services are co‐located and operate within an open‐concept design; training of ACCESS Clinicians to conduct an initial assessment; engaging youth and family in service‐level recruitment, planning, daily operations, and evaluation, including hiring of youth and family peer navigators; and, engaging the community through awareness and educational events. Conclusions The success of this transformation needs to be measured on various outcome parameters, but it is notable that neighbouring communities are already beginning to implement a similar model.


| INTRODUCTION
Young people in Canada experience significant challenges in accessing mental health services, including delayed identification of mental health issues, long wait lists and abrupt transitions in care (Malla et al., 2018). These barriers are compounded in rural, remote, and Indigenous communities where geographic, economic and cultural factors also influence access to services (Boydell et al., 2006). To respond to these challenges, ACCESS Open Minds (ACCESS OM), a pan-Canadian project aiming to transform and evaluate the way mental health services are delivered to youth between the ages of 11 and 25 in 14 diverse communities, was initiated in 2014 (Malla et al., 2018). In this study, we describe how service transformation occurred during the initial implementation phase in the semi-urban and rural region of Chatham-Kent.

| COMMUNITY CONTEXT
Chatham-Kent is mostly a rural municipality, located in the south- psychiatrists provide specialized mental health services (e.g., eating disorders, addictions and first episode psychosis), general psychiatric services for long-term care, and telepsychiatry services for individuals in rural communities. Moreover, children and adolescents with mental health issues were referred to CKHA or to Chatham-Kent Children's Services.
2.2 | Challenges pertaining to youth mental healthcare Despite the unique collaborative structure between the hospital (CKHA) and community organization (CMHA-LK), youth visits to hospital emergency departments and demand for services were increasing each year. Navigating the system was complicated for youth and their families with several factors contributing to these challenges, including: (a) services operating in a siloed manner with significant overlap; for example, Chatham-Kent Children's Services provided mental health services to individuals under 18, while the CMHA-LK offered services to individuals 16 and over, resulting in uncertainty regarding where individuals between 16 and 18 should access care; (b) lack of coordination among mental health education and awareness initiatives; (c) limited access to a child psychiatrist with paediatricians often filling this void and referring youth to a local psychiatrist for shared care or consultation; (d) no inpatient child and youth mental health services; and (e) minimal awareness of existing protocols, frameworks or structures to coordinate operations among community organizations providing services to youth.

| Community mapping
In January 2015, a community stakeholder meeting was facilitated by an international leader in innovation and change management who had been involved in many of the region's discussions related to youth mental health services. The purpose of the meeting was to introduce agencies delivering youth-focused services to the opportunity of establishing a youth hub in Chatham-Kent. Stakeholders attending this meeting included mental health and addictions services; social services, such as housing and employment; partners in the education sector; youth police diversion services and community organizations.
At the beginning of the meeting, each agency identified gaps in youth mental health services; however, as this process unfolded, the list of gaps reduced significantly as each agency became aware of the services that existed in the community. Next, an operational planning working group was formed to develop a comprehensive list of existing mental health and related community resources and to identify gaps in services. Two ACCESS OM ambassadors (a family peer navigator (PN) and a community volunteer) then took the lead in establishing a more detailed inventory of services and gaps. They approached each agency, inquiring about resources and services, compiling a list of stakeholders, their program type, and their type of contribution to the service transformation, as illustrated in Table 1.

| MEETING ACCESS OM OBJECTIVES
Building on the insights gained through community mapping, ACCESS OM Chatham-Kent created capacity by bringing together existing T A B L E 1 Description of stakeholder organizations (listed alphabetically) and their involvement in the transformed service resources to ensure that youth in need were connected to the appropriate providers. The aim was to reduce duplication of resources and address the disjointed experience of youth and their families in going from agency to agency, sometimes receiving overlapping or even contradictory services. Various youth services were integrated to optimize continuity of care and increase capacity through efficient sharing of resources and responsibilities. Next, we describe the specific strategies used in addressing the five primary objectives of the ACCESS OM model of service transformation. Home for Good") to identify youth at risk of becoming homeless (e.g., those who have dropped out of high school) and provide them with safe and affordable housing.

| Early identification
As part of the community education initiatives, youth have been involved in creating visually appealing marketing materials (e.g., pins, posters, business cards) using the slogan "What's your emoji?" (see Figure 1). These materials are disseminated during community awareness events with the aim of engaging audiences in a fun and interactive way in discussing how to recognize, relate to, and help youth connect to mental healthcare. ACCESS OM Chatham-Kent has also participated in radio interviews, has been featured in local news articles, and has disseminated agency-specific communications for broader community exposure. In addition, the site manages a website and a Twitter account, and it has hosted a well-publicized Twitter live-chat targeting youth. In

| Rapid access
To facilitate rapid access to an assessment within 72 hours (an ACCESS OM objective), a "youth space" was developed as the "go-to" place for youth, families, and friends seeking mental healthrelated support and services. Many core services (e.g., counselling, housing, case management and psychiatry) have been co-located in this youth space using an open-concept design. This co-location has removed barriers to care through removing walls, transforming the Youth and family peer workers are the initial points of contact helping to engage individuals seeking help and identifying their needs.
Including peer workers at the initial point of care aims to reduce the demand for specialized services (e.g., psychiatric consultation) and avoid unnecessary services as in our experience, sometimes all that is needed is to be heard and supported from someone with live experience. Youth have access to an inter-professional team, including ACCESS Clinicians (social workers, nurses and occupational therapist), trained to conduct an informative and engaging initial evaluation. A clinical coordinator/social worker assists with triaging individuals who need case management support vs counselling vs psychiatric consultations. When an initial evaluation indicates that a youth may be in acute crisis, a mental health nurse from the CKHA is invited to the youth space, and accompanies the youth to emergency or inpatient services, whenever possible. This procedure aims to facilitate a less traumatic experience for youth who may need inpatient care. Another key strategy deployed to facilitate rapid access is that no referral or clinical diagnosis is required to receive ACCESS OM services.

| Appropriate care in 30 days
The majority of services provided by the site are located within shared office space, facilitating access to appropriate care within 30 days. (d) single-session walk-in therapy two days a week for individuals who are not in crisis, not judged to have serious mental health problems such as psychosis, bipolar disorder or major depression, and are seeking an immediate response. Single-session therapy with a professional counsellor is based on the ideas that most clients can benefit from a single session; in many cases one session may be all that individuals attend; and for many, a single session is sufficient to reduce distress (Hymmen, Stalker, & Cait, 2013;Slive, McElheran, & Lawson, 2008;Stalker et al., 2016). Single-session therapy is a point of entry into care, providing an opportunity to engage youth, offer immediate services, and proceed to an ACCESS OM assessment. This immediate access is designed to make services available to individuals who are ready to access therapy and reduce the issue of no-shows; (e) consultation and treatment provided by .

| Youth and family engagement
Youth and families have been actively involved in the establishment and operation of the site, raising awareness in the community, and  Working in a model of shared-decision-making between stakeholder groups has also been a learning process. For example, during the renovations of the youth space, contractors created a graffiti wall without the knowledge of the youth advisory committee. This initially invoked a sense of panic among the leadership team since the decision had been made without youth involvement. Although it was an uncomfortable unveiling, the youth advisory council was pleasantly surprised. This incident reinforced the value of transparency and the practice of "nothing for youth, without youth." Establishing a human resource base with a clear understanding of ACCESS OM's objectives has also been a key challenge. There is a need for therapists, community social workers, and psychiatrists who can engage youth and appreciate the challenges that transitional age youth experience. Sustainable funding is also a challenge. Grant proposals and business case submissions have helped to maintain funding for ACCESS OM. The Chatham-Kent site is optimistic that this model is now on the radar of their provincial Ministry of Health, as evidenced through the investment towards the YWHO initiative.
While helpful in building awareness and promoting buy-in for sustainability, engagement and education events take resources away from direct services. This responsibility has now mostly shifted to a mental health promotion specialist, thus reducing demand on direct service providers.