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CMHA Toronto is one of the largest community-based mental health agencies in Canada and provides community support services to those living with mental health challenges as well as education and mental health promotion services for all members of the community.

The Intensive Case Management (ICM) team at CMHA Toronto implemented the Ontario Common Assessment of Need (OCAN), which is a standardized assessment tool that helps identify individual needs, match those needs to existing services, and identify service gaps.

The OCAN consists of an optional client self-assessment and a staff assessment to identify any needs across 24 domains such as accommodation, food, self-care, physical health, child care, transportation, money, relationships, alcohol and drug use or other addictions, psychological distress, and psychotic symptoms. The tool classifies needs as unmet, met or no need.

Upon reviewing the OCAN data, the CMHA Toronto team found that clients were commonly reporting that their physical health needs were not being met despite receiving ICM services.

To help reduce these unmet physical needs, the ICM team set out to complete a quality improvement project with coaching from the E-QIP team.

Health Quality Ontario had a chance to catch up with the CMHA project team to find out more.

How did you get started with the E-QIP project?

Using the OCAN data helped us discover that physical health was commonly identified as an unmet need among our clients. At CMHA Toronto, we have primary health care services integrated at our site, and we thought that having these services available meant we were meeting clients’ physical health needs. However, there was still a gap present.

We discovered that sometimes, there was discrepancy between a client’s and staff member’s assessment of unmet physical health needs in the OCAN. For example, a client with a dual diagnosis of developmental delay and a mental health condition may indicate that they have pain (an unmet physical need), but it may not be further assessed by a health care provider due to stigma.

Through the E-QIP project, we decided to set an aim to reduce unmet physical needs by 20% by December 31, 2019.

What strategies are you developing to help address your clients’ unmet physical needs?

Although the OCAN data was pointing us in the right direction, we needed more information and decided to develop a screening tool to help staff further assess clients’ unmet physical needs and a process map to determine how to address them. These tools are currently being piloted.

In future state, when an unmet physical need is identified using our new tools, the case will be brought to the team for a conference with our Nurse Practitioner. Together, a plan will be put into place triggering various clinical care pathways, and progress will be reviewed monthly. A case will also be brought forth to the team if a client has not seen a primary care provider in the last year and refuses to do so.

Drawing on Health Quality Ontario’s Quality Standards for Schizophrenia Care in the Community, the screening tool and process map specifically identifies if clients living with schizophrenia have recently started new anti-psychotic medication in the last 12 weeks but have not seen a primary care provider. The case will also be brought forth to the team to create a plan.

The team conferences are interprofessional to foster group decision-making in real-time.

What are your next steps?

Once the screening tool is finalized, we will use plan-do-study-act (PDSA) cycles to implement it with a few clients. We expect refinement will be needed as we go along, while also collecting process and outcome measures.

We need to draft a policy that supports the use of a screening tool in our team meetings to make this standard practice. We are also making a case for the need for more primary care provider hours allocated to the ICM.

Part of the work will involve helping clients feel that they can reach out more often for their physical health care needs. As a team we will need to address the underlying problems that interfere with someone’s motivation and do so without being paternalistic by using motivational interviewing techniques. We will ensure informed consent and lots of choice remain core to process.

At the end of the project, how will you know that you made an improvement?

We would know there has been an improvement as a result of this initiative if the prevalence of clients with unmet physical health needs decline.