Jeffrey W. Poss

Timely access to children’s mental health services depends on accurate identification of service urgency; however, triage practices in Ontario, Canada vary widely, contributing to prolonged wait times and inconsistent pathways to care. This study aimed to develop and validate an empirically based decision-support algorithm to support standardized triaging and prioritization in Ontario based children’s mental health agencies. Data were drawn from 17,564 children and youth aged 4–18 years assessed with the interRAI Child and Youth Mental Health Screener (ChYMH-S) as part of routine clinical practice. Interactive decision tree modelling was used to identify combinations of clinical indicators associated with high service urgency, with age-stratified models for children 7 years and younger, 8–11 years, and 12 years and older. The resulting interRAI Children’s Algorithm for Mental Health and Psychiatric Services (ChAMhPS) classified individuals into seven urgency levels. The algorithm demonstrated good discrimination for services required within seven days (c-statistic = 0.70) and for the urgency of a comprehensive assessment (c-statistic = 0.73), with stable performance across derivation and testing samples. Higher algorithm levels were associated with an increased likelihood of urgent assessment or service need. The ChAMhPS algorithm offers a standardized, empirically derived tool to support clinical decision-making and improve consistency in triage and prioritization of children and youth with urgent mental health needs.

Self-harm and risk of harm to others are large contributors to youth mortality. These mental health trends suggest a need for a quantifiable and comparable approach to evaluating outcomes related to risk harm to self and others. Canada has significant gaps in the ability to assess the quality of mental health services across jurisdictions — the development of Quality Indicators can fill these gaps. Quality Indicators allow comparisons across different agencies and provinces, promoting uniform quality of care despite disparities in youth demographics, social determinants of health, and mental illness complexity. Data were collected using two standardized assessment instruments: the interRAI ChYMH (Child and Youth Mental Health) and ChYMH-DD (Developmental Disabilities). The difference in assessment values between baseline and follow-up, as well as risk-adjusted variables, formed the basis for the Quality Indicators, ensuring they reflect care quality. Youth characteristic measures, including interpersonal trauma, abuse, and trauma, influence patient improvement or worsening for the risk of harm to self and others. Other risk adjustors were retained based on their significance determined by a multiple logistic regression model with the Quality Indicators outcomes. Challenges for the youth or parent/primary caregivers were associated with higher rates of worsening risk, as well as lower rates of improvement. While the median risk of harm to self and others improved across agencies, many agencies saw that risk of harm to self and others shifted in the same direction (i.e., both worsening or improving). With respect to provider/system-level factors, youth in inpatient services were less likely to improve in either domain compared to youth in community-based services. The study focused on developing Quality Indicators to measure the care quality for children and youth at risk of harm to themselves or others. These Quality Indicators can be utilized by mental health agencies to evaluate care for youth, provide feedback to providers and agencies to improve care, and compare care across jurisdictions.

(1) Background: Caregivers and families of children involved with mental health services face unique challenges. In Ontario, there is a dearth of information on outcomes for families following a child’s involvement with mental health services. Metrics known as Quality Indicators (QIs) offer a way to better understand these outcomes. Importantly, QIs can be risk adjusted to account for the influence of client complexity to allow for fair inter-agency comparisons. This study developed a set of risk-adjusted caregiver/family outcome QIs for children’s mental healthcare agencies. (2) Methods: Archival data from widely implemented interRAI child and youth assessment instruments was used. Previous methodology for QI calculation and risk adjustment was adapted and tested. (3) Results: Utilizing the interRAI suite of child and youth assessment instruments, a set of six QIs focusing on improvement or decline in parenting strengths, caregiver distress, and family functioning were developed. (4) Conclusions: The QIs established were sufficiently independent to represent different aspects of family wellbeing while the risk adjustment strategy developed was useful in removing client complexity from QI calculation. Implications for future directions, including the use of QIs at a systems level to more accurately direct resources and set performance benchmarks, are discussed.

Amongst school-aged children and youth, bullying is a significant problem warranting further investigation. The current study sought to investigate the influence of the COVID-19 pandemic waves and school closures on the bullying experiences of 22,012 children aged 4–18-years-old who were referred and assessed at mental health agencies in Ontario, Canada. Individual, familial, and mental health variables related to bullying experiences were also investigated. Data were collected from January 2017 to February 2022. The pre-pandemic period of study included January to June 2017, September 2018/2019 to June 2019/2020. The pandemic period was divided into categories of remote learning (17 March 2020 to 30 June 2020, 8 January 2021 to 16 February 2021, 12 April 2021 to 30 June 2021) and in-person learning (remaining pandemic dates). The summer holidays pre-pandemic were in July–August 2017, 2018, 2019 and during the pandemic they were in July–August 2020 and 2021. Logistic regressions were conducted to analyze data. Findings related to COVID-19 showed bullying rates to be lower during the pandemic when compared to pre-pandemic levels (bullied others during pandemic in school: OR = 0.44, CI = 0.34–0.57; victim of bullying during pandemic in school: OR = 0.41, CI = 0.33–0.5). Furthermore, bullying rates were lower during the pandemic periods when schools were closed for in-person learning (bullied others during pandemic remote: OR = 0.62, CI = 0.45–0.85; victim of bullying during pandemic remote: OR = 0.24, CI = 0.17–0.34). Children who lived in lower income areas, experienced home life challenges, exhibited mental health difficulties, or had behavioural concerns were more likely to be involved in bullying experiences. Finally, classroom type and school program impacted the child’s likelihood of bullying others or being bullied. These findings further our understanding of the impact of school closures on children’s mental health and behaviour during the pandemic. Public health and policy implications such as bullying prevention, supervision, and conflict management are discussed.

Background: In Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death). Methods: A retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance. Results: NS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community – either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period. Conclusions: By following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

Throughout the COVID-19 pandemic, population surveys revealed increased levels of anxiety and depression, while findings from large-scale population data analyses have revealed mixed findings with respect to the mental health consequences for children and youth. The purpose of this study was to examine the impact of the COVID-19 pandemic on the well-being and health-compromising behaviors of adolescents (12–18 years) previously referred for mental health services. Data were collected (pre-pandemic n = 3712; pandemic n = 3197) from mental health agencies across Ontario, Canada using the interRAI Child and Youth Mental Health assessment. Our findings revealed no increased incidence of witnessing domestic violence nor experiencing physical, sexual, or emotional abuse. Further, there were no increases in the risk of self-harm and suicide, anxiety, or depression among our sample of clinically referred youth. Finally, results demonstrated no increase in problematic videogaming/internet use, disordered eating, or alcohol intoxication, and a decrease in cannabis use. Our findings add to the growing body of knowledge as to the impact of the COVID-19 pandemic on children and youth. Further, findings underscore the importance of understanding the nuanced impact of the pandemic on various subgroups of children, youth, and families and highlight the need for continued monitoring of outcomes for these children and youth.

Background: The epidemiology of COVID-19 in retirement homes (also known as assisted living facilities) is largely unknown. We examined the association between retirement home and community level characteristics and the risk of COVID-19 outbreaks in retirement homes during the first wave of the COVID-19 epidemic. Methods: We conducted a population-based retrospective cohort study of licensed retirement homes in Ontario, Canada, from March 1st - September 24th, 2020. Our primary outcome was a COVID-19 outbreak (≥1 resident or staff confirmed case by validated nucleic acid amplification assay). We used time-dependent proportional hazards methods to model the associations between retirement home and community level characteristics and COVID-19 outbreaks. Results: Our cohort included all 770 licensed retirement homes in Ontario, which housed 56,491 residents. There were 172 (22.3%) COVID-19 retirement home outbreaks involving 1,045 (1.9%) residents and 548 staff (1.5%). COVID-19 cases were distributed unevenly across retirement homes, with 1,593 (92.2%) resident and staff cases occurring in 77 (10%) of homes. The adjusted hazard of a COVID-19 outbreak in a retirement home was positively associated with homes that had a large resident capacity, homes that were co-located with a long-term care facility, large corporate owned chains, homes that offered many services onsite, increases in regional COVID-19 incidence, and a higher community-level ethnic concentration. Interpretation: Readily identifiable retirement home-level characteristics are independently associated with COVID-19 outbreaks and may support risk identification. A higher ethnic concentration of the community surrounding a retirement home is associated COVID-19 outbreaks, with an uncertain mechanism.