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#+author: Armin Moradi
#+title: Community Mental Health
#+subtitle: From First Principles
#+date: 2023-03-02
* Thank you
Thank you all!
#+begin_notes
Hi everyone! First of all, thank you for coming today. I really appreciate everyone who is here today along with whoever couldn't make it.
Before we start, I want to give a huge shoutout to Dr. Reddi who has been the inspiration for this work.
Today's grand rounds is going to be a bit unconventional. My intention is not to prescribe an evidence-based thought process or decision-making hierarchy, and there are certainly no RCTs, statistics, and odds ratios to talk about. Instead, I'm hoping to promote thinking and explore problem spaces.
#+end_notes
* Background
#+begin_notes
Since I started residency some 3 4 years ago, certain themes have come up in day to day practice. I'd wager most, if not all, of us have at some point in our careers noticed the lack of mental health resources in the community. If headlines are anything to go by, it appears things are not getting better. In fact, they are getting worse, with the pandemic aftermath not helping the situation.
My own experience has been painful as well. When I'm on call, I see a fair number of people each night and many of them would really benefit from counselling. So, I'm ready to tell them exactly what they need, and they're ready to hear what will revolutionize their lives forever...and that's where things come to halt. I look at the list, see that all resources are maxed out on capacity. So I get the patient home and do my dictation and go home.
At this point, it's easy for me to blame the system. I'm only an employee, what am I supposed to do. But there is always that nagging feeling somewhere around my visual cortex in the far back, maybe little bit of my temporal lobe gets involved as well. Reminds me, I need to get checked out for my hallucinations as well.
Anyway, I go home, and I think did I really do what I could? Or did I just do the bare minimum that's expected of me. We do so much amazing work for the people who need our services, can we do a bit more for people who need mental health services, but maybe not psychiatric services per se? We have got to be able to leverage our position to help these people.
#+end_notes
** Current solutions
- Mental Health Clinic
- Catholic Family Services
- The Caring Place
- Family Services Regina
#+begin_notes
Whenever I have a idea, the immediate follow up is "someone has already thought about this, so what's been done already?" It turns out quite a bit! So, huge shoutout to Kacee from CL we compiled a list containing every accessible counselling resource in Regina. I'm focusing on Regina since this is where I live, my family lives, and is where I work. Most importantly, though, this is where my patients live.
So, let's dive a little deeper.
#+end_notes
** Mental Health clinic
- Intake triaging
- Public, free
- Comprehensive
#+begin_notes
Mental Health Clinic is the most prominent resource we have. They have quite a lot of programs.
- intake program: patients can get started with MHC through either physician referral or just by calling in to complete an intake assessment. The assessment is comprehensive and targets both services offerred at MHC and elsewhere.
- COAST team
- Adult community program for the severely distressed
- Individual counselling that is short term and goal focused
- DBT groups
- Online wellbeing course through UofR (I didn't know this was associated with MHC)
- Psych assessment
- Community Recovery Services
- Adult Psychiatry.
That's a looooong list. Trying to support all these services is amazing. But the waitlist is equally as astounding. If we could resize MHC and make it infinitely bigger, we'd have no problems.
#+end_notes
** Catholic Family Services
- Family oriented
- Free and sliding scale
#+begin_notes
Another wonderful resource: Catholic family services. Initiated by Archbishop Monahan in 1930s. This charity focuses on support programs, more specifically focused on family dynamics: RIFT and RAPS programs along with mentoring support is indicative of that. They also have counselling services as well for individuals on a sliding-scale system. Lastly, and perhaps most importantly, SHIFT rapid access counselling which is free and first-come first-served. Pretty much a walk-in system for counselling.
#+end_notes
** Family Services Regina
- Focused on family
#+begin_notes
Began life as Bureau of Public Welfare, administering poor relief. wonderful goal and they have since expanded beyond that. They are also mostly focused on families and they have tons of programs for this purpose, although not exclusively. They also provide THRIVE rapid counselling, free of change, kind of a walk-in system as well.
#+end_notes
** The Caring Place
- Individual and group
- Support groups
- Sliding scale
#+begin_notes
The Caring Place, it's mostly focused on counselling services and support groups. They are mostly focused on free support groups, and it's sliding scale for the rest, which is nice. It's all self-referral as well, so quite inclusive.
#+end_notes
** Done
#+begin_notes
Perfect, we're done for today, thank you for coming.
But wait, we've got all these places, all these resources, and yet we're so severely lacking.
#+end_notes
* Too much
#+begin_notes
Unfortunately, all of these services are running at maximum capacity. There is just no more room to accommodate. Except MHC which has astronomical waitlists, the others are inclusive. MHC itself is inclusive as well, but they have a triaging step which can help the burden a bit. We simply don't have enough. And that's bad...
#+end_notes
* Cost
80%
#+begin_notes
According to a recent meta-analysis 80% of people on continuous therapy do better overall than those who are not. If there was ever a convincing correlation in a study, this would be it.
What's more, while we have walk-in resources available, the number one most important factor in outcome of therapy is rapport. It turns out it's even more important than the type of therapy!
And that is nothing to say about the impact of untreated or suboptimally treated mental health issues in the community including lost productivity.
#+end_notes
* All talk?
#+begin_quote
Talk is cheap, show me the code
-- Linus Torvalds (inventor of Linux)
#+end_quote
#+begin_notes
We all knew this already. So far I've said nothing ground-breaking. So, what are we going to do about this?
This is a very famous quote by Linus Torvalds which I try to live by and which signifies the underlying attitude of a community I hold dear. The word code here refers to the work that needs to be done to address a long list of issues brought up by a colleague of Torvalds. Torvalds is also well-known to be very harsh, hence the succinct quote. But I digress.
#+end_notes
* Aspire Mental Health Foundation
#+begin_notes
My observations and the nagging feelings have, for the past few years, prompted the birth of what is now named the Aspire Mental Health Foundation.
#+end_notes
** Aspire
Evolution
#+begin_notes
Aspire foundation is a registered charity organization officially started as a non-profit in November 2021. Then became a charity in July 2022 (that's how long the paperwork took). It's taken a long time to put things in order, but it feels great to be able to finally talk about it.
Aspire foundation is an attempt to alleviate the burden I've talked about by taking a slightly different approach and taking inspiration from other industries and how they operate. The intention is to improve access to the most vulnerable section of the population and be a driving force for improvement in the state of mental health here in Regina. We're not doing anything revolutionary or radical, Aspire is an evolution in terms of the process, and will continue to evolve to match the needs of the community and fill the gaps.
#+end_notes
** Core
- Every penny to the patient
- Prioritize MVPs
#+begin_notes
There are 2 core tenets that drive every decision: every penny counts, and prioritize MVPs.
- Every penny to the patient
- we don't have front desk staff: it might seem like an odd choice, but we simply don't need one right now. Each staff wage can provide 2 full courses of CBT *per month*, that's 2 patients that can be served in the community.
- Is it thoughtfulness or frugality? It doesn't matter, the end goal is services for patients and that takes priority. If a dollar can go between process or patient, patient comes first. And that attitude applies throughout all processes. As a result, Aspire has extremely simplified processes which are highly efficient.
- For example, the operational cost so far has been $15/month. Yup, that's one five. That's how much is spent on keeping things going. That includes phone, fax, hosting, website, videoconferencing, and other operational costs. This is the kind of efficiency I think we should strive for when we're dealing with such an overload of demand, and it is this efficiency that I hope will enable us to make a significant impact in the community.
- The second goal is to prioritize Most Vulnerable Patients. They are our MVPs, they are the most important, the goal, the center of attention. That essentially means always leaving room for the most vulnerable.
How will we achieve these goals?
#+end_notes
** Triage
#+begin_notes
First and foremost, the foundation's services are intended to be deployed for those most in need. So, we've opted to start with a referral process from physicians including psychiatrists and family physicians who have identified mental health issues severe enough to warrant immediate or prioritized attention. Referrals are received through fax, and will go through an intake interview to elaborate on specific needs. If the services are already offered elsewhere and the waiting list is not too long considering patient's status, then we'll help them navigate the process with what is already out there and integrate them into the system that exists. Duplicating effort is not helpful in this case as we want to fill gaps. If that's not the case, and I suspect most of the referrals are going to be in this category, we'll provide the services, of course free of charge, but only to those who need the financial assistance. Again, we want to fill gaps, not duplicate effort.
The triaging stage will determine the problem area. There are specific patient selection criteria for type of therapy. I've found the criteria to be quite detailed as well, and includes things like ethnicity, age, occupation, and others. I won't pretend to understand every criteria for every type of therapy, but we have people who, in fact, do. Evidence-based patient selection will be paramount in the triaging stage.
The triage stage doesn't end there. The patient's status will be frequently revisited to see if the patient continues to be in need of services or another service will be more appropriate. This will enable the flow of higher volume of patients who need the services the most. It will essentially raise the minimum mental health state of the community which is a core goal of Aspire. It also ties nicely into our goal of filling the gaps as whenever there is a service being offered that's appropriate, the patient will be helped to integrate into that service.
It's important to note, everything that I just talked about is flexible. The entire foundation is based on flexibility and rapid response to community, and more importantly, individual needs.
#+end_notes
** Efficiency
- Introspection by metrics
- Low friction
- Continuous micro-optimization
#+begin_notes
Metrics will be the basis on which efficiency is built. Continuous micro-optimization is a driving force which pushes us ever closer to 100% efficiency. And in order to get there, we need to look toward the tech industry again. The tech industry is notorious for continuously optimizing processes to make them as efficient as possible. It's part of the tech culture to make minute, seemingly inoccuous changes the culmination of which make an impact. That's the goal here as well. We want to how efficiently we are using our resources, how many patients we are serving, how long does it take for them to get better, how satisfied are they with their progress, and whole slew of other data that are important to answer this question: are we doing a good job?
There are also no blanket standards or processes. This is an idea taken from the developer operations industry. The flexibility allows us to adapt to the needs of community faster, filling in gaps instead of providing a set of services that are constant. Processes are designed from the bottom up, rather than taking a top-down approach. That translates into flexibility in operation and makes for faster responses to the needs of each patient and even the community as a whole.
Can we achieve 100% efficiency? I think we can get very very close.
All of this sounds nice, but how do we know we're on the right track?
#+end_notes
** Transparency
Accountability
#+begin_notes
I've been the admin resident for about a year now and during that time have tried my best to make things as transparent as possible. Metrics, numbers, stats, everywhere! And that's exactly what Aspire Foundation...aspires to! Pun intended!
Everyone deserves to know what is happening behind the scenes, and all data we have access to will be available for others as well. This includes patient flow, and any analyses that come out of the data as well. I don't know exactly what data we'll need and how that will impact practice. And that's where micro-optimization and introspection come into play.
#+end_notes
** Will it work?
I think so!
#+begin_notes
When all is said and done, will this work?
To be honest, I have no idea. But I would venture a guess and say yes. I think it will work. The processes I talked about today are nothing new. They've been around for decades in other industries and they have a proven track record. Aspire is just taking what is already there, the processes that have made mega corporations, and is applying them for public benefit.
At the end of the day though,...
What I do know is that it's an adventure worth packing for. It's going to be scary, there will be many unknowns, many obstacles, many dragons along the path. but it will be worth it.
#+end_notes
** An adventure
[[./backpack.jpg]]
#+begin_notes
So I've packed my bag and I'm ready to go. And I would *love it* if others joined the fun. Hopefully one day my patients will say "you know what, I've got the resources I need and I feel better already".
It's gonna be a rough path ahead. I only hope I won't be alone.
#+end_notes
* Help!
- psychologists and counsellors
- lots of patients
- but no funds to connect the two
#+begin_notes
The foundation needs your help! It's a registered charity, so please donate, income tax receipts will be provided for any contribution you make. I would encourage everyone to adopt a patient. Each patient costs anywhere from $960 for simpler cases requiring 8 CBT sessions to $3000 for 15 sessions by a registered psychologist. This is excluding operational costs the amount of which you already know: $15. The good news is, you get to choose how much of your contribution goes toward what. If you want 100% to go toward sessions, or if you want 90% for sessions and 10% to support the foundation's underlying costs, or if you make a donation specifically to keep the foundation running, that's all up to you. If you don't specify, we'll give it all to patients (again, our MVPs) and whatever's truly left over will fund the survival of the charity itself so it can do what it does best.
#+end_notes
** Help!
- Volunteer
- Ideas
#+begin_notes
There are tons and tons of volunteer opportunities as well. If you think you can help people in the community in any form or shape, we'll be happy to support you in any way possible.
If you have an idea that you think might benefit the community or patients, or even for 1 specific person, please don't be shy. The whole purpose of this organization is to help whoever we can. There are certainly no small feats.
And looking inward, if you have expertise in triaging patients, designing stationary, or know how to raise funds, or anything else, we need you! The opportunities are endless to do what you want to do, and we definitely want you to do what you're passionate about, nothing else. This whole thing is a passion project.
As a result of all this work, if we can help one person be happier than they would otherwise be, I'd be happy. That's all I would ask for, but that's not all I'm hoping for. I know we can do better. I know we can do so so much better.
#+end_notes
** Let's do it!
- donate@aspirefoundation.ca
- aspirefoundation.ca
- fax: (306) 992-2919
- phone: (306) 992-9022 (voicemail)
#+begin_notes
So, let's do it. Let's pool our resources, our expertise, our compassion, and our drive to make Regina a better place with happier people. I know we can do it.
And let's do it *now*, spread the word, check out the website although it's not 100% finished, I'm still working on that, oh and another thing, if you enjoy writing about mental health, please write what you're passionate about, whatever that you think helps your patients and I'll post it on the website and now everybody can use it. This is an opportunity for us on the front line to make a difference for our own patients. We see them every day, we know them, we know we can help them, and this is how we, on the front line, can make it happen.
I know so many of you have the drive and passion, I have spoken to some of you over the past year and you know who you are, and I've heard, time and time again, that you want to help, but you don't know where to start. Shoutout to nurses on 1D, I know what you're up to, I know your frustrations with the system, and I know some of you have mentioned that you'd volunteer, and that was last year when Aspire was just an idea. Now it's here. Let's do it!
I will not believe for a second that any of you got into your line of work not thinking about helping others. I'm frustrated, you're frustrated, we know we need more, and we are doing all we can, but I believe if we put whatever resource is left, we can do so much more when we are together. So let's do what we set out to do when we got into job. Let's not blame the system, but become the system. Let's
Anyway, where was I, yes, send your patients who are in need and don't have the finances or the means, and donate today! Right now, in fact! You can donate through e-transfer, online through canadahelps.org if you prefer credit card, and of course cheque, cash, homing pigeons, etc.
#+end_notes
* Q/A?
* Thank you