1.1 Mental Health and the Burden on Health Services Utilization and Health Outcomes
Emergency psychiatric care, unplanned hospital admissions and inpatient health care are the costliest forms of mental health care [1]. The frequency of Emergency Department (ED) presentations with mental health concerns and length of psychiatric hospitalizations can have significant physical, psychological, and financial consequences for patients and their families and affects the infrastructural, human, and economic well-being of healthcare systems [2, 3]. This is especially true in the era of the COVID-19 pandemic when already limited services have been further stretched by growing hospital admissions, ED presentations and an increase in extended stays [4–6]. The World Health Organization reported in October 2020 that the pandemic had disrupted or halted critical mental health services in 93% of countries worldwide [7]. Consequently, the increased demand for mental health support has renewed the interest in seeking out solutions to mitigate avoidable hospital readmissions and ED visits, as well as to lower lengths of stay (LOS) in acute care facilities [8].
People with psychiatric disorders have the highest early readmission rates among all hospitalized patients [9–11]. Early readmission is defined as readmission within 30 days of previous discharge [9]. Although deinstitutionalization of care and transition to community-based mental health care has been an approach of focus for decades [12, 13], early hospital readmission rates remain high. In Nova Scotia, the 30-day re-admission rate for inpatient mental health treatment was 10.14% for the 2021/2022 fiscal year. The unmet need for psychological treatment and the limited human resources to address this gap is a major cause of readmission in acute psychiatry units [9]. The readmission rate is a prevalent indicator used for quality assessment of care and a focus of interest for health sector policymakers [14, 15]. In psychiatry, readmission rates are usually commensurate with relapse or complications following an inpatient stay. While it may reflect premature discharge from inpatient psychiatric units, it may also relate to the lack of coordination of post-discharge healthcare services [16, 17].
Similar concerns are related to frequent ED visits. Frequent ED visitors are commonly defined as people having 4 or more ED visits during the past 12 months [18], and they are more likely to suffer from chronic somatic diseases, drug and alcohol abuse and acute mental illness [18]. Predictors for recurrent ED visits due to acute mental health problems are usually substance abuse, single status and homelessness [19].
In addition to readmission rates and frequency of ED visits, length of stay (LOS) is another important quality of care indicator. LOS is defined as the number of days between admission and discharge dates for each admission experienced [20]. LOS is likely to be multifactorial, but some factors associated with longer LOS have been consistently identified: biological sex (being male), ethnicity (being Asian, Black, or having mixed background), accommodation status (being homeless) and having the primary diagnosis of psychosis. Although there is no ideal LOS, current international recommendations advocate for an early discharge as soon as stabilization is successful, with continuation of treatment in less restrictive environments [20]. On the contrary, concerns about prioritizing shorter stay admissions include increasing medical negligence and favouring the revolving door cycle, which can be aggravated with a history of repeated admission and frequent ED visits [20, 21].
Besides the high rates of health services utilization, mental disorders are associated with major social and economic consequences for patients and their families. Patients with mental disorders have high mortality rates [22], poor quality of life [23], lower self-esteem [24], and lack of educational and income-generating opportunities, thus limiting their chances of economic independency and depriving them of social networks and status within the community [14]. Individuals with mental disorders also experience a variety of chronic physical health problems, such as hypertension and cerebrovascular diseases [15]. Despite the pervasive need for mental health treatment among individuals with mental disorders, it is generally acknowledged that many do not use healthcare services [25].
According to Statistics Canada (2018), almost 18% (5.3 million) of Canadians reported their need for some mental health support, but just above half of this figure (56.2%; 3 million) have reported their needs were fully met, while the rest (43.8%, 2.3 million) have stated their needs were partially met or unmet altogether, particularly when considering those who do not have a regular health care provider [26]. Provincially, Nova Scotia is similar to these nationally reported figures concerning the mental health care gap [26]. The greatest unmet needs reported in the province were the lack of counselling and the service cost [25, 26].
Implementation of easily accessible early intervention programs that can help prevent the frequent use of high-cost services such as ED and inpatient treatments is needed. Early intervention programs have been shown to improve mental health outcomes for individuals and their families and improve quality of life, reduce disability, and increase productivity for the affected individuals [27]. There is, therefore, a pressing need to provide accessible early intervention mental health programs in flexible yet cost-effective ways. These programs can be incorporated into stepped models of mental health care, where clients receive rapid comprehensive mental health assessment prior to being matched to services that meet their needs [28]. The stepped care model includes easily accessible early intervention programs that widen access to care by offering the least restrictive and least costly interventions to most people, improving access to mental health services through better allocation of scarce resources, reducing wait times for clients and avoiding unnecessary use of high-needs/high-cost mental health services (i.e., inpatient, ED visits) [29].
1.2 Rapid Access and Stabilization Program
Nova Scotia Health (NSH) has been working to expand access to quality addiction and mental health programs through various services and technology-based health initiatives [30]. The provincial Mental Health and Addictions Program (MHAP) is delivered using the stepped care model, where a continuum of services and service providers are available to support people’s specific needs, from the least intensive interventions (health promotion, primary care, self-management, community care) to the most intensive treatment services (formal and specialized mental health & addictions care) for more complex needs [31]. To further expand capacity and access to mental health care, the province has launched a novel mental health initiative for people in need of mental health care at various intensity levels to reduce wait times for access to mental health and psychiatric support, reduce ED visits for mental health concerns and reduce inpatient psychiatric treatments.
This new service is referred to as the Rapid Access and Stabilization Program (RASP) [32], a tier 3 model of care (Fig. 1) implemented in April 2023, which aims to offer comprehensive mental health assessment, develop treatment plans, and provide short-term stabilization and mental health support to patients.
Primary Healthcare Providers (PHP) such as mental health clinicians, nurse practitioners and general practitioners, including those from walk-in-clinics, can refer patients to the service by using the existing central intake pathway. When fully implemented, the program will also welcome walk-in patients who would receive an assessment from a mental health clinician, and if necessary, referred to one of the program psychiatrists for further assessment. Additionally, psychiatrists participating in the program will provide telephone consultations and support for PHPs across the province. All patients accessing the RASP are scheduled to arrive at the clinic 30 minutes before their appointment with the psychiatrists to complete a range of standardized assessments, which are detailed in the section for data collection below. In addition, following the psychiatric consultation, each patient is offered the opportunity to provide feedback about their experience with the RASP provider by completing either a paper-based or an online satisfaction survey. A link for the online satisfaction survey is sent via text message to the patient’s cell phone after the psychiatric evaluation. Additionally, patients can opt-in to participate in an optional Text4Support randomized controlled trial (RCT) where they can either receive daily supportive text messages which are tailored to their primary presenting problem or a single text message which has a link to the NSH/MHAP suite of e-mental health programs [33]. After each psychiatric assessment, a detailed report which covers all essential elements of a comprehensive psychiatric assessment (i.e., presenting complaints, history of presenting complaints, medication history, past psychiatric history, medical and surgical history, family history of mental illness, drug and alcohol history, forensic history, personal history, current social circumstances, pre-morbid personality and a description of the mental status following an examination) is returned to the referring primary care provider within 24 hours. The report includes scores for standardized rating scales and their interpretation and a comprehensive treatment plan based on the biological, psychological and social model. The report encourages the receiving primary care provider to contact the psychiatrist at RASP through the program phone number if they have any follow-up questions. Providers are also advised to re-refer the patient back to the program for further evaluation if the patient's mental health issues are not fully resolved after exhausting the comprehensive treatment plan and recommendations offered. The RASP psychiatrist or a clinical coordinator (mental health clinician) offers each patient information about community resources and support organizations they could utilize in their recovery journey. They are also offered psychoeducation to improve their mental health literacy and information on lifestyle changes that can promote good mental health, such as an increase in physical exercise, good nutrition, avoidance of substance and alcohol abuse and use of self-help resources. Patients with complex presentations or deemed by the RASP psychiatrists to require further psychiatric or mental health support are transferred to the community mental health program for follow-up. In addition, patients accessing the RASP who present an acute risk of harm to themselves or others are transferred to the hospital Emergency Department for further assessment and consideration for inpatient treatment.
In this paper, we present the protocol for a service evaluation study that aims to assess the effectiveness and impact of the RASP on various aspects, including high-cost health services utilization, clinical outcomes, healthcare partners' perceptions, and patient satisfaction. The study employs a research hypothesis-driven approach to comprehensively evaluate the program's performance and potential benefits for individuals accessing mental health services and for the health system`. Additionally, we aim to identify and analyze the sociodemographic and clinical characteristics of the assisted population to gain a deeper understanding of the program's reach and effectiveness. Through this research, we seek to provide valuable insights that can contribute to improving and optimizing mental health service delivery models, ultimately enhancing patient care and outcomes.