January 25, 2016 - The Gerald Sheff & Shanitha Kachan Emergency Department at CAMH plays a pivotal role in providing care and comfort to those needing immediate support. With over 7,000 hospital visits in 2014, CAMH handles over 40 per cent of Toronto Central mental health and addiction emergency assessments.
But for youth and families seeking mental health help during a crisis, “it can be a very scary experience, at a time when they may be reaching out for their first contact with mental health services,” says Dr. Corine Carlisle, Clinical Head of the Youth Addictions and Concurrent Disorders Service in the Child, Youth & Family Program at CAMH. “A negative experience can impact future engagement with the system – an experience we’re trying to avoid.” That’s why CAMH has created a positive alternative.
Youth who arrive in the emergency room may be struggling with mental illness or concurrent disorders – the co-existence of mental illness and substance use disorders. But many of these are not actually considered emergency care cases. Dr. Carlisle is succinct in her explanation, stating that “The emergency department might be the place people go to, and it is the essential place to go when safety and severe mental illness symptoms are at issue, but often situations are urgent, not emergent. Urgent cases need a different avenue to care.”
In situations where patient safety or acute psychosis is not a concern, or where a psychiatrist is not needed for immediate assessment, youth are directed to CAMH’s Youth Urgent Care Clinic, an innovative initiative supported in part by several generous donations.
Enter Urgent Care
CAMH’s Intergenerational Wellness Centre is located south of Queen Street West, just east of Ossington Avenue. It’s unlike the busy hospital settings people are used to. The building is bright, with large windows overlooking the park on the north-east portion of the site. Wide hallways painted in warm tones accentuate the positive atmosphere of the space, and a large, colourful mosaic adorns the entrance of the building.
Dr. Amit Rotem and Social Worker Katie Stemeroff occupy a small portion of the fourth floor of the building. This wing of the hospital is dedicated to helping youth and their families cope with mental illness and concurrent addiction issues. This is where the Youth Urgent Care Clinic finds its home, and these two are its staff. In fact, they’re the clinic’s only staff.
Katie Stemeroff and Dr. Amit Rotem
Before coming to CAMH, Katie worked at a community walk-in clinic for youth, which brought her in contact with various community partners. She credits that experience with giving her a solid understanding of the social determinants of health and their interaction with mental health.
Dr. Rotem, a child and adolescent psychiatrist, came to CAMH on a fellowship three years ago from Israel. Initially interested in addiction and tobacco, his research and clinical duties led him to closer interactions with youth, where he came to the realization of the need for more understanding of youth concurrent disorders.
“We make sure to involve other care providers so that there’s a strong circle of care.” Indeed, the clinic takes pains to avoid providing care in isolation. “It’s about making sure that the youth are hooked into the necessary resources for their recovery,” said Katie.
A Delicate Balance
The Youth Urgent Care Clinic was formed to serve adolescents as young as 14, up to young adults in their early 20’s. Cases are assigned depending on immediacy and urgency of service, and come through one of three avenues: from the CAMH Emergency Department, from initial assessments by outpatient clients, and from community services.
Raju Bains, Manager of Youth Addiction and Concurrent Disorders Outpatient Services, has forged important partnerships and liaisons to optimize continuity of care in and out of the Youth Urgent Care Clinic. Under her skillful management, the clinic has grown steadily in a controlled way in order to balance demand and availability of care. Clients who are referred to the clinic are seen within 48 to 72 hours - a quick turnaround that doesn’t afford the kind of long-term case management that many clients need. But it’s a vital service to youth who find themselves in need of urgent care.
Armed with the knowledge that they are dealing with urgent cases on a limited time frame, Katie and Amit must act quickly yet thoroughly to help stabilize the situation that the young person is in. A rapid, comprehensive assessment is conducted, and psychiatric needs, safety concerns, and factors pertaining to the social determinants of health (housing, income, education, etc.) are all identified.
The concept of balance permeates through the clinic’s work. And not so much in a ‘Yin and Yang’ sense – there are no Good Cop/Bad Cop interactions to be found here. But Katie and Amit bring two diverse, yet complementary viewpoints to the table. They’re the first to admit that they may have differing views on certain situations, but are also cognizant that this is a positive rather than a negative.
“Sometimes having an opposing view is also useful. Seeing complex clients, if we always agreed and had the same point of view, we might be missing things,” says Katie. “And it’s not opposing views, but more like seeing things from different sides, different angles.”
A balanced approach goes a long way in helping their clients.
Checks and Balances: The Truth and Youth
Once youth have been assessed, Katie and Amit will introduce brief interventions to the client such as Cognitive Behaviour Therapy or Dialectic Behaviour Therapy, and perform motivational interviews to help the youth work through goals for recovery. Together they come up with an individualized plan – whether it is through medication, community case management, crisis family counselling, or referrals to groups within CAMH for longer-term services in order to address the obstacles the youth is facing.
It’s during this phase that a clinician’s ability and character are put to the test.
“When working with youth, you have to be real. They have that ‘Spidey sense’ turned on. They can read when you’re being real, and when you’re telling them something you don’t truly believe. It really keeps me on my toes about integrating my skills, doing things from a clinical perspective, but also being authentic at the same time,” says Katie. “That’s the most important thing – the connection. They might not necessarily buy the skills you’re teaching them unless there’s that connection.”
Being flexible is also a key part of how this small clinic can do so much. Working collaboratively allows the clinic to provide rapid response. In the outside world it is very rare, for instance, for a client to see a social worker, and then a psychiatrist within a short time frame, but by working closely CAMH’s Youth Urgent Care Clinic is able to provide this level of service for the most urgent cases.
Keeping Up With Demand
When asked about the demand this type of service places on clinicians, Dr. Rotem and Katie are quite frank yet optimistic about what they can achieve.
They acknowledge that support from other departments and community agencies is vital in allowing them to work more efficiently. “That’s what makes our partnerships with other community supports and other services so important,” says Katie. “Because of our relationships… if a client needs community supports right away, our partners will come and meet us here (at CAMH), because they understand we’re working with a small team and limited resources.”
Dr. Carlisle is also wary not to stretch the Youth Urgent Care Clinic too thin. “The emergence of urgent care came to address a specific set of circumstances. It’s not to take over care that may be provided by others. Our Youth Urgent Care Clinic joins other hospital-based urgent care services and the community crisis and walk-in services. Together we are all trying to get the right care to the right youth at the right time.”
That’s not to say that they’re slacking – far from it actually. Upon inception, they have been systematically increasing the workload, and the demand has been staggering. “Over last year, our intake numbers have increased four-fold.”
Longer-term clinics can track the progress of their clients through gradual improvement. Amit and Katie don’t have that luxury, which can be frustrating for some. When asked what keeps them going, they talk about the surprising gains they see in a short period of time. “My passion is helping youth feel connected, breaking down barriers and helping them get what they need, right now. When they come in, when they need help now, they need it immediately. We’re here to provide that help.”
And when young lives hang in the balance, sometimes you need a pair of passionate clinicians to tip the scales.