Eliminating Barriers to Access:
Creating New Roads to Care
Building a Plan to Enhance Urban Telepsychiatry in the
Toronto Central Local Health Integration Network
Final Report
July 2014
CSI
Consultancy
Telepsychiatry provides a
PREFACE
complementary service to
traditional psychiatric

A Clear Need - 1 in 5 Canadians experience mental health difficulties
in their lifetime. Access to care is paramount in any society that
believes it is important to support the needs of persons facing health
challenges.

Many providers feel they have inadequate resources to support the
growing needs. A large burden of responsibility for mental health
falls on primary care and community providers (including family
physicians, nurses, allied health professionals, and community
support workers). Many providers feel inadequately trained, have
limited resources, and are poorly supported in recognizing and
managing psychiatric disorders.

Psychiatrist is one of the most difficult specialists to access. In
Canada, 35% of family doctors rated access to psychiatrist as poor
(www.nationalphysiciansurvey.ca).

The efficacy and benefits of telepsychiatry are clear. Telepsychiatry
is feasible, increases access to care, enables specialty consultation,
yields positive outcomes, allows reliable evaluation, has few negative
aspects in terms of communication, generally satisfies patients and
providers, facilitates education, and empowers parties using it (Can
J Psychiatry 2004;49:12-23).

Telepsychiatry is the biggest user of telemedicine in Ontario.
Telepsychiatry services have been used throughout the Ontario
health system for years with demonstrable improvements in
timeliness of care, leading to improved outcomes. There are
numerous examples of telepsychiatry being the catalyst for changes
to practice, leading to better quality.

Urban Telepsychiatry is a logical next step in the evolution. While
mental health and addictions has been a lead user of telepsychiatry,
due to a lack of resources in rural and northern areas, the application
of telepsychiatry to urban settings is feasible and critically needed.
clinical
referrals andprovides a
Telepsychiatry
consultations
by
complementary
service to
traditional
psychiatric
addressing
barriers
that
clinical referrals
and
limit access
for patients
consultations by
addressing barriers that
healthcare professionals
limit access for patients
from providing
care.
and families,
andThere
restrict
is clear
evidenceprofessionals
that
healthcare
from providing
care.
telepsychiatry
benefits
There
is clear
northern
and
rural evidence
that telepsychiatry
communities, but is also
benefits northern and
applicable to urban
rural communities, but is
settings.
Building on
also applicable
tothe
urban
manysettings.
successes
Building on the
many successes
established
in
established
in
telepsychiatry, urban
telepsychiatry, urban
telepsychiatry has been
telepsychiatry has been
identified
as anas
important
identified
an important
enabler
to
enhancing
carecare
enabler to enhancing
and support
for clients
and support
for clients
and
and providers
across
providers
across Ontario.
Ontario.
and families, and restricts
r
e
.
A strategic plan to develop urban telepsychiatry
will support Ontario’s vision to make Ontario the healthiest
T grow old. This paper:
place in North America to grow up and
 Prepares the Foundation for h
Telepsychiatry by setting the context for the application of urban
e
telepsychiatry, and confirms needs and opportunities;
r
 Appreciates the Telepsychiatry Landscape by learning from telepsychiatry research and studies, and the
e
existing adoption of telepsychiatry in Ontario;
i
 Builds a Model for Urban Telepsychiatry
by articulating a vision that values the client and provider
s
experience, and sets an organizational framework to define the building blocks for a successful urban
c
telepsychiatry service across Ontario; and
l
 Sets a Roadmap for Moving Forward
by describing a clear and phased plan to strengthen urban
e
telepsychiatry in the Toronto Central LHIN, and more broadly across Ontario.
a
r
e Roads to Care - A Plan to Enhance Urban Telepsychiatry
Eliminating Barriers to Access: Creating New
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i
TABLE OF CONTENTS
EXECUTIVE SUMMARY........................................................................................................................ 3
PREPARING THE FOUNDATION FOR URBAN TELEPSYCHIATRY ........... ERROR! BOOKMARK NOT DEFINED.
Setting Context
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Eliminating Barriers to Access
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CONFIRMING NEEDS AND OPPORTUNITIES FOR URBAN TELEPSYCHIATRY ....... ERROR! BOOKMARK NOT
DEFINED.
APPRECIATING THE TELEPSYCHIATRY LANDSCAPE ............................ ERROR! BOOKMARK NOT DEFINED.
Learnings from Telepsychiatry Research and Studies
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Analyzing Telepsychiatry Adoption in Ontario
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BUILDING THE MODEL FOR URBAN TELEPSYCHIATRY ....................... ERROR! BOOKMARK NOT DEFINED.
Setting a Vision for Urban Telepsychiatry
Error! Bookmark not defined.
Designing a Conceptual Service Delivery Model
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Developing an Urban Telepsychiatry Organizational Framework
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BUILDING A PLAN FOR MOVING FORWARD ..................................... ERROR! BOOKMARK NOT DEFINED.
APPENDIX ....................................................................................... ERROR! BOOKMARK NOT DEFINED.
Appendix 1: Expert Engagement List
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Eliminating Barriers to Access: Creating New Roads to Care - A Plan to Enhance Urban Telepsychiatry
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EXECUTIVE SUMMARY
One of the most significant needs residents face within the Toronto Central LHIN is access to care. This is
especially true for marginalized populations. However, traditional solutions will not be sufficient to
address the growing volumes, acuity, and equally important, the evolving client needs and wants for the
right services, at the right time, by the right provider. A different solution is required.
The Toronto Central LHIN and CAMH initiated this project to explore the opportunities of urban
telepsychiatry to support clients requiring complex mental health and addiction services. The paper:

Confirms the need and opportunity for pursuing urban telepsychiatry as an additional modality of
care. Urban populations also struggle with access to psychiatry services due to physical barriers to
access (e.g., geriatric populations); hard to engage populations (e.g., substance abuse); marginalized
populations lost to follow-up (e.g., homeless); specialized populations where limited clinical
resources are available (e.g. children’s mental health; psychogeriatrics); and other hard to reach
populations (e.g., long term care, emergency, aboriginal health centres, crisis centers, CHCs).

Establishes a solid base of evidence of the benefits and impact of telepsychiatry services, and
suggests that some of these would be transferable to an urban setting.

Articulates a vision for urban telepsychiatry. Looking forward, urban telepsychiatry has the
opportunity to be a complementary service to support the transformation of mental health and
addiction services leading to better care for clients and their families; enhancing the quality of
providers and their services; and building a more sustainable, high quality service. As another
modality of care, urban telepsychiatry extends the current care delivery model by creating both new
capacity and shifting some additional services from face-to-face to urban telepsychiatry consults.

Defines a conceptual model for how urban telepsychiatry may work. Under the proposed model, a
client or a client`s provider may request a service from a number of locations of care (e.g., community
provider office, client home, CCAC, primary care office); requests are streamlined and triaged to a
central service with key supports and infrastructure to ensure the efficient and coordination of
services; and interprofessional services are provided either face-to-face or under a telepsychiatry
appointment, resulting in a client that gets the services they need.

Suggests an organizational framework that defines the key building blocks necessary to establish a
successful urban telepsychiatry service across Ontario. This includes six (6) care delivery structures,
five (5) support structures, and five (5) system enabler structures.
Today, there are individuals who may not be accessing care because they are unable to travel to a
psychiatric provider; primary care providers that have inadequate resources to support the mental health
and addiction needs of clients; and psychiatric providers wasting valuable time travelling to clients, thus
limiting the number of clients they can see. Simply put: there are numerous barriers to matching
resources to existing needs for mental health and addictions care.
Urban telepsychiatry is not intended to be a solution to all of these challenges. Nor is it inferred that it is
a solution for all populations. However, the paper supports moving forward with expanding urban
telepsychiatry for select populations where there is considerable need and opportunity; conducting
critical evaluations to assess impact and benefits; advancing education to enhance awareness and
understanding; and building necessary infrastructure and supports for greater adoption.
To assist CAMH and the TC LHIN to advance urban telepsychiatry, five demonstration populations have
been identified for review and consideration to determine if urban telepsychiatry may be applicable.
These include: clients in long term care homes; dual diagnosis clients in the community; clients in housing;
clients supported by primary care and community services; and emergency department (ED) clients
requiring access to specialized mental health and addiction ED consultations.
There is an opportunity to advance health care delivery through a demonstration of urban telepsychiatry
to these high-needs and low-resourced populations.
Eliminating Barriers to Access: Creating New Roads to Care - A Plan to Enhance Urban Telepsychiatry
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CAMH proposes that the Toronto Central LHIN and CAMH jointly invest in a demonstration project to
advance an urban telepsychiatry solution for a focused population (e.g., long term care, dual diagnosis,
and/or housing). This demonstration effort would include all required activities to put the model in
place for the selected population; support uptake and adoption of the model; evaluate the impact of
the model; and develop a plan to support future spread of the model.
CAMH believes that adoption of urban telepsychiatry for a selected population focus will lead to
significant benefits for clients, for provides, and the broader healthcare system. The following table
describes these positive impacts with respect to HQO’s Attributes of Quality.
If CAMH and the Toronto Central LHIN jointly invest in an urban telepsychiatry demonstration
project to benefit a focused population, CAMH and its partner providers will deliver significant
improvements to the quality of care for individuals accessing mental health and addiction care
within the TC LHIN. CAMH believes these benefits can be realized within one-year of project
initiation, and that this model would be translatable to other selected populations.
Attributes of
Quality
Benefits of an Urban Telepsychiatry Demonstration Project
Patient Centred
Care
Clients will access services in a location they are more comfortable in; one that
may better support their individual physical and social needs (e.g., in their long
term care home, or local housing provider); and reduce their amount of travel.
Accessible
Clients will have more timely and standardized access to services as a team of
psychiatric providers will have scheduled telepsychiatry visits with them (e.g.,
at a long term home, housing provider, community provider organization).
Effective
Clients and their local providers will have access to an interprofessional team
to provide care and services. The team-based model will reduce duplication of
efforts and help to streamline access to the right care by ensuring providers
know how work together.
Safe
An interprofessional psychiatric care team will work in partnership with the
local care team to ensure clients receive the care they need and want, and
reduce emergency visits and avoidable inpatient stays over the longer term.
Efficient
Psychiatric providers will reduce their time in transit and create opportunities
for providers in different locations to meet a client virtually. The goal will be to
turn non-value added time into clinical care time increasing overall capacity.
Focused on the
Population
Urban telepsychiatry will initially target populations who are in need; those
who generally do not have access to required services, and where the absence
of appropriate access results in the use of most costly services (acute care). The
goal will be to ensure more equitable and appropriate access to care and
services.
Equitable
Appropriately
Resourced
Integrated
Limited resources will be brought together under a new, integrated teambased model to ensure they are utilized and allocated more effectively. This
model will also encourage linkages with the broader care system through
enhanced relationships, and will specifically seek to build greater capacity of
primary care providers to strengthen their ability to support the needs of
clients.
Eliminating Barriers to Access: Creating New Roads to Care - A Plan to Enhance Urban Telepsychiatry
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Eliminating Barriers to Access: Creating New Roads to Care - A Plan to Enhance Urban Telepsychiatry
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