Abstract
Background: In North Toronto, primary care providers (PCPs) face significant barriers in accessing urgent mental health resources for youth aged 8-18, resulting in delays in treatment and increased strain on emergency and inpatient services. Leveraging the success of the SCOPE (Seamless Care Optimizing the Patient Experience) platform, SCOPE-KIDS was launched on May 29, 2023, to address this gap. This program provides a collaborative, integrated pathway, enhancing PCP access to youth mental health services that align with local needs and population health priorities.
Approach: SCOPE-KIDS was co-designed with input from PCPs, psychiatrists, and youth mental health providers to establish a shared vision for improving youth mental health access through collaborative care. Guided by the North Toronto Ontario Health Team (OHT), SCOPE-KIDS integrates youth psychiatrists, a mental health navigator, and a youth mental health consultant to form a multidisciplinary team that supports PCPs. By leveraging local population health data, the program targets prevalent youth mental health challenges. To streamline referrals, SCOPE-KIDS uses the Ocean e-referral platform, improving both efficiency and accessibility.
The program was rolled out in phases, reaching 226 (81%) of North Toronto PCPs by October 2024. To ensure continuous quality improvement (QI), SCOPE-KIDS incorporated real-time PCP feedback and evaluation metrics. A final qualitative assessment with youth and families is scheduled for late 2024, aiming to confirm that the program effectively addresses community needs and enhances care quality.
Results: In its first 16 months, SCOPE-KIDS managed 88 referrals, with 57 youth receiving formal psychiatric consultations. The program significantly reduced wait times, achieving a median wait time of 22 days for psychiatric consultations, with 69% of cases being seen within a month. This improved access aligns with SCOPE-KIDS’ commitment to population-focused service delivery, enhancing PCPs' capacity to address youth mental health in primary care settings.
The inclusion of a mental health navigator facilitated timely system navigation, social work assessments, and MD-to-MD consultations. Approximately 45.6% of psychiatric consultations involved moderate to high complexity cases that might otherwise have added to hospital waitlists. By managing these cases through SCOPE-KIDS, the program alleviated pressure on hospital-based psychiatric services, allowing resources to be prioritized for patients with acute needs and enabling timely, appropriate care.
Implications: SCOPE-KIDS demonstrates the impact of collaborative, integrated care models in addressing local mental health needs and providing rapid, accessible support. The program underscores the importance of co-design, shared values, stakeholder alignment, and QI practices in building sustainable care pathways. PCPs involved in SCOPE-KIDS reported increased confidence in managing youth mental health issues, enhanced communication with psychiatrists and navigators, and strengthened integration between primary and acute care settings.
Future plans include expanding the SCOPE-KIDS model to additional regions and OHTs, applying interdisciplinary lessons learned from North Toronto. This initiative highlights the value of partnerships, shared vision, and evidence-based QI practices in creating a responsive, population-centered approach to youth mental health. By fostering strong collaboration among healthcare professionals, SCOPE-KIDS serves as a model for integrated care solutions that meet the evolving mental health needs in primary care.