by Jill S.
The past couple of years have painted a strained picture of our healthcare system. You’re probably tired of hearing how burdened our services are. Our emergency rooms are crowded, our hospitals are understaffed, and healthcare workers are burnt out.
Emerging practice and research is exploring ways to provide better care using many of the same resources we already have — just by using them in a smarter, more efficient way. One particular approach that is growing in the youth mental health and substance use sector is a process known as “Stepped Care”.
Reorganizing the way we do things has the potential to address some of the gaps that have existed in our healthcare system for far too long. The mental healthcare system, specifically faces large discontinuities — confusing pathways to care, difficult transitions between services, lack of coordination, and long waitlists [1].
What happens to someone who visits the emergency room in emotional distress? They may be supported for a few hours or overnight — which can be crucial to stay safe — but often they return home the next day with little additional support.
Other Pieces of the Puzzle
Yes, emergency services are absolutely vital. But they’re only one piece of the puzzle. We can’t ignore what happens before someone ends up in the ER and how they are cared for after.
What support would have been helpful for someone to prevent them from ending up in an emotional crisis? How can we ensure that various resources, such as counseling or support groups, are accessible if they are needed? What else can we do to follow-up with someone after they leave the emergency room?
“Stepped care” approaches aim to answer these questions, among others.
As someone working and researching in the youth mental healthcare sector, and as a young person who has navigated fragmented services myself, I can see the value of such an approach from both sides. I know first-hand that it often takes a ton of time, energy, and resources to navigate disconnected services to try and find support that is right for you. I also know that this can result in poorer health outcomes, inaccessibility and patients falling through the cracks. The last thing someone seeking support needs is to feel like a burden within a system that fails to accommodate them.
A stepped care approach focuses on providing a variety of mental health interventions across a “continuum of care” to improve health service delivery.
With stepped approaches, we can offer services that are less intensive for folks with less acute needs or for those who don’t want higher-commitment interventions.
For instance, Georgian College has organized mental health services for their students based on a stepped care approach. Case managers at the college work to maintain partnerships with community organizations to provide services to their students, while mental health strategists and other school clinicians help connect students with supports that are most appropriate for them. Thanks to local partnerships, Georgian college can offer their students options ranging from online self-help programs, to group psychoeducation, and outpatient psychiatric care.
I’m sure you can imagine a variety of mental health services that exist to meet different patient’s needs already — think of self-help resources like books, apps, or even group support sessions. Then there are more comprehensive options like one-on-one counseling or inpatient mental health treatment.
The problem stepped care aims to solve is the disconnection and inaccessibility from service to service. We tend to prioritize some services over others and most of these are poorly connected [2, 3]. Thus, it becomes difficult to navigate your different care options. This is where stepped care comes in, aiming to bridge different mental health services together to improve access, efficiency, and to respond to diverse needs.
Every door is the right door
A stepped care approach is not necessarily a depiction of what services are offered, but how they are connected. Stepped care research is helping us understand how to organize the delivery of services so that we can offer something for everyone.
The idea behind this is that we provide accessible services to people depending on their needs and preferences,and we don’t have to wait until someone shows up in the emergency room in crisis with nowhere else to go.
This is facilitated in a stepped care system where every door is the right door. No matter how you connect with wellness services, if they are effectively integrated, you will end up in the right place.
Further, these services are connected in a way that someone can easily access different levels of care depending on their needs — e.g. “stepping” between different levels of support.
For example, a student who feels they are able to manage their anxiety over summer break may choose to attend occasional group support sessions throughout the summer months. Should they then face increased stress in the middle of the fall semester, in a stepped care system it would only be a matter of a phone call or two to add additional support to their recovery plan as needed — perhaps one-on-one counseling, more frequent group sessions, or connecting with a peer support worker.
Your Own Personal “Gold Standard”
Importantly, in stepped care approaches no “level” of care is more valuable than any other. The different steps in these models merely reflect the level of resources required to provide them. The “gold standard” is whatever service fits a person’s needs at any given time.
For instance, a lot of government money goes towards emergency services, which are vital for a small portion of folks at any given time, as we’ve seen, but they don’t meet everyone’s needs. Indeed, about 20 percent of young Canadians live with a mental health or substance use disorder that impacts their functioning at home, school, or in their communities [4]. So supports at home, school, and in the community are vital.
These “lower levels” of care may be less intimidating — allowing you to dip your foot in the water, build community support, and get introduced to different mental health concepts and recovery strategies.
For some, lower levels of care would never be appropriate or may not be preferred. Thus, stepped interventions offer a variety of treatment options.
The approach focuses on patient strengths and resources – providing space for them to guide their own care.
Another important consideration for stepped care approaches is that they are not an “either, or”. Accessing one type of treatment doesn’t prevent you from simultaneously accessing another one, or changing your mind and switching to a different approach altogether.
A “Step” depends on the context
So if stepped care approaches are mostly about organizing service delivery, how do we determine what the different “steps” actually are?
What makes stepped care approaches so interesting is that they generally adhere to a core set of values or principles, which can then be applied and adapted to diverse contexts. Effective stepped care approaches choose which services are included at different steps and how they can be accessed based on community needs and resources.
When considering mental healthcare for children and youth, this means including youth voices and those of their caregivers and families as well.
In addition to Georgian College, there are several examples of stepped care approaches emerging around the country in different contexts such as “Stepped Care 2.0” born at Memorial University [5], and case studies of its application at Algonquin College and the University of Toronto [6].
Research is still helping us understand how to scale these approaches up and better connect mental health services in various communities, but with the growing momentum, and by involving youth in the way forward, transformative change is possible.
References
Berger, M., Fernando., S., Churchill, A., Cornish, P., Henderson, J., Shah, J.,.. & Salmon, A. (2021). Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults. Early Intervention in Psychiatry, 1-15.
Mughal, S., Salmon, A., Churchill, A., Tee, K., Jaouich, A., & Shah, J. (2022). Guiding Principles for Implementing Stepped Care in Mental Health: Aligning on the Bigger Picture. https://doi.org/10.31234/osf.io/2pazw
MacDonald, K., Fainman-Adelman, N., & Anderson, K. (2018). Pathways to mental health services for young people: a systematic review. Social Psychiatry and Psychiatric Epidemiology, 53, 1005-1038.
Children and Youth Mental Health in Canada (2022). Canadian Institute for Health Information. https://www.cihi.ca/en/children-and-youth-mental-health-in-canada
SC2.0 Model (2022). Stepped Care Solutions. https://steppedcaresolutions.com/methodology/
Centre for Innovation in Campus Mental Health (2019). Stepped care for post-secondary campuses: A promising model to improve access to mental health care on campus. https://campusmentalhealth.ca/wp-content/uploads/2019/09/Stepped-Care-Guide-V13.pdf
