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Introduction: In Canada, approximately 4,500 individuals die by suicide annually. Approximately 45% of suicide decedents had contact with their primary care provider within the month prior to their death. Current versus never smokers have an 81% increased risk of death by suicide. Those who smoke have additional risks for suicide such as depression, chronic pain, alcohol, and other substance use. They are more likely to experience adverse social determinants of health. Taken together, this suggests that smoking cessation programs in primary care could be facilitators of suicide prevention, but this has not been studied. Study objectives: The objectives of the study are to understand barriers/ facilitators to implementing a suicide prevention protocol within a smoking cessation program (STOP program), which is deployed by an academic mental health and addiction treatment hospital in primary care clinics and to develop and test implementation strategies to facilitate the uptake of suicide screening and assessment in primary care clinics across Ontario. Methods: The study employed a three-phase sequential mixed-method design. Phase 1: Conducted interviews guided by the Consolidated Framework for Implementation Research exploring barriers to implementing a suicide prevention protocol. Phase 2: Performed consensus discussions to map barriers to implementation strategies using the Expert Recommendations for Implementing Change tool and rank barriers by relevance. Phase 3: Evaluated the feasibility and acceptability of implementation strategies using Plan Do Study Act cycles. Results: Eleven healthcare providers and four research assistants identified lack of training and the need of better educational materials as implementation barriers. Participants endorsed and tested the top three ranked implementation strategies, namely, a webinar, adding a preamble before depression survey questions, and an infographic. After participating in the webinar and reviewing the educational materials, all participants endorsed the three strategies as acceptable/very acceptable and feasible/very feasible. Conclusion: Although there are barriers to implementing a suicide prevention protocol within primary care, it is possible to overcome them with strategies deemed both acceptable and feasible. These results offer promising practice solutions to implement a suicide prevention protocol in smoking cessation programs delivered in primary care settings. Future efforts should track implementation of these strategies and measure outcomes, including provider confidence, self-efficacy, and knowledge, and patient outcomes. [ABSTRACT FROM AUTHOR]

Background: The success of continuing professional development (CPD) programs that foster skills in lifelong learning (LLL) has been well established. However, healthcare professionals often report barriers such as access to CPD and cost which limit uptake. Further research is required to assess how accessible CPD programs, such as those delivered virtually, impact orientation to LLL. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a CPD model that has a growing body of evidence demonstrating improvements in knowledge and skills. Central to this model is the use of a virtual platform, varied teaching approaches, the promotion of multi-directional learning and provider support through a community of practice. This study aimed to explore whether participation in a provincial mental health ECHO program had an effect on interprofessional healthcare providers' orientation to LLL. Methods: Using a pre-post design, orientation to LLL was measured using the Jefferson Scale of Lifelong Learning. Eligible participants were healthcare professionals enrolled in a cycle of ECHO Ontario Mental Health from 2017 to 2020. Participants were classified as 'high' or 'low' users using median session attendance as a cut-point. Results: The results demonstrate an increase in orientation to LLL following program participation (Pre: 44.64 ± 5.57 vs. Post: 45.94 ± 5.70, t (66) = − 3.023, p <.01, Cohen's d = 0.37), with high ECHO users demonstrating greater orientation to LLL post-ECHO. Conclusion: Findings are discussed in the context of self-determination theory and suggest there may be components of CPD programs that more readily support increased motivation for LLL for interprofessional healthcare professionals. [ABSTRACT FROM AUTHOR]

Introduction: With the proliferation of virtual learning programs during the COVID-19 pandemic, there is increased need to understand learner experiences and impact on developing expertise. Project Extension for Community Healthcare Outcomes (Project ECHO®) is an established hub-and-spoke tele-education model aimed at building capacity and expertise in primary care providers. Our qualitative study explored how learning experiences within an ECHO mental health care program supported provider learning and ability to solve complex clinical problems. Methods: We sampled ECHO sessions across a 34-week cycle and analyzed audio transcribed data. Two individuals coded participant interactions during 2-hour recorded sessions using an iterative, constant comparative methodology. Results: The authors identified four key mechanisms of learning in ECHO: (1) fostering participants' productive struggle with cases, (2) development of an integrated understanding, (3) collaborative reformulation of cases, and (4) generation of conceptual solutions based on a new understanding. Throughout the ECHO sessions, learning was observed to be multidirectional from both the hub-to-spoke and between spoke sites. Discussion: Despite the widespread implementation of Project ECHO and other virtual learning models, a paucity of research has focused on mechanisms of virtual learning within these models. Our study demonstrated a bidirectional exchange of knowledge between hub specialist teams and primary care provider spokes that aligned with the development of adaptive expertise through specific learning experiences in Project ECHO. Moreover, the ECHO structure may further support the development of adaptive expertise to better prepare participants to address patients' complex mental health needs. [ABSTRACT FROM AUTHOR]

Introduction: Residents of Northern Ontario have limited access to local psychiatric care. To address this, three program models exist: (1) telepsychiatry; (2) psychiatrists traveling to underserved areas; and (3) reimbursing patients for travel to a psychiatrist. Evidence shows that telepsychiatry has comparable outcomes to in-person consultations. The objective of this study was to determine the cost difference between programs.Methods: A cost-minimization analysis estimating cost per visit from a public healthcare payer economic costing perspective was conducted. Data on fixed and variable costs were obtained. Evidence-based assumptions were made where relevant. Base-case scenarios and a break-even analysis were completed, as well as deterministic and probabilistic sensitivity analyses, to explore the effects of parameter variability on program costs.Results: Costs per visit were lowest in telepsychiatry (CAD$360) followed by traveling physicians (CAD$558) and patient reimbursement (CAD$620). Among the 100,000 Monte Carlo simulations, results showed telepsychiatry was the least costly program in 71.2% of the simulations, while the reimbursement and outreach programs were least costly in 15.1% and 13.7% of simulations, respectively. The break-even analysis found telepsychiatry was the least costly program after an annual patient visit threshold of approximately 76 visits (compared to traveling psychiatrists) and 126 visits (compared to reimbursed patients).Discussion: Our analyses support telepsychiatry as the least costly program. These results have important implications for program planning, including the prioritization of telepsychiatry, increased integration of telepsychiatry with other modalities of outreach psychiatry, and limiting use of the patient remuneration program to where medically necessary, to reduce overall cost. [ABSTRACT FROM AUTHOR]

Objective: Rural areas in Ontario have fewer psychiatrists, making access to specialist mental health care challenging. Our objective was to characterise psychiatrists delivering and patients receiving telepsychiatry in Ontario and to determine the number of patients who accessed a psychiatrist via telepsychiatry following discharge from psychiatric hospitalisation.Method: We conducted a serial panel study to evaluate the characteristics of psychiatrists providing telepsychiatry from April 2007 to March 2013. In addition, we conducted a cross-sectional study for fiscal year 2012-2013 to examine telepsychiatry patient characteristics and create an in-need patient cohort of individuals with a recent psychiatric hospitalisation that assessed if they had follow-up with a psychiatrist in person or through telepsychiatry within 1 year of discharge.Results: In fiscal year 2012-2013, a total of 3801 people had 5635 telepsychiatry visits, and 7% ( n = 138) of Ontario psychiatrists provided telepsychiatry. Of the 48,381 people identified as in need of psychiatric care, 60% saw a local psychiatrist, 39% saw no psychiatrist, and less than 1% saw a psychiatrist through telepsychiatry only or telepsychiatry in addition to local psychiatry within a year. Three northern regions had more than 50% of in-need patients fail to access psychiatry within 1 year.Conclusions: Currently, relatively few patients and psychiatrists use telepsychiatry. In addition, patients scarcely access telepsychiatry for posthospitalisation follow-up. This study, which serves as a preliminary baseline for telepsychiatry in Ontario, demonstrates that telepsychiatry has not evolved systematically to address need and highlights the importance of system-level planning when implementing telepsychiatry to optimise access to care. [ABSTRACT FROM AUTHOR]

Background: Project ECHO is a virtual education model aimed at building capacity among healthcare providers to support optimal management for a range of health conditions. The expansion of the ECHO model, further amplified by the pandemic, has demonstrated an increased need to evaluate implementation success to ensure that interventions are implemented as planned. This study describes how Proctor et al.'s implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) were adapted and used to assess the implementation of ECHO Ontario Mental Health (ECHO-ONMH), a mental health-focused capacity-building programme., Methods: Using Proctor et al.'s implementation outcomes, the authors developed an implementation outcomes framework for ECHO-ONMH more generally. Using this, outcome measures and success thresholds were identified for each outcome for the ECHO-ONMH context, and then applied to evaluate the implementation of ECHO-ONMH using data from the first 4 years of the programme., Results: An ECHO-ONMH implementation outcomes framework was developed using Proctor's implementation outcomes. ECHO-ONMH adapted implementation outcomes suggest that ECHO-ONMH was implemented successfully in all domains except for penetration, which only had participation from 13/14 regions. Acceptability, appropriateness and adoption success thresholds were surpassed for all 4 years, showing strong signs of sustainability. The programme was deemed feasible all 4 years and was found to be more cost-effective. ECHO-ONMH also showed high rates of fidelity to the ECHO model, and high rates of penetration., Conclusions: This is the first study to use Proctor et al.'s implementation outcomes to describe implementation success for a virtual capacity-building model. The proposed ECHO implementation outcomes framework provides a base for similar interventions to evaluate implementation success, which is an important precursor to understanding learning, service or health outcomes related to the model. Additionally, these findings can act as a benchmark for other international ECHOs and educational programmes., (© 2022. The Author(s).)

Introduction: Telepsychiatry can improve access to psychiatric services for those who otherwise cannot easily access care. Family physicians are gatekeepers to specialized care in Ontario, so it is essential to understand predictors relating to referrals to telepsychiatry to better plan services and increase telepsychiatry adoption., Methods: This study used an annual retrospective cross-sectional study design to compare physicians who referred their patients to telepsychiatry each year from fiscal year (FY) 2008 to FY 2016. A 1-year (FY 2016) comparison of family physicians who referred to telepsychiatry (FPTs) compared to family physicians who did not refer to telepsychiatry (FPNTs) matched (1:2) by region was also conducted. Finally, we used statistical modeling to understand the predictors of referring to telepsychiatry among physicians., Results: Between FY 2008 and FY 2016, the number of patients receiving telepsychiatry increased from 925 visits to 13,825 visits. Thirty-two percent of Ontario primary care physicians referred to telepsychiatry in 2016. Several characteristics were notably different between FPTs and FPNTs: FPTs were more likely to be from a residence with less than 10,000 people, to have more nurse practitioners in the practice, and to be from a family health team than FPNTs. Rostered patients of FPTs were more likely to reside in rural areas, have more clinical complexity, and to utilize more mental health services compared to FPNTs., Conclusions: There has been an increase in the use of telepsychiatry by patients and family physicians over the study period, although there remains opportunity for significant growth. Family physicians who live in rural areas, are part of an FHT, have more NPs, with more rural and complex patients were more likely to refer to telepsychiatry. As recent pro-telemedicine policies support the growth of telepsychiatry, this study will serve as an important baseline.

Objective: Project Extension for Community Healthcare Outcomes (Project ECHO©) addresses urban-rural disparities in access to specialist care by building primary care provider (PCP) capacity through tele-education. Evidence supporting the use of this model for mental health care is limited. Therefore, this study evaluated a mental health and addictions-focused ECHO program. Primary outcome measures were PCP knowledge and perceived self-efficacy. Secondary objectives included: satisfaction, engagement, and sense of professional isolation. PCP knowledge and self-efficacy were hypothesized to improve with participation., Methods: Using Moore's evaluation framework, we evaluated the ECHO program on participant engagement, satisfaction, learning, and competence. A pre-post design and weekly questionnaires measured primary and secondary outcomes, respectively., Results: Knowledge test performance and self-efficacy ratings improved post-ECHO (knowledge change was significant, p < 0.001, d = 1.13; self-efficacy approached significance; p = 0.056, d = 0.57). Attrition rate was low (7.7%) and satisfaction ratings were high across all domains, with spokes reporting reduced feelings of isolation., Discussion: This is the first study to report objective mental health outcomes related to Project ECHO. The results indicate high-participant retention is achievable, and provide preliminary evidence for increased knowledge and self-efficacy. These findings suggest this intervention may improve mental health management in primary care.