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The Sooke Navigator Project: 

The Sooke Navigator Project Dr. Ellen Anderson & Susan Larke 8th National Conference on Collaborative Mental Health Care June 4th 2007


Acknowledgements Navigators: Lynn Simonson & Jim MacSporran Sponsoring Agency Sooke Family Resource Society District of Sooke, British Columbia Dr. Ken Moselle, VIHA Dr. Donna Jeffery, UVic Dr. Elliot Goldner, SFU


Overview The Place The Problem The People The Plan The Project Critical success factors Service activities and objectives Research activities and objectives Project Outcomes

The Place: Sooke, Vancouver Island, BC: 

The Place: Sooke, Vancouver Island, BC



The Problem: Burden of Mental Health & Addictions (MHA): 

The Problem: Burden of Mental Health & Addictions (MHA)

Sooke Mental Health and Addiction Service (MHAS) Situation in 2005: : 

Sooke Mental Health and Addiction Service (MHAS) Situation in 2005: Rural & Remote communities Very few local services No local youth MHAS; Limited adult service 6 family doctors, no MH nurses, or MH center Many adults have no family doctors Population ~15,000, growing 2.3% yearly ~20% of population under 19 3 First Nations: Scia’Neu, T’Souke, Pacheedaht NO local data on MHAS need

Generic issues in MH Service Delivery: 

Generic issues in MH Service Delivery Clients with least resources & most barriers negotiate most complex service system Clients ‘bounce off’ & ‘bounce around’ the system Hard to get accurate data on local need Need to improve communication between service providers Need to connect with, and support primary care

Youth Service Issues: 

Youth Service Issues Many institutional players: school district, primary care, MCFD, health authority, NGOs Institutions don’t talk to each other -- or they speak different languages Parents and kids get lost in the maze No voice for youth in service planning Need integration of youth services & family/parent services Youth much less likely to seek out care for themselves

Family Physician Survey* (August 2005): 

Family Physician Survey* (August 2005) * Survey courtesy of Dr. Nick Kates, McMaster University

What would MH services look like if:: 

What would MH services look like if: Communities owned local problems? Communities collected their own data? Communities determined their own research agenda? Communities provided valid data and informed direction to health authorities and government service planners?

What if…..: 

What if….. Service planning was based on need rather than utilization? Service planning was based on recent relevant local data? Services were designed to meet client need? Services were designed to help the ‘hard to help’ clients?

The Sooke Navigator Project: 

The Sooke Navigator Project

The Plan: The ‘Navigator Project’: 

The Plan: The ‘Navigator Project’ Community Initiated Participatory Action Research Mixed Method data collection: Quantitative and Qualitative Stories and relationships are as important as statistics Transparent, open, ethically sound process

The People Research Partners: 

The People Research Partners Members of the community of Sooke BC Vancouver Island Health Authority University of Victoria BC Ministry of Children & Family Development Sooke Family Resource Society Simon Fraser University Centre for Applied Research in Mental Health and Addictions (CARMHA)

The People Funders: 

The People Funders BC Provincial government Vancouver Island Health Authority BC Ministry of Children & Family Development Foundations Vancouver Foundation Sutherland Foundation Victoria Foundation Michael Smith Health Research Foundation Local Sooke District Council Sooke Lions Lionesses The Rotary Club – Sooke Branch

Community Involvement Navigator Steering Committee: 

Community Involvement Navigator Steering Committee T’Souke First Nation Shopper’s Drug Mart – Sooke Edward Milne Community School Sookeworks Employment Port Renfrew Health and Social Service Society Community members Sooke Crisis Centre Sooke Family Resource Society RCMP/Victim Services BC Ambulance Service Sooke Seniors Centre Sooke Transition House Sooke Family Physicians Pacific Centre for the Family

Steering Committee Activities: 

Steering Committee Activities Monthly Meetings Ongoing data and service reviews Navigator Policy & Practice reviews Anonymized Case Review meetings Community training opportunities Celebrations of key successes

The Project: Goals: 

The Project: Goals Improve MHAS access using pilot Navigator service Document and characterize MHAS needs Optimize Navigator role in local context Identify/manage barriers to MHAS Gather, analyze, evaluate, and share knowledge to support most effective appropriate use of Navigator service in Sooke Share what we learn to support accessible appropriate service delivery models elsewhere

Research Questions: 

Research Questions What are the current behavioral health needs of the Sooke catchment area? Are currently available programs and resources able to meet that need when organizational/informational/access barriers are reduced? Will an optimized Navigator model enhance community capacity by improving access to appropriate mental health and social services?

Data Sources: 

Data Sources Client data Quantitative and qualitative Admin dataset (N=258) Research dataset (N=145) Client feedback forms Familes (N=36;no research consent process)

Data Sources: 

Surveys and Interviews Service Provider Interviews Focus groups Youth Seniors Physician survey Year One Physician interviews Year Two Steering Committee written feedback Data Sources

Service Objectives: 

Service Objectives Integration of MHAS with primary care and NGOs Improve Access for all clients to assessment & service Efficient, effective, appropriate Support/‘Navigate’ Client today Appropriate client referrals Community service providers Address barriers Avoid unnecessary repetition of assessment, inappropriate referrals, duplication of service Document individual client barriers to service access


Navigator Service Model: “Navigators have a ‘can-do’ approach” Timely, Low-threshold Access: “Every door is the right door” Ethical & Transparent Process Flexible Therapeutic but not psychotherapeutic Support self management NAVIGATOR SERVICES Timely communication Client-centered; Client owns the plan

Strengths-based Assessment : 

Strengths-based Assessment Collaborative Empowering for clients Uses client strengths/capacity and desire to improve their life Creates momentum for change Can ‘un-stick’ clients, and service providers Can remove stigma from help seeking

Strength based assessment: : 

Strength based assessment: Standardized measures (e.g., YRADS)* Longitudinal approach Clients need ‘coaching’ Sample questions Tell me about the last time things were going well for you…. What would people who know you say about your strengths or the things you are good at? Do you have any family traditions, and/or are you part of a culture that has traditions that you follow? Can you tell me about them? Tell me about something you have changed successfully in your life. How did you do that? * Courtesy of Wayne Hammond, Resiliency Canada

Project Outcomes: 

Project Outcomes What was the impact of the Navigator service on the community? What were the characteristics of clients seeking Navigator service? How did clients experience the Navigator service? When barriers to client assessment and linkage were reduced, were existing services adequate? What were the limitations constraints and risks of the Navigator Project? Project Evaluation

Client Characteristics Age and Gender: 

Client Characteristics Age and Gender

Data Summary: 

Data Summary Number of Clients Adult: 184 Youth: 74 Families: 36 Research consent Adult: 145 Youth: 37 Clients with follow-up data: 145

# New Client Referrals per Month: 

# New Client Referrals per Month 2005 2007 2006

Adult Clients: Source of Income: 

Adult Clients: Source of Income

All Clients: Housing: 

All Clients: Housing

36 Families: Reasons for Referral: 

36 Families: Reasons for Referral

All Clients: Research consent or not… any differences?: 

No significant differences across age, gender Total Clients=258 Research Consent=145 Possible trend: individuals with more presenting concerns more likely to give consent All Clients: Research consent or not… any differences?

Youth Referral Sources (n=74): 

Youth Referral Sources (n=74)

Adult Referral Sources (n=184): 

Adult Referral Sources (n=184)

Substance Use Reported: All ages (N=145): 

Substance Use Reported: All ages (N=145)

Number of Clients Reporting Specific Issues at Intake (N=258): 

Number of Clients Reporting Specific Issues at Intake (N=258)

Substance use: Navigator-rated Client needs (N=145): 

Substance use: Navigator-rated Client needs (N=145)

Duration to Follow-up (n=145): 

Duration to Follow-up (n=145)


MH Diagnosis Clarification or Re-evaluation 74% of clients needed This need not met for 50% of these clients Support with Managing Psychiatric Symptoms 45% of clients needed This need not met for 50% of clients No local access to psychiatric consultation Client Needs Post Navigation: Adults

Client Needs Post Navigation: Adults: 

Addiction Dependency: 93% of clients with Addictions needs had these partially or fully addressed through Navigation. Many needs were met with informal, family and/or community supports Risk Management Only 50% of clients needing support had it in place at follow up; Basic Self Care/ADLs: 37% of clients needed ADL support; Need met in 50% of those clients Service seldom available for high prevalence disorders; Client Needs Post Navigation: Adults

Client Needs Post Navigation: Youth Clients: 

Client Needs Post Navigation: Youth Clients Bridging school, youth and family; Half of clients needed bridging; One third had it in place. Family counseling; For two thirds of youth who needed it, service in place. (does not include family referrals)

Navigator Client Feedback: 

Navigator Client Feedback “People were very understanding and didn’t judge me for what happened mentally. This program is the best thing that happened to the community. Thanks so much – if it wasn’t for the program, I proberly (sic) wouldn’t be here today.” “I am feeling cautious/optimistic about my future. I am aware that I will continue to need assistance for mental health issues and medical issues. The Navigator helped to connect me to those resources so I feel like I am leaving [transitional housing] with help in place.”

Other Client Needs Met through Navigation: 

Other Client Needs Met through Navigation Service or resource provided: Supports: Assistance with Transportation Support around appointments (e.g., reminders) Assistance with paperwork (e.g., disability application) Wait-list support Crisis support Advocacy (either Navigator, or connected to a community advocate)

Other Client Needs Met through Navigation: 

Other Client Needs Met through Navigation Care Coordination Primary care link Family meeting Navigator coordinated case conference Ad hoc monitoring Navigator helping client to re-connect with pre-existing services Resources Self-care depression guide (Bilsker, CARMHA at SFU) Other written resources

Identified Barriers at time of Navigation: 

Identified Barriers at time of Navigation Service related barriers Service unavailable in region (South Vancouver Island) Service unavailable in Sooke (East Sooke to Port Renfrew) Service available but client does not fit service mandate Barrier(s) for client Transportation/geographical Time constraints Communication issues Relationship issues Waitlist Financial Housing needs/Homelessness * of client with that barrier who were Navigated through it

Referral status at Followup (4-12 weeks post referral) (n=145, all ages): 

Referral status at Followup (4-12 weeks post referral) (n=145, all ages)

Barriers revealed at Nav Follow-up: 

Barriers revealed at Nav Follow-up Client capacity No childcare Client too busy Didn't connect with counselor Life circumstances change Waitlist Other, (includes lost contact, no phone, physical illness, travel or distance, and unknown)

Community Responses: Service Provider Interview Themes: Client-related: 

Community Responses: Service Provider Interview Themes: Client-related The Navigator Model can… Lead to appropriate and efficient service access; Influence a client’s ‘referral readiness’ for MHA services; Reconnect marginalized clients to primary care; Empower clients (through strength-based assessment and collaborative service plan); De-stigmatize need for MH services for some clients;

Community Responses Service Provider Interview Themes: SP Impact: 

Community Responses Service Provider Interview Themes: SP Impact The Navigator Model can… Reduce MHA burden on non-MHA service providers; Effectively link service providers together; Help service providers find direction with their MHA clients; Increase local capacity to meet MHA need; Give all service providers a sense of being part of a supportive team

Feedback from Referring Agencies: 

Feedback from Referring Agencies “We are seen by the clients as being part of a team – working to serve their needs – [this service] is a great information resource for my program “Our client was very distraught and barely able to function. [She] received fast, effective, empathic service from the Navigator. It helped to change her outlook almost immediately, and helped put her at ease enough to get the job done.”

Feedback from Referring Agencies: 

“[Navigators offer] Support, Answers, Options, Connection to services. They make services viable. Navigator was at my door to see my client within 15 minutes! Without direction from the Navigator, we would have lost valuable time, and we may have lost [the client] as well. Tremendous support and follow-up as well.” “Navigators offer hope… help and a bridge for those who can’t access the mental health maze on their own” Feedback from Referring Agencies

Project Evaluation: 

Project Evaluation Increased connection and capacity across the network of care Navigator service model optimized and documented Timely access to strength based assessment and appropriate referrals Navigation of clients towards ‘referral readiness’ Increased local understanding of MHA need and services Detailed local data available Partnerships and working relationships developed and maintained

Critical Success Factors: 

Critical Success Factors $$$ Community awareness and engagement MHAS treatment/service availability Service + Research Bi-Directional Knowledge Available and Used

Preliminary Conclusions...: 

Preliminary Conclusions... What do clients need for successful MHAS access? Low threshold access: ‘every door is the right door’ and ‘open at the right time’… Strength-based comprehensive assessment early in the help-seeking process Collaborative service planning: client ‘owns’ the plan Timely communication with important providers Pre-emptive barrier identification Linkage facilitation On-going Service evaluation informed by good data

Preliminary conclusions…..: 

Preliminary conclusions….. Navigator service model may help other communities reconnect primary care, community services & MHAS services into an effective network of care Engaging primary care and community service providers in MHAS planning can increase effective links in health care system

Preliminary Conclusions….: 

Preliminary Conclusions…. Community Steering committee increases likelihood of successful service delivery and local knowledge transfer and use process builds local understanding and capacity Collect good data – it supports community understanding, and advocacy for service! Service capacity and data collection strategy needs to match front line service provider workload and flow

Thank You!: 

Thank You! Ellen Anderson: Principal investigator 250-642-4233 Susan Larke: Project manager/research coordinator 250-642-1852

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