Northern Connections: Providing Mental Health Services via Telehealth to

1. Northern Connections: Providing Mental Health Services via Telehealth to First Nations Communities eHealth 2013: Dr. Mo Watanabe Memorial Lecture Mark Koltek MD FRCPC Child and Adolescent Psychiatrist

2. Objectives • Telehealth in Manitoba • Rural and Northern Telehealth Services • Challenges and Opportunities • Cultural Safety and Awareness

4. The Golden Boy

5. Telehealth

6. An Overall look at MBTelehealth Growth MBTelehealth Utilization

7. First Nations and Inuit Health (FNIHB) Utilization

8. Mental Health Overall Clinical Utilization

9. Mental Health Clinical Utilization by Specialty

10. Total Mental Health vs. Pediatric Mental Health Clinical Utilization

11. Manitoba Adolescent Treatment Centre (MATC)

12. MATC Clinical Activity to FNIHB sites

13. Telehealth at MATC Psychiatric consult model – 2001 Rural - Northern Telehealth Service -2010 Staff funding is secure into the future Utilized existing resources

14. Goals of the Program • Reduce suicide behaviors and outcome • Improve access • Collaborate • Create awareness • Link to Reclaiming Hope at http://www.gov.mb.ca/healthyliving/mh/hope.html

15. Dene Cree Ojibway • Dahlu T’ua Lac Brochet • Mathias Colomb • Pukatawagan • PimicikimakCross Lake • Manto Sakikan • God’s Lake Narrows • Kinosawi Sipi • Norway House • Mememwi-Ziibiing • Berens River

16. Program Data by Community Community # of clients seen in 2012 43 11 15 1 4 Cross Lake Pukatawagan God’s Lake Narrows Berens River Lac Brochet Sunset in Cross Lake, MB Our team

17. Referral Sources • Medical professionals • School personnel • Child protection workers • Community service providers ( e.g. BFI, BHC, NAADAP, FNIHB)

18. Process • Intake • Assessment • Intervention • Referral • Follow-up

19. Reasons for Access • Suicidal thoughts and behavior • Anxiety • Post-traumatic symptoms • Grief and loss • Mood-related concerns • Medication review

20. Reasons for Access • Psychotic symptoms • Parent-Child relationship difficulties • Substance-related difficulties • School-based issues • Neurodevelopmental challenges • ADHD • Peer difficulties, bullying • Situational stressors

21. Case Report - JOEY • 16 years old • Suicidal • Self-Injurious • Hopeless • “Two-Spirited”

22. Guiding Principles • Community-focused • Sustainable • Collaborative • “At-risk” Youth • Capacity Building • Accessible • Mental Health Promotion • Culturally Safe

23. Community-Focused • Protocols followed • Recognize assets and strengths • Identify needs • Build relationships

24. Sustainable • Services ongoing • Not a “research-based” project • No limits Nikawiy Health Centre, Pukatawagan

25. Collaborative • Multi-systemic collaboration • Consultation • Treatment plans “Welcome to Pukatawagan”

26. City hospital services • Facilitate admission and discharge • Acute care • Reduce re-admissions

27. Focus on Youth At-Risk • Suicide • Substance Use • Child Protection • Neuro-development • Justice System God’s Lake Narrows School

28. Capacity Building • Enhance, not replace • Consultation • Education

29. Accessible • Local Service • Minimal Barriers • Open Criteria • Flexible Our team on the road to Lac Brochet

30. Mental Health Promotion

31. Culturally Safe • Avoid Assumptions • Explore Cultural Variables • Dimensions

32. Case Report – DEE DEE • 12 year old girl • No school • Bannished • Solvent abuse • At risk of S. Abuse

33. Telehealth-based Challenges and Opportunities • Engagement • Equipment • Distance • Confidentiality • Limited treatment models

34. Engagement • Therapeutic Relationship • “Presence” • Affect Recognition • “Intuition”

35. Engagement Strategies • Energy and Extroversion • Establish Trust • Electronic “distance” • In-person opportunities

36. Equipment Strategies • Explain equipment • Manage interruptions • Advocate • Designated telehealth coordinator

37. Distance • Coordination • Consent • Connection • Milieu Aerial view of God’s Lake Narrows, MB

38. Confidentiality • Infrastructure • Stygma • Small communities

39. Limited Treatment Models • Play therapy • Sensory Self Regulation • Behavior Modification • Long-Term psychotherapy

40. Strategies to Address Limited Models • Modify • Assist • Communicate

41. Culture • Bestowed and Inherited • Values and Knowledge • Social behaviors and practices • Foundation of Mental Health Resiliency

42. Cultural Identity • Racial and ethnic identity • Professional or vocational identity • Religious affiliation, practice, and worship • Sexual identity • Artistic and leisure activities

43. Cultural Safety • New Zealand – 1990’s • Awareness of Power • Protects Perspectives (Papps E. & Ramsden I.: Int J Qual Health Care. 1996;46:383-405)

44. Mental Health Commission of Canada • First Nations, Inuit, and Metis contributions • Seven goals • Third Goal: Respond to diversity (Mental Health Commission of Canada, 2009; Toward Recovery and Well-being: A Framework for a Mental Health Strategy for Canada)

45. Training and Cultural Competence • Implicit de-emphasis on history • Institutional racism • Cultural formulation interviews (Kirmayer et all, 2012, CJP:57(3) Guidelines for Training in Cultural Psychiatry)

46. Cultural Competence • Self-awareness • Knowledge • Skills (Kirmayer et al, 2012, CJP:57(3) Guidelines for Training in Cultural Psychiatry)

47. Case Report - MATTHEW • 6 year old boy • Foster home • Mother incarcerated • Reputation • Aggression

48. Intergenerational Trauma • Massive group trauma • Effects suffering in subsequent generations • Undermines identity • Bill 14, 1920 (Bombay, Matheson, and Anisman – J Aboriginal Health 2009)

49. Intergenerational Trauma • Trauma linkage • Benefits • Limitations (Kirmayer, Tait and Simpson in” Healing Traditions” Kirmayer and Valaskakis, 2009)

50. Historical Trauma • Cumulative • H.T.E. • Inter-generational • Post genocide DR. MARIA YELLOW HORSE BRAVEHEART - 2000