Northern Connections:Providing Mental Health Services via Telehealth to

First Nations Communities

eHealth 2013: Dr. Mo Watanabe Memorial Lecture

Mark Koltek MD FRCPCChild and Adolescent Psychiatrist

ObjectivesObjectives

• Telehealth in Manitoba Telehealth in Manitoba • Rural and Northern Telehealth Services Rural and Northern Telehealth Services • Challenges and Opportunities Challenges and Opportunities

• Cultural Safety and AwarenessCultural Safety and Awareness

The Golden BoyThe Golden Boy

TelehealthTelehealth

An Overall look at MBTelehealth GrowthAn Overall look at MBTelehealth Growth

MBTelehealth Utilization MBTelehealth Utilization

First Nations and Inuit Health (FNIHBFirst Nations and Inuit Health (FNIHB))Utilization Utilization

Mental HealthMental HealthOverall Clinical UtilizationOverall Clinical Utilization

Mental HealthMental Health

Clinical Utilization by SpecialtyClinical Utilization by Specialty

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

Manitoba Adolescent Treatment Centre (MATC)Manitoba Adolescent Treatment Centre (MATC)

MATC Clinical Activity to FNIHB sitesMATC Clinical Activity to FNIHB sites

Telehealth at MATCTelehealth at MATC

• Psychiatric consult model – 2001Psychiatric consult model – 2001

• Rural - Northern Telehealth Service -2010Rural - Northern Telehealth Service -2010

• Staff funding is secure into the futureStaff funding is secure into the future

• Utilized existing resourcesUtilized existing resources

Goals of the ProgramGoals of the Program• Reduce suicide behaviors and outcomeReduce suicide behaviors and outcome

• Improve accessImprove access

• CollaborateCollaborate

• Create awarenessCreate awareness

Link to Reclaiming Hope at Link to Reclaiming Hope at http://www.gov.mb.ca/healthyliving/mh/hope.htmlhttp://www.gov.mb.ca/healthyliving/mh/hope.html

Dahlu T’ua Lac Brochet Mathias Colomb Pukatawagan Pimicikimak Cross Lake Manto Sakikan God’s Lake Narrows Kinosawi Sipi Norway House Mememwi-Ziibiing Berens River

Dene Cree Ojibway

Program Data by Community Program Data by Community

CommunityCommunity

Cross LakeCross Lake

PukatawaganPukatawagan

GodGod’’s Lake Narrowss Lake Narrows

Berens RiverBerens River

Lac BrochetLac Brochet

# of clients seen in 2012# of clients seen in 2012

4343

1111

1515

11

44

Sunset in Cross Lake, MB Our team

Referral SourcesReferral Sources

•Medical professionalsMedical professionals

•School personnelSchool personnel

•Child protection workersChild protection workers

•Community service providers Community service providers

( e.g. BFI, BHC, NAADAP, FNIHB) ( e.g. BFI, BHC, NAADAP, FNIHB)

ProcessProcess• IntakeIntake• AssessmentAssessment• InterventionIntervention• ReferralReferral• Follow-upFollow-up

Reasons for AccessReasons for Access

•Suicidal thoughts and behaviorSuicidal thoughts and behavior•AnxietyAnxiety•Post-traumatic symptomsPost-traumatic symptoms•Grief and lossGrief and loss•Mood-related concernsMood-related concerns•Medication reviewMedication review

Reasons for AccessReasons for Access

• Psychotic symptomsPsychotic symptoms• Parent-Child relationship difficultiesParent-Child relationship difficulties• Substance-related difficultiesSubstance-related difficulties• School-based issuesSchool-based issues• Neurodevelopmental challengesNeurodevelopmental challenges• ADHDADHD• Peer difficulties, bullyingPeer difficulties, bullying• Situational stressorsSituational stressors

Case Report - JOEYCase Report - JOEY

• 16 years old16 years old• SuicidalSuicidal• Self-InjuriousSelf-Injurious• HopelessHopeless• ““Two-Spirited”Two-Spirited”

Guiding PrinciplesGuiding Principles

• Community-focusedCommunity-focused

• SustainableSustainable

• CollaborativeCollaborative

• ““At-riskAt-risk”” Youth Youth

• Capacity BuildingCapacity Building

• AccessibleAccessible

• Mental Health Mental Health PromotionPromotion

• Culturally SafeCulturally Safe

Community-FocusedCommunity-Focused

• Protocols followedProtocols followed• Recognize assets and strengthsRecognize assets and strengths

• Identify needs Identify needs

• Build relationshipsBuild relationships

SustainableSustainable• Services ongoingServices ongoing

• Not a Not a ““research-basedresearch-based”” project project

• No limitsNo limits

Nikawiy Health Centre, Pukatawagan

CollaborativeCollaborative

• Multi-systemic collaborationMulti-systemic collaboration• ConsultationConsultation• Treatment plansTreatment plans

“Welcome to Pukatawagan”

City hospital servicesCity hospital services

• Facilitate admission and discharge Facilitate admission and discharge

• Acute care Acute care

• Reduce re-admissionsReduce re-admissions

Focus on Youth At-RiskFocus on Youth At-Risk

• Suicide Suicide • Substance UseSubstance Use• Child ProtectionChild Protection• Neuro-development Neuro-development • Justice SystemJustice System

God’s Lake Narrows School

Capacity Building Capacity Building

• Enhance, not replaceEnhance, not replace

• ConsultationConsultation• EducationEducation

AccessibleAccessible

• Local ServiceLocal Service• Minimal BarriersMinimal Barriers• Open CriteriaOpen Criteria• FlexibleFlexible

Our team on the road to Lac Brochet

Mental Health PromotionMental Health Promotion

Culturally SafeCulturally Safe

• Avoid AssumptionsAvoid Assumptions• Explore Cultural VariablesExplore Cultural Variables• DimensionsDimensions

Case Report – DEE DEECase Report – DEE DEE

• 12 year old girl12 year old girl• No schoolNo school• BannishedBannished• Solvent abuseSolvent abuse• At risk of S. AbuseAt risk of S. Abuse

Telehealth-based Challenges Telehealth-based Challenges and Opportunitiesand Opportunities

• EngagementEngagement

• EquipmentEquipment

• DistanceDistance

• ConfidentialityConfidentiality• Limited treatment Limited treatment

modelsmodels

EngagementEngagement• Therapeutic RelationshipTherapeutic Relationship• ““Presence”Presence”• Affect RecognitionAffect Recognition• ““Intuition”Intuition”

Engagement StrategiesEngagement Strategies

• Energy and ExtroversionEnergy and Extroversion• Establish TrustEstablish Trust• Electronic “distance”Electronic “distance”• In-person opportunitiesIn-person opportunities

Equipment StrategiesEquipment Strategies

• Explain equipment Explain equipment

• Manage interruptions Manage interruptions

• AdvocateAdvocate

• Designated telehealth coordinator Designated telehealth coordinator

DistanceDistance

• CoordinationCoordination• ConsentConsent• ConnectionConnection• MilieuMilieu

Aerial view of God’s Lake Narrows, MB

ConfidentialityConfidentiality

• Infrastructure Infrastructure • StygmaStygma• Small communitiesSmall communities

Limited Treatment ModelsLimited Treatment Models

• Play therapyPlay therapy• Sensory Self RegulationSensory Self Regulation• Behavior ModificationBehavior Modification• Long-Term psychotherapyLong-Term psychotherapy

Strategies to Address Limited Strategies to Address Limited ModelsModels

• Modify Modify • AssistAssist• CommunicateCommunicate

Culture Culture

• Bestowed and InheritedBestowed and Inherited

• Values and KnowledgeValues and Knowledge

• Social behaviors and practicesSocial behaviors and practices

• Foundation of Mental Health ResiliencyFoundation of Mental Health Resiliency

Cultural IdentityCultural Identity

• Racial and ethnic identityRacial and ethnic identity

• Professional or vocational identityProfessional or vocational identity

• Religious affiliation, practice, and worshipReligious affiliation, practice, and worship

• Sexual identitySexual identity

• Artistic and leisure activitiesArtistic and leisure activities

Cultural SafetyCultural Safety

• New Zealand – 1990New Zealand – 1990’’ss

• Awareness of PowerAwareness of Power

• Protects PerspectivesProtects Perspectives

(Papps E. & Ramsden I.: Int J Qual Health Care. 1996;46:383-405)(Papps E. & Ramsden I.: Int J Qual Health Care. 1996;46:383-405)

Mental Health Mental Health Commission of CanadaCommission of Canada

• First Nations, Inuit, and Metis contributionsFirst Nations, Inuit, and Metis contributions

• Seven goalsSeven goals

• Third Goal: Respond to diversityThird Goal: Respond to diversity

(Mental Health Commission of Canada, 2009; Toward Recovery and (Mental Health Commission of Canada, 2009; Toward Recovery and Well-being: A Framework for a Mental Health Strategy for Canada)Well-being: A Framework for a Mental Health Strategy for Canada)

Training and Cultural Training and Cultural CompetenceCompetence

•Implicit de-emphasis on historyImplicit de-emphasis on history•Institutional racismInstitutional racism•Cultural formulation interviewsCultural formulation interviews

(Kirmayer et all, 2012, CJP:57(3) Guidelines for Training in Cultural (Kirmayer et all, 2012, CJP:57(3) Guidelines for Training in Cultural Psychiatry)Psychiatry)

Cultural CompetenceCultural Competence

• Self-awareness Self-awareness

• KnowledgeKnowledge

• SkillsSkills

(Kirmayer et al, 2012, CJP:57(3) Guidelines for Training in Cultural (Kirmayer et al, 2012, CJP:57(3) Guidelines for Training in Cultural Psychiatry)Psychiatry)

Case Report - MATTHEWCase Report - MATTHEW

• 6 year old boy6 year old boy• Foster homeFoster home• Mother incarceratedMother incarcerated• ReputationReputation• AggressionAggression

Intergenerational TraumaIntergenerational Trauma

• Massive group traumaMassive group trauma• Effects suffering in subsequent Effects suffering in subsequent

generationsgenerations• Undermines identityUndermines identity• Bill 14, 1920Bill 14, 1920

(Bombay, Matheson, and Anisman – J Aboriginal Health 2009)(Bombay, Matheson, and Anisman – J Aboriginal Health 2009)

Intergenerational Trauma Intergenerational Trauma

• Trauma linkageTrauma linkage• BenefitsBenefits• LimitationsLimitations

(Kirmayer, Tait and Simpson in” Healing Traditions” Kirmayer and Valaskakis, (Kirmayer, Tait and Simpson in” Healing Traditions” Kirmayer and Valaskakis, 2009)2009)

Historical TraumaHistorical Trauma

• CumulativeCumulative• H.T.E.H.T.E.• Inter-generationalInter-generational• Post genocide Post genocide

DR. MARIA YELLOW HORSE BRAVEHEART - 2000

RelevanceRelevance

• Re-conceptualizationRe-conceptualization• Sophisticated formulationSophisticated formulation• Social justiceSocial justice• Educational ProgressEducational Progress

Questions?Questions?Thanks Aulneau Centre, Ms Frankie Scribe, Ms Lori Thanks Aulneau Centre, Ms Frankie Scribe, Ms Lori Middendorp, Ms Ainsleigh Marcinychyn, Ms Lise Turenne, Middendorp, Ms Ainsleigh Marcinychyn, Ms Lise Turenne, Ms Katelin McDermott, and Mr. Stan Kipling for their Ms Katelin McDermott, and Mr. Stan Kipling for their contributions to the presentation and our workcontributions to the presentation and our work

Photo credits:Photo credits:

Sunset in Cross Lake by Gerald McDonald c/o CTV NewsSunset in Cross Lake by Gerald McDonald c/o CTV News

Aerial view of GodAerial view of God’’s Lake Narrows c/o Gods Lake Narrows c/o God’’s Lake Narrows s Lake Narrows First Nation School First Nation School

Photos of Pukatawagan by K. HillmanPhotos of Pukatawagan by K. Hillman

Cross Lake and MB Youth (Front and slide # XX) aadnc-aandc.gc.ca