With more than 81,000 mental health patient visits last year, Osler is home to one of the largest Mental Health and Addictions community hospital programs in the province. Each month, Osler receives about 1,400 referrals for several outpatient clinics offered across its three sites (this number does not include referrals for addiction treatment). 

To better meet the intense demand for outpatient services—without any additional resources—Osler implemented a Stepped Care model in 2019. This flexible approach means patients can be referred to any one of four different levels of psychotherapy, depending on their needs, and can ‘step up’ or ‘step down’ to any other level when more or less intense treatment becomes appropriate. Each level includes individual and group therapy sessions, and wait time to join a program is no more than 2 or 3 weeks.

When COVID-19 restrictions made in-person meetings impossible, Osler’s Mental Health and Addictions team mobilized quickly to implement virtual sessions to ensure crucial mental health care was available. The first two groups were rolled out in April; since then virtual sessions have been rolled out for the remaining Stepped Care groups.

“Because we can't bring people into the building, especially in groups, we looked into different technology and decided on Zoom,” says Faiza Khalid-Khan, Clinical Director of Mental Health and Addictions. “Referrals come in as usual and the patient then gets a link to join the group. With Zoom, you're able to see the people that are in the room and use various signs to communicate back and forth. We have essentially the same clinicians as before, so the familiarity is there with existing patients, just on a new platform.”

Staff have been enthusiastic about the virtual care model right from the beginning says Faiza. “They were very eager to start and in the weeks before we launched, the staff were practising with each other to get comfortable with the platform. Staff have all different comfort levels with technology, but they've adapted really well.”

The Stepped Care model is rooted in a hybrid model of virtual and in-person care, so even before the pandemic, virtual care was on the radar for the Mental Health and Addictions team; therefore they were able to mobilize rapidly during the pandemic.

“Originally in the Stepped Care model, we had hoped that we could do some blended virtual therapies, where some initial sessions could be in person, so that you build a rapport,” says Faiza. “Right now because we can't offer any in person, we've gone ahead and done everything virtual. There'll be some people that will always need to be in person, but even they can benefit from some blended sessions.

“Stepped Care in England is based on step one using a web-based digital platform. I always had in mind that we would have a virtual component to increase access for our communities—geographic boundaries mean nothing,” says Faiza. “But it's not for everybody. In normal circumstances, some people prefer to come in. It is another tool in our toolkit.”

While Zoom is the preferred platform for group sessions, the team leverages other technologies for different needs.

“There are other ways of delivering therapy virtually. It's not just video conference technology. It can also be over email or preferably on a web-based platform where patients have access to modules and communicate with online chat. In the absence of such a platform, we are using email to send patient modules and using telephone and email to provide skill-based psychotherapy,” says Faiza. “Ontario Telemedicine Network (OTN) is always there, but it was made for the one-on-one physician encounters, not for groups, so we're using that for the one-on-one interactions. Ultimately, we use a mixture of Zoom, phone and OTN. Clinicians have access to all three to provide care.”

Faiza notes that this method of delivering therapy has been very effective and staff feel confident that they are providing the same evidence-based and structured material in a virtual format. Both staff and patients have asked if these virtual options will continue in the long-term.

“Post pandemic, we are planning to have a hybrid model of in-person and virtual sessions for our structured psychotherapy Stepped Care program, where all group sessions and individual psychotherapy can be provided either in person or virtually.  This will increase access for patients who live too far to attend in person or who are unable to attend regularly due to academic or employment obligations, and it will provide an option for those who prefer virtual care or a hybrid model. The pandemic has opened up endless possibilities to provide options that are more patient focused and convenient without sacrificing quality,” she says.

The team has also had to respond to an increased demand for mental health services brought on by the pandemic.

“Depression is compounded by staying home and not having a job. We are hearing that not only from patients but even our own staff,” says Faiza. “A lot of people are having health anxiety related to COVID-19, so we've decided to offer a group related to COVID-19 health anxiety on its own. Patients’ pre-existing mental health concerns are triggered due to the uncertainties of the future, also elevating their level of anxiety.  We are seeing a larger number of referrals to our programs and patients are extremely grateful that they have access to effective virtual care programs with the same quality as they were expecting from in-person sessions.”