PROMISING PRACTICES
A Podcast about Mental Health and Addictions

Episode 3: Manitoba

Episode 3: Rapid Access to Addictions Medicine (RAAM) Clinics (MB)

April 6, 2021 – A RAAM clinic is an accessible walk-in clinic that people can visit to get help for substance use without an appointment or formal referral. Those aspects: easily accessible, self-referral, timely help – are key to this service model. RAAM clinics are for people seeking help with high-risk substance use and addictions.

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Loretta O’Connor: Welcome back to the Promising Practices podcast, a 13-episode series on mental health and addictions. This podcast is an initiative of Canada’s Premiers. Its purpose is to highlight promising practices in each province and territory. My name is Loretta O’Connor. I’m the Executive Director of the Council of the Federation Secretariat, an organization that supports the work of Canada’s Premiers.

Today we are in Manitoba, a Prairie province that is home to 1.4 million people. The median age is 38, and about 18 per cent of the population is Indigenous. Like many Canadian provinces and territories, Manitoba has faced challenges with people struggling with addictions. Dealing with an alcohol or drug problem can be extremely difficult.

Today, Manitoba offers services to those in need through six Rapid Access to Addictions Medicine Clinics, known as RAAM clinics. These are easy to access, walk-in clinics that people can visit to get help for substance use without an appointment or a referral. Patients are able to receive assessments, counselling, be prescribed medications, and referred to community treatment plans. The RAAM clinics are part of a multifaceted approach to enhance Manitobans’ access to mental health and addictions care. Here today to tell us more, and to put the clinics in the context of the bigger picture, is Manitoba Premier Brian Pallister.

Premier Brian Pallister: Hi, I'm Brian Pallister, Premier of Manitoba. Like so many jurisdictions, our province has been deeply affected by the scourge of addiction. Now, some may say, well, I don't have an addiction, so this issue doesn't affect me. But, in fact, it affects all of us.

Manitobans of all ages, from all walks of life, in both urban and rural locations, our entire province feels the ripple effect of addiction, through its impact not only on healthcare delivery, but also in areas such as justice, employment, and social services. More importantly, the human costs of addiction are immeasurable, hurting not only individuals, but children, families, workplaces and communities.

So, of course, we set out to address this complicated issue by helping people get the help that they need to get healthy and to get their lives back on a positive path. In 2018, we commissioned a study of Manitoba’s mental health and addiction services by VIRGO Planning and Evaluation consultants. The study identified key challenges experienced in navigating Manitoba’s mental health and addiction services. And it also outlined the need for a more integrated and comprehensive provincial plan.

In response, our government created a Department of Mental Health, Wellness and Recovery, a first of its kind department, with staff assigned to develop and manage a whole-of-government response that is sensitive to the needs of our province’s diverse population. This department is quite unique, but it was very necessary. Under the direction of the new minister, this department is responsible for:

  • continuing to develop a mental health and addiction plan to guide the transformation of mental health services, with a focus on improving access, investing in early prevention, and youth mental health,
  • continuing to consult with internal and external stakeholders to determine the most effective way to deliver quality mental health and addiction services,
  • continuing to develop partnerships that can immediately respond to mental health needs that includes pivotal investments and improvements in services
  • continuing to partner with Indigenous … As you know, Manitoba has the highest Indigenous population of any Canadian province. And we're going to continue to partner with Indigenous and Northern Relations departments to support First Nations and Métis peoples to develop culturally appropriate wellness supports,
  • engaging and empowering community services to deliver a continuum of services,
  • leading the delivery of mental health services for adults and children with a focus on women, Indigenous persons and youth at risk,
  • and establishing a plan to build proper inter-operative information and communications technology and support tools to assist with decision making and funding.

We have since developed Manitoba’s first provincial clinical and preventative services plan which includes a specific focus on improving access, quality and equity of mental health and addiction services across the province. Clinical experts and frontline health care providers are involved in the development of new models and settings of care to improve coordination and communication between providers and to enhance the capacity to provide appropriate care in the community.

As part of our continued commitment to improving addiction services, our government opened six Rapid Access to Addictions Medicine clinics, they are known as RAAM clinics, while enhancing the level of care. RAAM clinics are easy-access walk-in clinics that people can attend to get help for substance use without an appointment or a formal referral. They are specifically designed to address the unique needs of patients experiencing mental health and addictions related issues. The centralized RAAM hub in Winnipeg provides provincial support, mentorship, training, recruitment and collaboration for all RAAM clinics throughout Manitoba. This will help develop skilled and supported clinical teams that can provide high quality services in our communities. The investments in the establishment of the RAAM model include $1.2 million in annual funding to enhance staffing resources at the clinics that we announced last year.

Our investment in this multifaceted program builds on many other initiatives announced over the past year to enhance Manitobans’ access to mental health and addictions care. Just in the last year and a half, we've invested more than $47 million in 28 separate initiatives aimed at improving mental health and addiction services throughout the province of Manitoba. These investments fulfill recommendations made in the VIRGO report, which were to increase capacity for opioid agonist therapy and community-based treatment services. The sooner and the more easily that Manitobans can access mental health and addictions care, the sooner we can get them the help they need to getting healthy and onto a more positive path toward achieving their full potential.

Loretta O’Connor: Thank you, Premier Pallister for the overview of how Manitoba is investing in access to addiction services for its residents. Here to explain the RAAM clinics in further detail is Audrey Gordon, Minister of Mental Health, Wellness and Recovery.

Minister Audrey Gordon: Hello, I'm Audrey Gordon, and I'm proud to be Manitoba’s first-ever Minister of Mental Health, Wellness and Recovery. Premier Pallister has already given a great overview of what we are working to achieve in my department and through our whole-of-government approach to helping all Manitobans, both rural and urban citizens in need of mental health and addictions care and treatment. We continue to strive to provide Manitobans with timely access to evidence-based treatment, as well as support for patients and their families in their journey through recovery and healing.

The RAAM hub has been key to helping us achieve our goals and help more Manitobans get the help they need and in a timely fashion. We have two provincial physician co-leads Dr. Erin Knight and Dr. Ginette Poulin, fulfilling the medical director role to engage recruit, train, mentor and coach primary care providers. These doctors will also champion the implementation of withdrawal protocols, establish RAAM clinic protocols, and develop clinical and safe care pathways for patient transfers to and from RAAM clinics.

We've also hired Brent Anderson as a full-time provincial coordinator to engage with RAAM clinics, stakeholders and the community to promote understanding, improve and standardize processes, lead a community of practice and measure performance. Another significant achievement was our development of a provincial on-call service to support and mentor practitioners who are providing care to patients who access RAAM services or who are receiving addictions medication.

Clearly, this is a full team effort. I'm pleased to note the sixth RAAM clinic was opened in Manitoba in October 2020 in Portage la Prairie. Other RAAM clinics include two in Winnipeg, and one each in Brandon, Selkirk and Thompson. The investment in the hub and the clinics is more than $650,000 per year, with regional health authorities providing additional funding in one-time renovation costs. It follows previous investments in the establishment of the RAAM model, including $1.2 million in annual funding to enhance staffing resources at clinics announced last year.

As Premier Pallister noted, a RAAM clinic is an accessible walk-in clinic that people can visit to get help for substance use without an appointment or formal referral. Those aspects: easily accessible, self-referral, timely help – are key to this service model. RAAM clinics are for people seeking help with high-risk substance use and addictions. This includes people who want to try medical assistance to reduce or stop their substance use. Patients may experience frequent intoxication or overdose symptoms, as well as unpleasant withdrawal symptoms when attempting to reduce, or stop, their substance use on their own. Clinic staff can help them weather those recovery storms.

RAAM clinics are also for people who may have substance-related health issues, such as hepatitis or pancreatitis and infections. RAAM clinics are not for people need an urgent medical attention for serious physical problems, or mental health symptoms such as psychosis, extreme agitation, active risk of harm to self or others, or those whose behavior required police security involvement. The staff working at these clinics are non-judgmental. They understand how hard it can be for some people to ask for help. Patients don't need an appointment to visit the clinic – just show up during clinic hours to gain access to safe and effective treatment and support.

Loretta O’Connor: That was Minister Audrey Gordon on the RAAM clinics and how their development is impacting addictions services in Manitoba. For a closer look at the clinics and some of their key benefits, here is Dr. Erin Knight, who has been involved with the clinics since their inception in 2018.

Dr. Erin Knight: Hello, my name is Erin Knight. I am a fellowship-trained addiction physician and a family physician. Among other roles, I am the Medical Director of Addiction Services including the addictions unit at the Health Sciences Center in Winnipeg. I have been involved with the RAAM clinics as the medical lead of the clinic located at the Crisis Response Center. That was the first clinic to launch in August of 2018. I am now also the medical co-lead for the RAAM hub in Manitoba.

Premier Pallister and Minister Gordon have done an excellent job of providing some of the background regarding RAAM and why it's been an important part of expanding services for all Manitobans.

One of the greatest benefits of RAAM is that it makes it easier for people to access care in one place, instead of having to go to multiple different places for service. RAAM clinics offer Manitobans access to an interdisciplinary team all through a single clinic which people can access without an appointment or a referral. At a drop-in RAAM clinic a person can see a specialized nurse, a clinician who may be a nurse practitioner, a physician or a physician assistant, and a counselor, in a single visit. All of these caregivers work together to create treatment plans that are tailored to the patient's needs.

It's important for people to know that substance use disorders are treatable just like other chronic conditions like diabetes, depression or heart disease. As is the case with other chronic conditions, treatment for substance use can take many forms including lifestyle modification to reduce harms, counseling, and supports. It can also include prescribed medications to treat overdose or withdrawal symptoms, as well as to prevent cravings and prevent relapse.

After the first visit, the length of time a person remains involved with a RAAM clinic may vary. For some, after brief education and connection to relevant resources, including withdrawal management and treatment programs, they may require no specific follow up or may be able to return to the care of their family physician. For others who do not have a family physician, or who require more specialized care, including opioid agonist therapy with buprenorphine or methadone, they may be followed by RAAM for a longer period of time until we connect them with a long-term care provider.

Before I go into more details, it's important to note that if this podcast is causing undue anxiety or a trigger event for you, there are places that you can reach out to for support. in Manitoba, the clinic Crisis Line offers 24-hour support available at 1-888-322-3019. You may also be able to access local or regional crisis services by telephone or in person in your area.

So, let's walk through what happens when a person goes to a RAAM clinic. The clinic team will complete a health history for you including questions about your substance use, such as when and how you started using, how much and how frequently you use, and how much it impacts your life and responsibilities. Again, it's important to remember that there's no judgment from the treatment team. These questions are asked only to get a picture of you and how we can best help.

Once a health history is complete, the RAAM clinic team will make treatment recommendations. In general, there are several options available. The first possible option is education. The RAAM clinic team will give you information on how to make choices that will lower the risks of substance use, such as tips about how to pace your use as well as situations to avoid. The second option or tool is counseling. The RAAM clinic team provides brief counseling, or you may be referred to counseling programs as part of your treatment. Counseling programs can include education on substances and healthy lifestyle choices. group and individual counseling sessions, help with developing coping skills and connections to support groups. The team will work with you to determine what form of counseling would be most helpful for you.

A third option is medication. Addiction to some substances such as alcohol or opioids can be treated with medication that will help to lessen cravings, as well as decrease the withdrawal symptoms that may accompany your early days of sobriety. Medication may make other types of treatment more effective and reduce the risk of relapse. These medications are safe and effective when prescribed by a RAAM physician. The team will discuss appropriate options with you as well as risks and benefits.

A fourth option is a referral to additional or other supports. Some more intensive services such as withdrawal management services or detox, as well as residential addiction treatment, may be needed. The RAAM clinic team can arrange referrals to these services, as well as to other specialized services.

In addition to the low-barrier, evidence-based clinical services provided to patients and families by the individual clinics, the RAAM hub, which was established in the spring of 2020, has been able to provide:

  • standardized policies and protocols to ensure consistent practice across the province’s RAAM services.
  • a 24/7 on-call addiction medicine service to support pharmacies, primary care and acute care providers caring for people followed by RAAM,
  • mentorship to enhance capacity to treat substance use disorders within primary care, and
  • outreach and support for community initiatives to respond to people with substance use disorders during COVID-19.

Loretta O’Connor: Thank you, Dr. Erin Knight for that excellent overview of the RAAM clinic process. As she points out, it's important for people to know that problems with substance use are treatable, just like other chronic conditions like heart disease, diabetes or depression. The clinics have made a lot of progress since their inception and feature a robust, comprehensive approach to addictions management. Let’s return to Dr. Knight to hear more about the RAAM clinics and how they have recalibrated their approach during the COVID-19 pandemic.

Dr. Erin Knight: From August 2018 through December 2020, 4,757 people registered at a RAAM clinic for care. High volumes for both initial assessments and follow-up have led to the gradual expansion of clinics including the development of dedicated follow-up clinics. RAAM has been asking for feedback from patients and families through a combination of ongoing surveys, as well as interviews conducted in the summer of 2019. Overall feedback has been extremely positive. Suggestions for improvement have been integrated by developing enhanced information-sharing tools.

Like all other clinical services, RAAM has been impacted by the COVID-19 pandemic. Early in the pandemic, virtual clinics were established at the RAAM clinic located at the Crisis Response Centre, and work is underway to expand these services across the province. We are also actively exploring partnerships with Indigenous communities to ensure access to care in remote settings.

A major challenge for RAAM both in Manitoba and in other jurisdictions is creating capacity for providing substance-use care, including opioid agonist therapy within the primary care setting. This challenge with capacity results in patients being followed through RAAM for a longer period of time than is necessary, creating a bottleneck that limits capacity for new assessments. Since the establishment of RAAM clinics, a strong partnership with primary care has been developed, and work continues on enhancing care and referral pathways between services. Similarly, the RAAM hub is working with emergency departments and urgent care centres to ensure strong pathways between services and to help establish evidence-based protocols for the treatment of substance use disorders in the emergency setting.

Part of the strategy to develop capacity within the larger medical community for these important care services is to provide education and mentorship through the RAAM hub. In line with the clinical and preventive services plan, the RAAM hub is actively developing an ECHO program for substance use. ECHO which stands for Extension for Community Health Care Outcomes is a model developed by the University of New Mexico. ECHO provides an online platform to connect experts and care providers across large distances to increase local capacity through case-based learning. The first ECHO session for substance use is planned to launch in the spring of 2021.

Overall, we are pleased to note that RAAM clinics have been extremely successful in reducing the barriers to accessing care that people have traditionally experienced when seeking help with substance use. It is not without its struggles, including capacity to handle the ever-increasing demand for services. This is not unexpected, because whenever you open a new resource for assessment it often highlights the need for other services. However, I'm confident that RAAM clinics, by continuing to work actively with our partners in primary care, emergency, acute care, mental health, withdrawal management, peer support and treatment programs, can be used as a central service to build a more cohesive substance use system that is nimble and responsive to the needs of the population.

Loretta O’Connor: Thank you to Premier Brian Pallister, Minister Audrey Gordon, and Dr. Erin Knight for sharing the addictions services and care available through the RAAM clinics in Manitoba. What a successful approach to reducing barriers to care.

Join us again next week when we will learn more about Ontario’s Tele-Mental Health Service for Children and Youth. This initiative uses videoconferencing to provide children and youth in rural, remote and underserved communities with access to specialized mental health consultations. It connects Ontario children and youth to a specialist who can help them.

Thank you for listening, and be sure to join us again next week!

 

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