Table 4 Summary of qualitative findings

Insufficient resources to enact SC2.0

O1.1 Insufficient resources available for a SC2.0 continuum

Providers felt that there were insufficient resources to populate an SC2.0 continuum. This included resources for care (e.g., peer support, guided self-help, peer reviewed educational materials, etc.), and for increasing client literacy about the new model (e.g., handouts explaining the new care delivery model)

–

7

104

I think it could work if we had the resources to be implemented and if we yeah, it would work if we had the resources, if we don't, then it's not going to work and I think you have to I have enough buy-in from people (P1074)

CC2

O1.1.1 Variance in available resources due to region

Different regions may have different resource availability, impacting providers’ ability to implement stepped care into their practice. Further, services may be inaccessible in rural communities due to distance and lack of transportation

–

3

–

There's a lot of walk in counselling where they would just come to our office and meet with us but for us, like our office is at least 30 min from every school that we have cause our schools are in the outskirts. So they can't come to our office. Our communities are very small with not a lot of people that have methods of transportation to our offices (P1133)

CC2

O1.2 Insufficient space to enact OAAT therapy sessions within child and youth services

The lack of physical space (e.g., not having office space) is a barrier to implementing OAAT therapy within the SC2.0 model for child and youth services. This also may pertain to rural areas

–

3

12

We don't have offices in each region nor do we have the space to add to our current offices to accommodate how they want to implement this. (P12)

CC1

CC4

O1.3 Insufficient staffing

Some providers indicated that there are insufficient employees to adequately serve the amount of clients presenting for services. Others thought that SC2.0 would result in an unmanageable increase in client demands relative to staffing capabilities. This may result in challenges with the rollout

–

–

43

Our organization is already extremely understaffed, while stepped care is supposed to help us manage waitlists and decrease wait times, we are also being told that every member of staff is to start implementing this; adding another responsibility to clinicians is going to take them from clients they're already serving. (P92)

CC1

CC4

Interprofessional and interorganizational misalignment

O2.1 Stakeholder and management lack of support of SC2.0 model

Lack of support and disagreement between stakeholders and management about the value and evidence of SC2.0

–

–

13

I feel that health management will not agree to the process of the Stepped 2.0 process. To understand my answer you would have to understand the power struggle between health and education that exists in the Integrated Service Delivery model. (P1123)

–

O2.2 Stakeholders do not have a shared understanding and vision of the SC2.0 model, which acts as a barrier to collaboration and cooperation among professionals and work settings

Each stakeholder (e.g., community partner, healthcare partners) has a unique contribution and plays an important role in the continuum of care. A unified approach stems from collaboration and a shared understanding of the model. Numerous child and youth providers felt that partners (e.g., from the school districts) were insufficiently engaged, and further education is needed to help them understand their role in the model and the role of lower intensity services

3

3

33

All systems need to aim to be aligned with this—therefore they must talk and work together to ensure fidelity for it to work efficiently (P1208)

CC1

O2.3 Current organizational protocols and procedures are incongruent with the procedures of OAAT therapy sessions

Current organization procedures (e.g., information technology systems for documentation, intake assessment processes, etc.) and frameworks will create difficulties in transitioning to the provincial SC2.0 model, specifically with OAAT therapy sessions. For example, at time of interview, practices involved completing an intake and placing clients on a 7-month waitlist. Providers expressed uncertainty whether employers would support them moving away from a model that involved completion of a comprehensive intake

5

–

25

Assessments. We currently complete an Intake Assessment for all new referrals. with SC2.0, there are no formal assessments like the one we use. Not sure if not completing our normal Intake Assessment would be supported by our employer. (P1038)

CC1

CC4

 O2.3.1 Individuals in leadership may not have sufficient background experience

Some providers feel that "higher up" individuals had insufficient field experience to hold realistic expectations. Providers would like the organization to privilege their expertise

4

–

–

I just hope those who are in the managerial and those director positions listen to the front-line workers because so often we're not heard and we're dealing in it. We're emersed in it every day. (P250)

–

Uncertainty in the organization's planning and preparations

O3.1 Uncertainty in the organization's planning and preparations

Providers reported suboptimal trust in governmental organizations. Concern was expressed around the history of poorly planned provincial change initiatives, influencing providers’ perceptions of how the SC2.0 model will be executed and rolled out

6

7

15

That being said, I don't have confidence that the government can support system wide changes that will implement stepped care properly. (P1198)

–

Provider resistance to the implementation of SC2.0 into practise

PBar1.1 Perceived provider lack of support of SC2.0 model

Perception that a lack of support for the SC2.0 model by clinicians, stakeholders, and management will reduce the likelihood of enacting required processes or policies, and undermine implementation

–

–

16

Not all providers agree with this method of intervention. (P1219)

–

PBar1.2 Difficulty overcoming complacency with current practice

Providers expressed hesitancy or resistance to OAAT therapy and SC2.0 because they are comfortable with the methods of their current practice and do not want to deviate. This may be more common among: 1) clinicians that have been practicing for an extended period of time and/or highly value traditional methods of practice (e.g., need for long-term treatment); or 2) providers who just settled into their role who may be reluctant to make additional changes

5

5

37

Some clinical-minded professionals present with a traditional mindset of the clinical/professional is best suited to determine the needs of the client and that things cannot or should not be changed. This is a barrier I can see to implementing step care. (P1140)

–

PBar1.3 Difficulty accepting and adjusting to change

A belief was held that providers or colleagues struggle to adjust to change in general. This may result in hesitance or difficulty enacting the SC2.0 model. Providers felt that they will require a period of adaptation to adjust to this change process

–

–

25

Overall, I think it will be a challenge for staff to shift their thinking and processes. (P161)

–

PBar1.4 Difficulty enacting change during a time when providers are already overburdened with work demands

With already high work demands (e.g., caseload), finding time to complete training and prepare/gather resources to adapt their practice to the model will be a challenge. Some providers indicated that OAAT therapy would be added to their existing caseload and create additional days of being "on call."

–

–

19

Worry that the work of creating these additional steps will be placed on the front line workers;I worry that offering same day OAATS appointments will mean additional days of being "on call" in addition to the days we are already expected to do. (P1199)

–

Insufficient perceived self-efficacy to enact OAAT therapy sessions

PBar2.1 Not feeling prepared and confident in delivery of skills required for OAAT therapy sessions

Some providers believe they do not know what they are doing. They may not feel confident in their skills or enacting their skills in practice

3

–

–

When I did the online training- just the online training I found it harder to [implement OAAT into practice] because it gave me a good sense of what everything was, but I didn't really know what to do yet. (P1002)

CC7

PBar2.2 Providers have an insufficient awareness of accessible resources

Despite the existence of resources, providers are unaware or lack knowledge of them. A compilation of resources for provider reference would be beneficial

–

–

13

Difficulty in knowing what all the community resources are, many groups in clinic are ending/starting/shifting (P205)

CC2

Provider concern regarding universality of OAAT within SC2.0 across populations

CBar1.1 Provider concern about how OAAT therapy sessions will work for individuals with complex presenting concerns

Uncertainty regarding suitability of model for clients experiencing intersectoral issues and/or complex concerns (e.g., housing issues, addiction, personality disorders)

8

–

20

We have had a couple of moments or a couple of clients where we found out halfway through the session that this was not a good idea (P194)

CC3

CC5

CBar1.2 Provider concern that the SC2.0 model will not fit for child and youth clients

Difficulty understanding how the child and youth integrated service delivery model aligns with the SC2.0 model/approach, particularly given the interaction between children and youth, their families, and the school system

–

–

27

The model does not explain how to apply with children, teenagers, their families and the schools we work with every day. It can be difficult to even know who has the autonomy of the treatment, the parent? teenager? (P1005)

CC1

CC5

Inequitable access to services

CBar2.1 Inequity of access to services due to economic barriers

Lack of economic resources (e.g., transportation, internet, access to technology) prevents clients from being able to access the full continuum of care

4

4

14

NB is the province with the lowest literacy rate. Having step one being a self-information style process, I can foresee many barriers from many NB'ers (P1040)

CC1

CC6

Incongruent expectations of service delivery

CBar3.1 Client preference for or expectation of long-term therapy when attending OAAT therapy sessions

Client (or parent of client) expects or requests long-term therapy. The unmet expectation to receive long-term therapy may result in client resistance towards the SC2.0 approach

–

–

27

Some clients expect traditional treatment and want long term support even if it is not necessary. (P1005)

CC2

CC7

CC8

CBar3.2 Client preference for or expectation of higher-intensity service during OAAT therapy sessions or when referred to other resources throughout the SC2.0 continuum

Client (or parent of client) expects or requests more intensive services or is told that a higher-intensity service will work better. Often, these higher-intensity services are not warranted to meet the needs of the client, but the misalignment with client expectations may lead to resistance towards the SC2.0 approach

–

–

30

We notice that many clients expect intensive psychotherapy for situations that could be resolved by a much less intensive intervention. Also we notice that many clients ask to be seen by a psychologist, even if their situation could be answered by a practitioner from another discipline (P1011)

CC2

CC7

CC8

Low client capacity for change and engagement

CBar4.1 Client’s may experience low readiness and motivation to engage in a service/treatment

Clients (or parents/guardians of clients) may not be ready to engage in the service. This may become apparent through low motivation and lack of willingness to participate in the service and put effort into their recovery

–

–

31

Getting the client to see themselves as the expert of their own life when sometimes they are looking for a quick fix. (P190)

CC6

CC9

CBar4.2 Client difficulty accepting and adjusting to change in service to OAAT therapy sessions

Clients may have difficulty adjusting to the change because of their comfort with the approach to care that they were receiving, and/or expectations for a service. This may result in resistance towards the SC2.0 approach. Clients will need time to adjust to this change process in order to become more engaged

12

–

34

It has taken a little while to kind of get [clients] used to the fact that things have changed. You get a few clients where they’re just so used to the old system, but that's what they just expect (P22)

CC7

CC9

 CBar4.2.1 Client dependence on the provider

Client may become securely attached to a provider or service and may have difficulty transitioning to an OAAT therapeutic approach. Client may rely on the provider to be the expert and make decisions for them, or “fix” them

–

–

13

Many clients seem to depend on their caseworker to guide them. A lot of clients say I don't know when trying to come up with what they need; they may feel like the professional is not helping them… some people want to be told what to do because it's easier; teens today are used to googling answers, are not asked to think of their own answers very often. (P1051)

-

Increased efficiency throughout practice

PBen1.1 Efficient use of time during OAAT therapy sessions

More efficient use of time with clients when implementing OAAT therapy

7

–

10

I like the One-at-a-Time because it's not shutting the door from people coming back and getting services, but I find we waste a lot of our time chasing after clients and getting frustrated because people aren't changing (P13)

CC7

 PBen1.1.1 Shorter assessments and treatments when using an OAAT therapeutic approach

Client assessments and treatments are shorter when using OAAT therapeutic approach in comparison to traditional non-SC2.0 service models

12

5

–

a lot of what I do is the screening cause we have our screening is really like 26 pages when we screen new clients. They're fixing that because of OAAT. We're going to switch it to a much- from what I saw it's going to be a much cleaner. Not so much information, there's a lot of stuff that we ask that we don't probably need to. (P1013)

–

PBen1.2 Fewer “no shows” by using OAAT therapy throughout the SC2.0 continuum

Fewer no shows as a result of drop-in services (i.e., OAAT therapy) and offering services that are better suited to client needs. Clients rarely miss their scheduled appointments (i.e., appointments are not wasted) 

–

–

16

I think that there will be fewer wasted appointments (fewer no shows and cancellations) that arise from a client who is receiving an ill-fitting service. (P164)

CC7

PBen1.3 Increased general efficiency due to the SC2.0 model

Provider describes increased efficiency (i.e., generally, resources, costs to practise)

–

5

22

More efficient and effective. (P1117)

CC6

PBen1.4 Clients transition in and out of care more rapidly due to timely improvements in outcomes, resulting from an OAAT therapeutic approach

Treatments occur over fewer sessions or for a shorter duration of sessions as clients receive improved outcomes sooner. In turn, more clients can be seen sooner

–

–

19

Seeing more clients making progress in a more timely fashion. (P1018)

 PBen1.4.1 Provider is able to see more clients due to an OAAT therapeutic approach for service delivery

Provider can provide treatment for more clients and clients have easier access to treatment

–

–

23

Provide some service to more clients, rather than a lot of service to a few. (P16)

–

Increased provider job satisfaction

PBen2.1 Feeling of accomplishment by providing OAAT therapy sessions to clients in a time of need

Provider feels that their work is more impactful in meeting clients’ needs (e.g., making small changes with clients that results in immediate benefits). Providers feel that they are making a difference

–

–

18

Much more satisfaction and feel like I am making a difference today (P206)

–

PBen2.2 General satisfaction

Provider describes anticipating improved satisfaction with their job, but does not elaborate

–

–

12

Better satisfaction from the employees. (P1073)

–

PBen2.3 Greater provider morale

Increased provider morale accomplished by improved confidence, satisfaction, and work-life balance through the SC2.0 model

-

3

11

Will result in happier staff. (P1174)

–

Reduced provider burden

PBen3.1 Reduced caseloads for providers

Through the implementation of a SC2.0 model, providers anticipate having reduced caseloads, possibly related to a reduction in long-term clients on caseloads

–

3

23

The references keep coming in people coming in for services and move them to other resources at the time, you end up with this ever-increasing caseload, higher rate of burnout people having less time to dedicate to every individual. I think it's so important to be able to manage caseloads to adequately meet the needs of people and the increasing need for mental health services. That's been present for a number of years so it's great that we finally have SC2.0 now. (P42)

–

 PBen3.1.1 Encourages interprofessional support

SC2.0 fosters a collaborative environment among colleagues in which providers can look to each other for advice or support

–

3

–

With clinicians, we have lunch together and stuff and sometimes it's heavy… You know, like, sometimes clients are not at a good space. It can be demanding for clinicians. So once they identify where, what support that client needs, or, like, what level they are, they can distribute it evenly, so you don't have a clinician that has a lot of cases … (P54)

–

PBen3.2 Sense of relief in practice due to upcoming implementation of SC2.0

Providers feel less stress, pressure, and frustration due to the change in service due to the SC2.0 approach (e.g., less pressure for clinicians/service to have all the answers or fix client concerns)

–

–

22

Less pressure on clinicians to feel like they have to fix everything. (P1173)

–

PBen3.3 Client's readiness to engage in a particular service within the SC2.0 continuum reduces the burden of the provider

Provider burden is reduced because the client is ready to engage in their care and the provider does not have to "chase" or repeatedly follow up with the client

–

–

17

People who actually want services receive them.(P1215)

–

Model fosters provider’s understanding of their role and engagement in the system, promoting more effective practice and tangible change

PBen4.1 SC2.0 is congruent with professional standards and is felicitous for the current climate

This model encompasses the treatment style that providers believe is their perceived standard of care

–

3

–

They are coming in, we’re helping them, they’re leaving feeling better. That’s the whole point of what we’re doing (P217)

–

PBen4.2 An antidote to complacency

Provider describes that the implementation of the SC2.0 model changes their past approach to practice, and jolts providers out of their old way of doing things

–

5

–

Every now and then I will catch myself falling back into that, you know, ‘ah, what's really going on here? What’s wrong?’ and then want to dive into it. I probably still do that because I've been doing it for years, right? If can identify what's going on with you, then I can pick the best treatment for you, right? So, one of the things that this program has done for me is help me remember there's other ways to treat problems that don't involve a person coming into my office for an hour every 2 weeks. (P203)

–

PBen4.3 Provider readiness for change

Providers welcome the shift in practise and believes it will benefit clients and practise

–

6

–

it's sure I think it's a transition, but I think everybody's going to get there and I think they’ll see the benefit. (P54)

–

Services are better matched to client

CBen1.1 Client-centred care to meet clients’ needs and preferences

Services in the SC2.0 continuum provide clients with catered and specialized care that is targeted to their needs and preferences

–

7

41

[referring to stepped care] it's not about the clinician and my case load and what I think they need, or don't need it really is listening to that client, that student and, and trying to figure out what do they need in this moment (P1120)

CC9

 CBen1.1.1 Client is matched to service based on readiness and motivation

“Meets the client where they are at”; Clients are enrolled in the appropriate services that align with their level of motivation and readiness to engage in care

11

4

52

I really liked the idea that we could meet them where they were at, at that moment, to kind of help to diffuse some of those crises rather than later on down the road (P22)

CC9

 CBen1.1.2 Client is matched to service based on appropriate intensity for their needs and preferences

Clients are enrolled in the appropriate services, aligning with the level of intensity they need and level of commitment they are ready for. Clients have the flexibility to step up or down the continuum as needed

–

5

21

I have this client who absolutely loves the online modules. It was like, that's all I need – I’m good to go. And yeah, I was thinking I was like, that's interesting because that's probably someone who we would have for counseling for, like, 3 to 6 sessions or more in the past. And then she took these modules on anxiety and just ran with them. Just felt like she learned so much from them. (P1014)

CC9

CBen1.2 Increased collaboration between client and clinician

Providers are implementing key principles into practice, particularly relating to collaboration and considering client’s needs, readiness, and preferences, rather than care being dictated by the provider or fully autonomous. Further, providers were reminded about the value of collaboration in the online courses

7

4

19

collaboration, right, treating the client as an equal, not assuming I'm the expert and that I can tell them what to do. So I've always have that any way, that collaborative approach and and definitely trying to empower them. (P203)

CC8

Client-centricity

CBen2.1 Client empowerment

Suggests that new services will function to empower clients to lead their own mental healthcare journeys

–

3

27

I think they feel more empowered when they realize that, ‘Oh, you know, I have the ability to do these things by myself. (P37)

CC5

CBen2.2 Strengths-based approach within OAAT sessions of the Stepped Care model

Directly talks about emphasis put on the strengths of the client or that OAAT sessions takes a positive approach within the Stepped Care model

4

3

21

If they're coming in really problem focused, trying to tease out with them when has it been less of an issue for them and what other situation in life have they been able to overcome them. How they did that, and kind of taking that to try to figure out, based on that, what do you think the next step is for with the issue that you're coming with. (P16)

CC5

CBen2.3 Opportune timing of treatment as clients can avail of OAAT therapy sessions within the SC2.0 model

Any response alluding to care being received at the time that the client needs it, or when they are most motivated and ready (i.e., the right care offered at the right time)

4

3

40

They get that point of entry to the service. And if it's not you know they still made contact they've got confidence in the system, and you're able to refer to them for a higher intensity if need be (P42)

CC6

CBen2.4 Solution-focused OAAT therapy sessions

Addresses clients actual and practical issues. Focus is placed on the clients presenting concern, rather than “digging” for the root cause

14

5

33

It'll be less hard for the clinician; it'll be easier because sometimes you're feeling like you're always going in circles. You're not really getting anywhere, but here it's focused. With stepped care you really focus on what’s the issue today? what do you want to work on? (P1032)

CC7

CBen2.5 Increased client autonomy

The client is provided with a sense of control, autonomy, and choice in their care (i.e., shared decision making). This is viewed as leading to clients who are active in their own care. A belief was held that increased autonomy would lead to better outcomes

13

3

88

I think this model encourages people to have autonomy and with support, work to address the issues that they are having. And I think with that we have better success that way. (P217)

CC7

CC9

 CBen2.5.1 SC2.0 prevents client dependency on the provider

Providers feel that SC2.0 encourages the client to have responsibility over their own recovery, thereby preventing dependency on the therapist for the client's well-being. Clients learn to identify their needs, promoting autonomy and independence

–

5

–

I don't want them to be dependent on me. I don't want to take over their life, right? I'm trying to give them the skills that they need to build themselves up…(P203)

–

Improved overall experience with the mental health care system

CBen3.1 Client satisfaction with OAAT therapy

Clients are described to enjoy OAAT therapy, leaving sessions happy and satisfied with their outcome

–

3

13

I think clients will have a better chance of getting the care they are hoping for. (P167)

CC8

CBen3.2 Improved client outcomes

Clients leave treatment with better results. Discusses SC2.0 resulting in real change, improvements, and being more useful

–

3

30

Recovery at the forefront of practice. (P128)

CC8

CBen3.3 Improved quality of treatment through SC2.0 model

Quality of treatment provided to clients is described to be improved from past approaches. Change to the previous system was welcomed and noted as “long overdue”

–

–

10

A clear Framework that assists with aligning who we help, how we do it, when we do it, where we do it and why we do it. (P90)

CC4

CBen3.4 OAAT therapy sessions are appropriate for clients in crisis

Providers felt the model is a great approach for clients in crisis

5

–

–

It's a really great approach for people who just are having a crisis and that's a lot of our clients (P266)

CC7

CBen3.5 Quicker access to care through reduced wait-lists and wait-times

Suggests that services will be more easily accessed. Clients can access services faster and therefore the wait-times are reduced, including mention of same-day services and bypassing the intake process

15

8

178

Receive quicker service instead of waiting a significant amount of time on a waitlist. (P1098)

CC6

CC7

 CBen3.5.1 Clients can avail of OAAT therapy and lower intensity sessions while waiting on a wait-list

The SC2.0 continuum offers clients various forms of support, even while on a waitlist for higher intensity services

–

4

–

With the single session we’ve recently talked about what if you had a group of, you know, 5 or 6 people, and you did 4 or 5 coping skills and then if they have to sit on the waitlist, then at least they are sitting there with some skills. So, yeah, we're just sort of trying to figure out how to put it all in place. (P37)

CC7

CBen3.6 Increased accessibility to a greater variety of services for clients

More diverse resources and types of services will be offered through the SC2.0 continuum of care, which will offer clients informed choice when deciding on the best care option to meet their needs. Clients will feel like they have more choice in options of care that can better meet their level of readiness

–

–

64

Knowing they have options when accessing services. (P344)

CC6