Key attributes of integrated community-based youth service hubs for mental health: a scoping review

See Table 2 for a summary of the characteristics of ICYSH models. Many programs focused on adolescence through early adulthood. For example, headspace and Jigsaw include youth ages 12–25 [30, 31, 36, 45], and ACCESS Open Minds serves youth ages 11–25 [38‐41]. The 15–17 age range is the peak age of presentation at headspace [45‐48] and Jigsaw [49], with an overrepresentation of females (e.g., headspace, 63.7%) [45‐48]. However, nearly half of youth at Jigsaw were male (43.5%) [49]; there have been other encouraging findings regarding male youth accessing ICYSHs, despite evidence of greater difficulty engaging males in traditional mental health (MH) treatment [34, 50]. Service access at headspace is improved for youth who are socially and economically marginalized as compared to the general population, or those youth who lack support from their families and peers; however, young adults (18–25) and those from non-English speaking households are underrepresented [50].

Most models identified a focus on intervening during early stages of distress, possibly before diagnostic criteria are met [13, 36, 39, 40, 43, 51, 52]. In headspace centers, mood and anxiety symptoms and disorders were the most common presenting problem [46, 52‐55], although formal diagnosis was available for only few clients [46]. Additionally, 69–73% of headspace youth presented with high or very high levels of psychological distress [46, 48], and 19–29% of young adult clients were not engaged in education, employment or training [46, 56]. Jigsaw similarly reported seeing youth with high levels of psychological distress [49], with four main types of issues identified among youth: developmental, comorbid, anxious and externalizing disorders [57].

Documents varied in the level of detail provided about service settings. Several documents emphasized efforts to make settings accessible to youth, non-stigmatizing, and youth-friendly. For example, some programs were located in shopping centers and storefronts and involved youth in decisions about design and décor [43, 58]. Others were centrally located or close to public transportation [31, 38, 50]. In headspace centers, physical aspects of the settings described as youth-friendly include couches and bean bag chairs, colorful walls and creative artwork for a vibrant look, and an open waiting area and high ceilings to promote a feeling of safety and openness [59]. Youth-friendly environments were key for Foundry, including an informal, non-clinical space where youth can spend time with peers in addition to attending appointments [43]. Jigsaw discussed plans to develop a youth café with a public youth space and a program delivery area [34]. Some headspace centers encourage recreational use with pool and air-hockey tables [60].

Documents describing the types of service providers typically include a range of professionals from several disciplines. For example, the intensive mobile youth outreach service subprogram of Orygen Youth Health consists of two psychologists, two social workers, one occupational therapist, one psychiatric nurse, and a part-time consultant psychiatrist [61]. Very few documents provided detailed information about service providers’ roles. Within New Zealand’s Youth One Stop Shops, several services are offered by physicians, nurses, counsellors, social workers and youth staff [62], providing primary care, sexual and reproductive health, mental health, drug and alcohol services, counselling, smoking cessation, family planning, and health promotion and education services [38]. For the Foundry prototype, primary care and sexual health services are provided by general practitioners and nurse practitioners, mental health services by psychiatrists, and substance use counseling by social workers and nurses. Additionally, partnerships provide other services, including psychosocial rehabilitation, housing support, income assistance, and peer support. ACCESS Open Minds clinicians include professionals with psychology, nursing, social work, or occupational therapy backgrounds who assess youth needs and provide need-based care [40, 43]. In YouthCan IMPACT, each integrated collaborative care team includes youth workers, social workers, psychiatrists, nurse practitioners, peer support workers, access to primary care providers, and a care navigator [52]. For higher-risk youth, psychiatrists and/or nurse practitioners provide psychiatric assessment and medication management, along with other clinically appropriate interventions. Several ICYSH models in this review included peer support workers as service providers [38, 40, 43, 52, 63], reflecting the importance of youth with lived experience supporting other youth experiencing similar issues.

Many documents did not provide information on their service provider training process. Some documents broadly indicated that there is training in evidence-based interventions and best practices [36, 59, 64], in working with youth and youth-friendly approaches [59, 65], and professional development or continuing education activities [38, 66, 67], though difficulties with releasing staff for professional development opportunities were also noted [38]. Some documents mentioned ongoing supervision and regular team meetings [51, 68]. As part of Jigsaw, a structured training program addresses adolescent development and mental health, strengths-based and solution-focused approaches, risk assessment, goal setting, crisis response, interagency working and collaboration, consultation processes, and integrated planning and evaluation [34]. Initial training ensures a shared understanding of the Jigsaw philosophy and implementation process, with the plan of extending the training more broadly to others in the community who work with youth to increase service capacity.

More information was provided on broad types of services included in ICYSHs than on specific interventions (Table 2). headspace includes four core service streams: mental health, drug and alcohol services, primary care, and vocational assistance (e.g., [31, 69, 70]). Primary care is a component of several other models (e.g., [38, 43, 71]). Social services, including vocational assistance, education and training support, and housing support were a component of other models [37, 38]. Several models use brief, solution-focused interventions (e.g., [13, 34, 37, 45, 52]), as well as peer support and mentoring (e.g., [34, 52, 72]).

Some models provided information on specific psychosocial interventions utilized. Services provided by Jigsaw include case management, problem-solving, mindfulness, cognitive-behavioral therapy (CBT), substance use services, psychoeducation, and social skills [57]. In headspace centers, CBT was reported to be the most common treatment provided for all presenting concerns, followed by supportive counseling and psychoeducation [73]. In YouthCan IMPACT, standardized protocols are used for interventions including solution-focused brief therapy (SFBT) and group dialectical behavioral therapy (DBT) skills [52]. Early intervention approaches for psychosis including CBT were mentioned as part of enhanced headspace services, ACCESS Open Minds, and Orygen Youth Health [13, 14, 41]. ACCESS Open Minds provides services depending on a youth’s needs, including specific therapies (e.g. DBT for emotion dysregulation), transition to a specialist service (e.g. eating disorder program), or admission to a hospital (e.g. high risk of suicide) [40]. Some documents mentioned the use of evidence-based approaches, but not specific interventions (e.g., [42, 49]). For example, an independent headspace evaluation interim report indicated that implementation efforts were prioritized over tracking the extent of use of evidence-based treatments [74].

Intake and assessment processes were described in some papers; however, little information was provided on the use of standardized assessment measures. One exception, however, is the use of Kessler Psychological Distress Scale (K-10), Clinical Global Impression (CGI) scale, and the Social and Occupational Functioning Assessment Scale (SOFAS) by ACCESS Open Minds clinicians as part of a measurement-based care approach [40]. Some models mentioned following a stepped-care or clinical staging model (e.g., [51, 52]). Other work did not use this terminology, but described analogous processes. For example, headspace interventions are said to be delivered according to severity and complexity of an individual’s needs [64]. Some documents discussed personalized treatment plans [37] and person-centered approaches [42].

Infrastructure aspects included use of health registries, outcome tracking, information sharing through electronic records, and cross-organization administrative processes, although many documents did not discuss infrastructure.

The Foundry model uses a centralized infrastructure and structured processes that coordinate ongoing collaboration, such as data capture systems that support cross-partnership service integration, clinical care, research, and evaluation [43]. Tele-health and information sharing guidelines are promoted to increase the effectiveness and coordination of team-based care [75, 76]. At headspace, data are collected through a minimum dataset process in which all youth accessing centers and their service providers enter data electronically at each service occasion [31, 46]. The headspace national office is responsible for infrastructure efforts including developing funding and assessment guidelines, negotiating contracts, developing reporting structures and key performance indicators, and providing policies and tools including partnership documentation, memorandums of understanding, governance guidelines and a business model guide [74]. In Jigsaw, youth data are captured through an online system that records clinical, case management, service delivery, and outcome-related information [49]. The use of a single, shared health record to facilitate collaboration and streamline care was mentioned in several documents (e.g., [58, 66, 72]). Shared infrastructure has been identified as positively contributing to service coordination and integration [74].

Other methods of care coordination include identifying point persons to facilitate service access and coordinate care across specialists, with titles such as care navigators, youth workers, and youth access clinicians [38, 51, 52, 77]. These workers engage in activities such as exchanging information and participating in joint coordination meetings and planning activities [74]. Some models discussed the role of support or outreach workers in linking clients to services outside the ICYSH and maintaining connection and follow up [34, 72]. Coordinating external referral pathways was viewed as helpful by youth accessing headspace services [59] and care coordination is a key headspace performance indicator [70].

A number of programs emphasized timely access to care, with the ACCESS Open Minds providing access to assessment within 72 h and appropriate care within 30 days [40, 41], the Forward Thinking Birmingham Program providing rapid response and assessment within 1 week [13, 37], and the Orygen Youth Health program providing a 24/7 triage, assessment and crisis response [14]. In addition, diverse access pathways were provided, e.g., self-referral [14, 31], walk-in or drop-in services [41‐44], and online access to services [48] including telemedicine [41, 42]. Similarly, a number of programs highlighted the importance of early intervention [14, 31, 34, 36, 39, 43, 52, 78] and some included clinical staging [78] or stepped-care [52] to provide services at the earliest stage necessary.

Multiple programs mentioned involving youth and families in design, implementation and evaluation of ICYSH models [14, 31, 34, 37‐40, 43, 52, 57, 61, 74, 79, 80]. The programs established Youth Advisory Groups [31, 34, 43, 59, 74] or conducted focus groups [65, 70, 75] and surveys [70], and collected feedback from social media/websites [70] to ensure youth and family engagement.

Several documents mention establishing a non-stigmatizing setting [37, 43] with a youth-friendly environment [13, 31, 37, 38, 40, 43, 52, 70], for example with art [31, 70], couches, music, or recreational activities [38]. Youth-friendly services include not only the environment, but also welcoming and friendly staff [31, 38, 42, 60]. headspace and Jigsaw engaged youth in the development of service settings in order to create a youth-friendly environment [31, 36, 74].

All programs were found to stress the utilization of evidence-based practices [14, 31, 36, 39, 42, 52, 61, 65, 78], using CBT [14, 52, 65, 78], DBT [52], or other evidence-based or -informed practices [36, 42, 52, 61]. However, details regarding establishing and monitoring fidelity were rarely provided.

Another core value was forming partnerships and collaborations with a diverse set of agencies. Most programs had partnerships with various stakeholders including youth, families, service providers, community agencies, researchers, hospitals, policy makers, etc. [13, 14, 31, 41, 43, 52]. Partnerships help provide multidisciplinary, co-located services [38] including social, educational, employment services [14], housing support, income assistance [43] and other specialist services [78]. A social network analysis of the headspace staff reported interprofessional collaboration existed in both routine and uncertain situations [81]. In addition, a study conducted with internal and external staff of Youth One Stop Shops reported that individual staff’s trusting personal relationships was crucial for successfully overcoming agency differences, and collaborative care was found to be essential to the successful care of youth with high needs [82].