Invited commentary: “Everybody has won, and all must have prizes” (Carroll, 1865)

Many of us are familiar with the verdict of the Dodo bird in Alice's Adventures in Wonderland after a “race” (Carroll, 1865). In this commentary on the implementation of ACCESS Open Minds (ACCESS OM) I will show how aptly “everybody has won, and all must have prizes” fits the pan-Canadian reach of the programme. I will offer further comment on issues that face ACCESS OM as the initial funding provided by the Strategy for Patient-Oriented Research Network funded by the Canadian Institutes of Health Research (CIHR) and the Graham Boeckh Foundation (GBF) winds down. And finally, I will consider the research potential for implementation science that ACCESS OM represents. Seven of the 14 sites that are part of ACCESS OM are represented with descriptions that aim to fit a template of the components of the transformation of care for youth mental health. These are community mapping, early identification, rapid access, appropriate care, continuity of care, youth and family engagement and research and evaluation (Malla et al., 2018). Critical to all of these is the definition of youth as age 11-25 and the elimination of the traditional silos that divide youth between child and adolescent services and those for adults. Each of the sites represented in this supplement provides a different slant on the model and the adaptations required. Sites joined ACCESS OM with different levels of services and care already in place and therefore needed to adapt to those conditions forging relationships and integrating with ongoing services while at the same time registering the novel vision represented by the model. One of the most striking differences among the sites is the degree to which “professional” mental health providers are available at point of first contact and how access is managed; the small Inuit community of Ulukhaktok in the Northwest Territories (Etter et al., 2019) and at the University of Alberta in Edmonton (Vallianotos et al., 2019), highlight this. Language also presents challenges in Canada, a nation with two official (English and French) and many Indigenous languages. ACCESS OM becomes ACCESS Esprits ouverts in the programme for homeless youth in Montreal (Abdel-Baki et al., 2019). Although “ouvert” translates cleanly and only to “open” in English, “esprits” can also be translated as “spirit” which may be more empowering. Dubé et al. (2019) describe provision of services for a rural francophone community located in New Brunswick, which is majority English speaking. Sometimes ACCESS OM is housed in dedicated physical space providing access outside of traditional service settings that may have negative associations and be stigmatizing for youth. Reaume-Zimmer et al. (2019) describe a centrally located youth space in Chatham-Kent as the point of access rather than the traditional hospital and community organizations that serve the community. Although there is no requirement for referral, almost 50% of the youth seen at the Chatham-Kent youth space are referred by traditional community agencies. Services provided also vary greatly. Hutt-McLeod et al. (2019) describe the Eskasoni First Nation “two-eyed-seeing” approach to mental health care; seeing from one eye the strengths of Indigenous ways of knowing, and from the other eye, the strengths of Western (or mainstream) ways of knowing, and using both perspectives to benefit those being served. Eskasoni ACCESS OM built on integrated services in a small geographic community to renovate their Youth Space, the dedicated centre for activities that go beyond mental health care to youth and families. In contrast, ACCESS OM in Edmonton, Alberta, a sprawling city with a population of 1.3 million faced a very different problem: where and who to focus services initially (Abba-Aji et al., 2019). The decision was to focus narrowly initially on high-school youth in leased space at a YMCA in centre city—a neutral and accessible location, with scaling to include all of Edmonton a future goal. These are just some examples of the variability and innovation shown by sites within the unifying ACCESS OM framework. Clearly, all have won and all must have prizes! All of the groups point to challenges faced; some met and some still await. The ACCESS OM model has demonstrated flexibility and adaptability in a wide range of settings. The next critical question is whether it makes a difference in mental health and other outcomes for the youth who are being served. That will represent the next challenge. The research mandate of ACCESS OM includes collection of uniform data across sites both to characterize the youth being served and to develop longitudinal data that can address outcomes. We will await the answers that will emerge from these data. Last, but not least, are the questions of sustainability for the sites, where ACCESS OM has been initiated, and scalability. ACCESS OM was funded in 2014 and the central team formally opened its door in 2015. Support will end in 2021, following an extension. Several of the articles speak to the challenge and efforts underway to ensure that the programmes continue after funding ends. Money is always problematic and in the same way that community mapping served to inform the initiation and implementation of the model at sites, it will be valuable to document the processes, more and less successful, that come into play in the effort to sustain the model after funding ends. Malla et al. (2018) have clearly demonstrated that ACCESS OM can be implemented in five Canadian provinces and a territory that span the continent and the complex linguistic environment that characterizes Canada. The final remaining question is whether the model can be scaled so that all youth in need have access to services that are timely, sustained and are not artificially constrained by whether one is under or over 18.

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