This paper discusses the collaborative efforts between the Cambridge University Hospitals NHS Foundation Trust, the University of Cambridge, and the Cambridge and Peterborough NHS Foundation Trust to advance the co-design of integrated physical and mental healthcare services for children, young people, and their families.
Approach - Advances in medical care and treatments have extended life expectancy, resulting in a growing number of individuals being diagnosed with two or more co-morbidity. As healthcare evolves, individuals can no longer be placed solely in mental or physical health silos, as there is strong evidence of the interconnection between the two, highlighting the need for integrated care. It is essential to consider the whole person and the impact that a physical condition can have on mental health. When left untreated, mental health issues can exacerbate both physical and psychological conditions, ultimately increasing the cost and complexity of care.
Historically, physical and mental healthcare have been treated as separate entities, but the rising prevalence of comorbidity is increasing the need for integrated services for all patients. While there has been progress in integrating care within specific pathways, many services still operate in isolation. Mental health problems are highly prevalent in acute physical health settings and can significantly influence the outcomes of care for physical illnesses. Research has shown that targeted approaches for children and young people can reduce the lifelong cost impact associated with managing long-term conditions.
To improve the health and well-being of children and young people in the South East of England, the Cambridge Children’s Hospital project has been initiated. This initiative was developed with extensive engagement from all healthcare sectors within the region. Moreover, the care pathways and the hospital's design have been co-developed in collaboration with children, young people, and their families, ensuring that their needs are at the centre of the healthcare model.
Results - The collaboration to develop Cambridge Children’s Hospital is currently underway and will culminate in the construction of a state-of-the-art facility designed to support the ongoing integration of healthcare services. Cambridge Children’s Hospital will embody a holistic approach to care by bringing together physical and mental health services under one roof. The hospital aims to revolutionize care for children and young people by utilizing genomic medicine, not only to treat diseases but to prevent them altogether. This innovative approach will foster a comprehensive model of care, addressing the whole person and advancing both treatment and prevention strategies.
Implications - While planning for Cambridge Children’s Hospital continues, the integration of services is already in progress, with several case studies showcasing the significant positive impacts of integrated care on children, young people, and their families. These case studies provide compelling evidence of how combining physical and mental healthcare can improve outcomes, enhance the patient and family experience, and demonstrate the potential benefits of this approach even before the hospital is built.

Background: Mental health is an essential component of overall health across the life course that should be integrated into research, policy, and practice for sustainable health and well-being. However, in Canada, research and care provision related to aging, mental health and physical health are often siloed. There is a need for intentional partnerships with experts-by-experience to collaboratively generate a meaningful aging and mental health research agenda based on a shared vision for and values around integrated care.
Approach: This project engaged experts-by-experience, including older adults, family and friend caregivers, and health and social care providers to identify priority research questions on aging and mental health in Canada. A modified James Lind Alliance priority-setting partnership approach was used, with guidance from a diverse steering group of experts-by-experience. Collaborative solution-building with the working group included identifying approaches to diverse recruitment and ensuring authentic and meaningful engagement during the transition to online activities during the COVID-19 pandemic. Consultation methods included two pan-Canadian surveys and four pan-Canadian online workshops. Consensus-building was guided by qualitative and quantitative data analysis, a rapid review of recent evidence, and a nominal group technique.
Results: Survey 1 (n=305) was open-ended and led to the identification by Canadians of 42 unique questions about aging and mental health. Twenty-five questions were determined to be unanswered (partially or completely) through a rapid review of recent evidence. The second pan-Canadian survey (n=703) prioritized a short list of 18 unanswered questions, which were carried forward into a series of 4 online workshops (n=52). In perspective-specific and mixed-perspective workshops, older adults, caregivers, and health and social care providers from across Canada came together to select the top 10 unanswered questions through individual reflection and ranking, sharing of stories, small and large group discussion, and voting. The top 10 unanswered questions incorporate topics around skill-building and burnout of providers, experiences of social isolation and loneliness, access to services specifically for older adults, and support of caregivers and their integration in care decision-making.
Identification of the priority research questions has led to the publication of an open access research paper and two projects involving essential collaborative partnerships with experts-by-experience across Canada. First, the Canadian Aging Action, Research, and Education (CAARE) for Mental Health Group formed to mobilize the questions and continue building research partnerships with experts-by-experience representing diverse perspectives. Second is a research project to address the top unanswered question by co-designing evidence-informed mental health conversations and integrating these at the point of care in home and community settings across Canada.
Implications: This work demonstrates the value of engaging experts-by-experience in meaningful collaborative partnerships to guide future research aiming to realize more effective and sustainable integration of mental and physical health care. The questions identified can guide researchers, funders, and organizations in shaping future inquiry and action that reflect the shared values and priorities of aging Canadians. They can also suggest key areas of focus for international settings, which can be verified and investigated with context-relevant experts-by-experience.

Background:

SunRYSE (Sunnybrook Restoring Youth Summer Experience) was developed to address the growing need for integrated youth mental health support in North Toronto. Recognizing that many existing mental health programs cater primarily to adults, SunRYSE provides targeted support for youth aged 13-16 experiencing complex mental health challenges. This innovative summer pilot program is a collaborative effort led by Sunnybrook’s Department of Psychiatry and the North Toronto Ontario Health Team, alongside community partners including the Toronto Catholic District School Board (TCDSB), SPRINT Senior Care, and Pine River Institute.

Objective:

SunRYSE aims to support youth with school avoidance, social anxiety, and emotional regulation challenges. The program offers a holistic, camp-like experience, focusing on enhancing mental, emotional, and physical well-being. Additionally, youth participants receive academic credit, helping to bridge their return to school. Parental involvement is also a key component, providing families with psychoeducation and support to reinforce the program’s impact.

Approach:

The program uses an integrated care model that brings together psychiatrists, allied health professionals, primary care providers, and recreational therapists to offer a supportive environment. Through therapeutic interventions, life skills training, academic support, and recreational activities, SunRYSE aims to build resilience, confidence, and social skills among participants. The structure and routine foster personal growth and readiness for the upcoming school year.

Program Impact and Feedback:

In its initial run, SunRYSE supported 7 youth participants. Quantitative data showed improvements in symptom rating scales for anxiety and depression (GAD-7 and QIDS), and 100% of parents reported satisfaction with the program’s structure, communication, and environment. Qualitative feedback highlighted the benefits of professional guidance, social belonging, and routine for the youth, as well as suggestions for deeper parental involvement and clearer program content. Observed improvements included increased resilience, social engagement, and independence in participants.

Conclusion and Implications:

SunRYSE exemplifies how integrated, collaborative approaches can support the multifaceted needs of youth with complex mental health challenges. By fostering cross-sector partnerships and aligning program objectives with youth and family needs, SunRYSE offers a replicable model for mental health support in other regions. Future directions include expanding the program’s scope, increasing parental education, and creating feedback loops with schools to support individualized learning plans.

Significance:

SunRYSE demonstrates the impact of integrated care on youth mental health, illustrating the potential for hospital-community partnerships to fill critical service gaps and promote long-term mental well-being for young people facing adversity.

Background: Adverse Childhood Experiences (ACEs) have been associated with poorer long-term patient health outcomes. However, screening and intervention methods vary widely, and patient face significant challenges related to access to effective treatment options. The present quality improvement study examined trauma screening processes and intervention practices across three pediatric integrated primary care (IPC) clinics and their impact on patient outcomes.
Approach: A systematic medical record review was conducted for patients aged 5-17 who completed a well-child encounter (WCE) between October 2022 to June 2023 in three IPC clinics within a large academic medical center in the Midwestern United States. Physician use of ACEs-related questionnaires, trauma-related diagnoses, and behavioral health referrals associated with WCEs were collected. Chi-square tests were analyzed for variability.
Results: Patients (n = 4611) had a mean age of 10.8 years, were majority male (52.6%) and English-speaking (95.6%). Patient race, ethnicity, and preferred language varied significantly across clinics (p < .01). Measures assessing ACEs were completed in 51.1% of WCEs. Physicians placed a behavioral health referral at 13.5% of encounters that used an ACEs screener compared to 11.8% of encounters that did not use a screener. Trauma-related disorder diagnoses were made in 1.8% of WCEs and were associated with 6.3% of behavioral health referrals. Rates of screener completion, behavioral health referral, and trauma-related diagnosis were found to significantly vary (p < .01) based on demographic factors (e.g., age, race, clinic location, and preferred language).
Implications: Significant variability in screening practices was evident across clinics despite them existing within the same health system. The absence of systematic implementation practices results in inadequate and inequitable identification of patients with trauma exposure and critical mental health needs. Clearer guidelines and standardized practices are crucial to effectively and equitably identify and support patients with ACEs. An integrated primary care approach enables collaboration among physical health providers, mental/behavioral health professionals, community resource agencies, and patient families and is essential to manage the high volume of trauma concerns identified in the primary care sector. Currently, we are engaging primary care providers and patient families to improve the efficiency, acceptability, and sustainability of screening practices and to more effectively connect families to needed interventions and resources. Future research will examine patient follow-through with behavioral health referrals and long-term health outcomes.