Background:
Over a quarter of Dutch adults experience mental health disorders, yet the current system cannot meet the growing demand. Long waiting lists and limited capacity underscore the need for alternative, community-based approaches. One such initiative is GEM, a value-driven mental health ecosystem that integrates social and medical domains. GEM is based on three principles: collectivizing (promoting group-based over individual support), demedicalizing (distinguishing medical from social issues), and normalizing (reducing stigma and adopting a person-centered approach). By leveraging social resources and community activities, GEM promotes recovery-oriented care. Current interventions include a group house, an e-community, and exploratory conversations involving both professionals and experts by experience.
Approach:
To examine how GEM is experienced in practice, 20 semi-structured interviews were conducted with service users across diverse backgrounds in residence, socioeconomic status, and type of service use. An expert by experience was consulted to refine the topic guide. The interviews explored the influence of GEM on clients’ mental health and compared their experiences with GEM to those within traditional mental health services.
Results:
Data collection is ongoing, and final results are expected before April 2026. Nevertheless, early findings reveal promising outcomes. Despite GEM being in its early stages, participants reported several benefits. Clients highlighted accessibility as a major benefit: services were immediate, free of charge, and avoided the lengthy waiting times characteristic of traditional systems. Respondents also valued the greater sense of agency in shaping their care pathways.
The group house, in particular, fostered a sense of belonging and mutual understanding. Collaboration between healthcare professionals and experts by experience enhanced peer support, reduced isolation, and created a more empathetic, recovery-oriented atmosphere. Clients described feeling acknowledged and validated—something they often found lacking in conventional mental health services.
Participants acknowledged that GEM’s rapid support was not always sufficient for complex or severe problems. Even so, the availability of early, community-based intervention frequently reduced the need for intensive or long-term treatment. This suggests broader benefits for both clients and the healthcare system by reducing pressure on specialized services.
Overall, participants’ experiences affirmed GEM’s three guiding principles. Collectivizing fostered peer learning and resilience; demedicalizing allowed for support that addressed social as well as medical needs; and normalizing helped to reduce stigma and promote acceptance. Together, these elements improved accessibility, strengthened continuity between social and medical support, and supported clients in ways the traditional system often struggled to provide.
Implications:
Value-based mental healthcare, as exemplified by GEM, offers a promising response to the structural challenges facing Dutch mental health services. For GEM’s potential to be fully realized, however, a broader paradigm shift is needed. This requires embedding its principles of collectivizing, demedicalizing, and normalizing not only within GEM but also across the wider system. Achieving this means integrating these values at multiple levels—among clients, professionals, institutions, and society at large. In doing so, mental health care can move toward being collaborative, community-based, and tailored to personal needs and wishes rather than being confined to a purely medical model.

Background: Youth with mental health and/or addiction (MHA) concerns experience considerable barriers in finding, accessing, and transitioning through MHA care. MHA navigation services are an integrated care approach that prioritizes individualized barrier reduction and inter-professional collaboration to provide expert guidance to youth and families in the MHA system. To effectively implement youth MHA navigation services, they should be co-designed with interest-holders and adapted for the local context.

Approach: This presentation shares the findings from an experience-based co-design (EBCD) study that sought to adapt a youth MHA navigation service (the Family Navigation Project) to a novel rural/remote/northern context, where it had previously only been in operation in a large urban setting. All EBCD sessions were planned, co-developed, and co-led by individuals with lived experience and/or who identified with the target group for each session. Youth with MHA concerns (n=50), family caregivers (n=13), service providers (n=20), and decision-makers (n=5) took part in a series of six sessions (youth, caregiver, rural/remote, Francophone, service provider/decision-maker, open) to share experiences finding and participating in MHA care, learn about navigation models of care, and co-design their desired navigation pathway and service approach. Thematic analysis identified experiential drivers of expressed needs from the navigation service, as well as desired features of the navigation service to be implemented.

Results: Themes that emerged in participants’ experiences of accessing/providing MHA care revealed concerns regarding physical inaccessibility of services, limited coordination of services, and lack of available resources of appropriate intensity. While service availability was a concern, participants also expressed that knowledge/information barriers may be preventing access to otherwise available services. Co-designed service elements highlighted the need for the integrated youth MHA navigation service to be accessible, personalized, proactive, knowledgeable, and collaborative. The Family Navigation Project is now in early-stage implementation in northern Ontario.

Implications: Co-designing an integrated youth MHA navigation service with multiple interest-holder groups gleaned insights well beyond that which would have been achievable through any one group. Community participation and partnerships in co-developing contextually-tailored solutions to system challenges will help ensure care is coordinated in a manner that appropriately addresses local needs and priorities.

Background: Since 2013, the Family Navigation Project (FNP) has helped youth and families in the Greater Toronto Area navigate the complex mental health and addictions (MHA) system. FNP is an integrated youth MHA system navigation model, focusing on barrier reduction, inter-professional collaboration, and expert guidance through the MHA system. FNP is implementing its services in districts in northern Ontario, including Greater Sudbury, Sudbury, and Manitoulin (henceforth referred to as Sudbury-Manitoulin). This region experiences considerable health disparities and challenges with integration of MHA care for youth and families. For example, rates of youth ED usage for MHA concerns and youth deaths by suicide are the highest in the province. Furthermore, there exist regional challenges regarding lack of availability and/or accessibility of appropriately intensive MHA care and support options. Local advocates have expressed the community’s desire for an integrated youth MHA system navigation service for many years, and have partnered with the Family Navigation Project to bring this support to the region.
Approach: This community-based participatory research study is grounded in Implementation Science, guided by the Consolidated Framework for Implementation Research (CFIR). The project is four years long (currently in year 2) and is funded by a federal research grant and philanthropic donors. Local partners include youth mental health agencies, a hospital, an Indigenous health centre, a rural/northern health research centre, parent and youth advocacy and support groups, and individual patient partners. Relationship-building and sustainment with these partners is continuous, along with ongoing relationship-building with new community partners that express interest in the project. Phase one of the research focused on pre-implementation needs assessment, discovery, and planning, and included literature review, environmental scanning, and experience-based co-design of the locally adapted navigation service model. Phase 1 concluded in autumn 2025. Phase two will implement the program and assess outcomes through a mixed-methods, adaptive pragmatic clinical trial to be launched in mid-2026. As with the navigation program to be implemented, clinical trial processes and measurement tools will be co-developed with community representatives.
Results: Results to be shared will highlight how CBPR and Implementation Science have informed research and operational activities, as well as outcomes to date of these approaches. The implementation process is intentionally slow and methodical to foster trust, build strong relationships, and transparently communicate with diverse local interest-holders, which has resulted in deep and extensive engagement with the community. Alignment with the CFIR has ensured that the integrated youth MHA navigation model is co-developed, adapted for and responsive to the local context, and sustainable. This community-based and implementation science-informed approach to the project phases have helped ensure the integrated youth MHA system navigation model to be implemented and evaluated reflects shared community values.
Implications: This project centers meaningful engagement, partnerships, and relationship-building with communities to ensure local relevance, trust, and sustainability. This work will result in an implementation toolkit to enable further spread of the FNP’s model of integrated youth MHA system navigation, ensuring integrated and positive care experiences for youth and families in a range of local contexts and settings.

Background and Motivation:

Accessing mental health care in primary care settings can be challenging due to long waiting times, limited awareness of available programs, and poor coordination between providers. The SCOPE (Seamless Care Optimizing the Patient Experience) in Toronto, Canada, was developed to bridge these gaps by integrating mental health service navigation within primary care. Grounded in the philosophy of “people as partners in health and care,” the program emphasizes collaboration, empowerment, and prevention—supporting individuals to take an active role in their well-being while reducing need for emergency services.

Objectives:

This presentation aims to describe the SCOPE Mental Health Navigation (MHN) program’s integrated model of care, highlights its key outcomes, and demonstrates its effectiveness in improving access, coordination, and patient empowerment. The objectives include:

1. Examining how mental health navigation enhances people-centered and preventative care.
2. Describing the integration of psychiatry consultation, primary care collaboration, and community case management pathways.
3. Evaluating the program’s operational outcomes and patient engagement metrics.

Methodology:

A mixed-methods evaluation combined service utilization data, navigator case documentation and feedback from patients and Primary Care Provider (PCP). Quantitative metrics included referral volumes, caseload sizes, duration of engagement, psychiatry consultation wait times, and call volumes. Qualitative insights are drawn from patients and PCP feedback on accessibility, satisfaction, and self-management outcomes.

Key Results:

The SCOPE MHN program supports an average of 40 new referrals per month, with navigator managing a caseload between 20-48 patients, while also offering approximately 40–75 calls monthly from both PCPs and patients. The navigator’s role is both PCP-facing and patient-facing, aiding in direct consultation, education, and coordination support to providers while working closely with patients to ensure quality, trauma-informed, and community-focused care. Services are delivered through phone and virtual care, increasing accessibility and flexibility.

The navigators provide their own assessment of a patient’s mental health and can offer short-term navigation services, counselling, therapeutic modality skills learning, advocacy, and bridging patients to longer term care. This can be essential to patients accessing mental health care for the first time. The navigator provides short-term care to patients with an average service time of 1-2 months. Strong pathways and partnerships with LOFT Community Services mental health case management teams facilitate smooth transitions to longer-term supports if needed. The navigator coordinates the appointments for the Shared Care Psychiatry Program, which ensures timely psychiatric consultations with an average wait time of 6–9 weeks. Patients report feeling “validated, seen, and understood”, with feedback describing the services as “life-changing” and “deserving of expansion.”

Conclusion:

The SCOPE Hub’s integrated mental health navigation model demonstrates how combining PCP collaboration, short-term patient-facing interventions, and shared care psychiatry can reinforce person-centered and preventative mental health care. By empowering patients and equipping primary care teams with accessible, trauma-informed, and community-based resources, SCOPE offers a scalable approach to reducing system strain while improving access, coordination, and outcomes for individuals with mental health needs.