CMHA Ontario’s May 2009 presentation to the Select Committee on Mental Health and Addictions. (June, 2009)
Presented by Lorne Zon, Chief Executive Officer, and Michelle Gold, Senior Director, Policy and Programs
Mental health and mental illness are complex issues. They cannot be addressed by focusing on one or two solutions. Provincial efforts require comprehensive directions and an integrated approach. We have come to share a good news story that has begun — but is far from complete. It requires the attention and concerted efforts of policy-makers within and beyond the health sector.
While a vision of deinstitutionalization and an enhanced community-based mental health system has existed in Ontario for over 25 years, it was only a decade ago that the Ontario Health Services Restructuring Commission recommended closure of all provincial psychiatric hospitals and the re-direction of a proportion of bed funds to community mental health services. Provincial psychiatric hospital closures and/or divestment were not completed until 2007. While the Canadian Mental Health Association has been advocating for over 50 years for community based services and resources as the foundation for support,1 the impetus for mental health reform is relatively new, and implementation of a comprehensive community mental health system is in fact, only in its early years.
Investing in Community Mental Health Makes a Difference
A 2004 Ontario study identified that progress has been made in delivering community mental health services and supports, however there are still significant unmet needs in Ontario.2 In 2004, federal transfer payments under Health Accord funding enabled Ontario to allocate $177 million to community mental health services; and in 2005, the Service Enhancement Initiative, an inter-ministerial collaboration allocated an additional $50 million. The goal of these recent investments is to increase access for people with serious mental illness to court support, intensive case management, assertive community treatment, crisis services, safe beds, supportive housing and early intervention programs.
We’ve already learned a great deal about these new investments.3 The Ministry of Health and Long-Term Care commissioned a multi-year evaluation that coincided with the start-up of new programs and services. CMHA Ontario has actively participated on the Executive Advisory Committee involved with these nine studies. These new investments have increased the number of people served in Ontario. They have seeded the development of innovative and effective new programs and increased system integration — these initiatives are making a difference and improving people’s lives. We would be pleased to refer you to any number of innovative community mental health programs in Ontario.
The evaluation also found that people with serious mental illnesses still lack access to a range of broader services and supports such as housing and employment support.
Employment is a key determinant of health and wellbeing. For those who experience mental illness, work can be an essential part of recovery, and a vital strategy for reducing poverty. In spite of the benefits, employment rates remain low for persons with mental illness in comparison to their non-disabled peers. According to the Canadian Community Health Survey, 30 percent of people with a diagnosed mental illness in Ontario did not work in 2003.
Supported employment helps people with serious mental illness secure and retain employment. Supported employment programs combine employment assistance with mental health support. Employment supports programs can be provided by non-profit mainstream and cross-disability employment agencies; as well as community mental health agencies. However, these resources are often difficult to access because they involve multiple providers, each operating in isolation from the others. The resulting silo effect has unintentional consequences for programs that are intended to assist the individual to move from government dependence to self-reliance. Silos need to be eliminated by developing a coordinated strategy for employment supports for persons with serious mental illness.
Housing is Essential for Recovery
In addition, we believe it is essential to note for the Committee that there are shortages in affordable housing, as well as, supportive and supported housing programs in Ontario. Individuals with serious mental illness frequently identify housing as an important factor in achieving and maintaining their health. The cost of housing is fundamentally connected to income security, and we encourage the poverty reduction strategy to include initiatives to increase the supply of affordable housing, and programs to improve the affordability of market rents for people on low income.
Supportive housing is a model that brings together affordable, decent shelter with the supports that many people need to live in the community. Supportive housing is economical — it costs far less to provide supportive housing than to provide a shelter bed for a homeless person or hospital care. Ontario needs more supportive housing units in order to promote the recovery of persons with serious mental illness and enhance their capacity to live in the community, rather than in institutional settings.
In addition, visits to emergency rooms are greater and hospital stays are longer for people with serious mental illness who are homeless, than the population as a whole. Increasing the stock of affordable housing, as well as supportive and supported housing programs can decrease the need for emergency and hospital services.
Funding for Community Mental Health is Unevenly Distributed and Not Secure
Given the range of services and supports needed to foster recovery, Ontario’s community mental health system still lacks sufficient capacity to serve all those in need. More so, there are substantial inequalities across the province. In 2007, funding for community mental health services ranged from $19 to $123 per capita across Local Health Integration Network areas. However, standardized population based funding is not a one-size fits all solution, as remote and rural areas have special needs that must be factored in, such as addressing reasonable distance expectations in order to provide Ontario residents with ‘services close to home’, as well as dealing with barriers to available and affordable transportation.
Also of concern is the fact that much of current funding for community mental health services is not protected under LHINs, should they decide to redirect parts of their global budget to other sectors.
While Ontario has a framework for a comprehensive basket of community mental health services and supports, we still lack a forecasting model that can serve as the basis for defining the range and intensity of service use we would expect individuals with serious mental illness to use over their lifetime. This is needed in order to develop a better mental health strategy, as well as support the identification of targets and monitoring of progress in achieving a responsive, effective and efficient mental health system for people in Ontario.
Increasing Access and System Navigation throughout the Health System
We recognize that a key priority of the Committee is to improve health system access and navigation. We would like to identify for the Committee a number of advancements already underway which should demonstrate results, as these new approaches gain momentum.
The Ontario Common Assessment of Need (OCAN) project is being piloted in Ontario to enhance the sector’s capacity to streamline and standardize the assessment process. This common assessment tool will ensure that every consumer is assessed using a standardized decision-making tool that allows key information to be electronically gathered in a quick and secure manner. It offers consumers an effective way to voice their needs and preferences for care that is consistent with a recovery approach.
There is now a provincial information and referral registry, Mental Health Service Information Ontario (MHSIO), which provides up-to-date comprehensive information and referral services to mental health services throughout the province, accessible through a 24/7 toll-free bilingual telephone line or online.
In addition, many local initiatives exist or are in development across Ontario to improve coordinated access to community mental health services. The two most common models for coordinated access in Ontario are coordinated/joint access approaches — where partnering agencies share intake procedures and jointly review assessments to determine the most appropriate placement of clients into services across their organizations. Alternatively, what is occurring in some regions of Ontario are centralized access approaches — where one service provider agency or dedicated intake worker performs the functions of assessment, intake, and placement on behalf of the partnering agencies.
Intensive case management improves access and coordination of services for persons who are marginalized and at-risk of falling through the cracks. Intensive case management has been shown to significantly improve housing stability, community functioning and reduce both visits to the emergency department and hospital admissions among people with serious mental illnesses.
We have brought with us copies of CMHA Ontario’s Winter 2008 issue of Network magazine, which profiles many issues and enhancements taking place in Ontario that are improving how people navigate through the mental health system.
Despite the impressive number of integration initiatives underway, new ways of working will be restricted in the absence of adequate infrastructure to plan, coordinate and monitor the performance of the system. Since the province’s move to decentralized health system planning, monitoring and funding, we are concerned that there is insufficient collective provincial leadership available to guide the implementation of health system reform. We are hopeful that the creation of the new LHIN Collaborative (LHINC) will serve as a forum for provincial discussions that can guide development of the mental health system; and certainly CMHA Ontario feels it can offer much to this table based on our experience and cross- provincial knowledge.
Addressing Emergency Room Use
A key government priority is reducing emergency room wait times. Emergency rooms are an appropriate point of entry for some people experiencing a psychiatric or medical emergency. Individuals presenting to an emergency room with mental health needs routinely experience stigma, leading to delays in receiving services and increased wait times. This can occur regardless of whether they are seeking medical or psychiatric care. Anti-discrimination in-service training needs to be implemented to ensure that people with mental health needs are treated in the emergency department with dignity and respect, and in a timely manner.
Emergency department use and repeat visits are oftentimes the result of hospitals having insufficient information to refer individuals to more appropriate and long-term resources in the community. The “treat ’em and street ’em” approach is a missed opportunity for continuity of care.
The placement of community-based workers in emergency departments has been shown to effectively divert people out of the emergency room and to more appropriate community care. In addition, community-based discharge workers, assigned from the local community and located in inpatient settings, can improve access to community services following discharge. Results from community-based discharge programs have decreased the rate of readmissions to hospitals.
Lack of access to primary health care and community-based psychiatric care are two other reasons for unnecessary emergency department visits. Even persons with access to physicians and psychiatrists are likely to be confronted by telephone messages advising them to go to their nearest emergency department, should they require services outside of regular business hours. Community mental health agencies tell us that 24-hour community-based mental health crisis services are a preferred alternative for people not requiring medical care. We are currently identifying innovative community-based crisis programs which already exist in pockets of Ontario.
Importance of Primary Health Care
As mentioned, many Ontarians with serious mental illness lack access to primary health care. In one Ontario community, a new primary health care program specifically targeted to individuals with serious mental illness and co-located in a community mental health agency resulted in a 50 percent reduction in emergency room visits for those individuals. People with serious mental illness of course also require access to primary health care for physical health needs.
Primary health care is also important for people with mild to moderate mental disorders. In 2005/06, there were over 4.7 million OHIP-billed physician visits for mental health related conditions alone.4 This is an under-estimate of demand, as it does not take into account the number of family physicians providing services under alternative billing models for primary health care.
There are many initiatives taking place in Ontario that are increasing access and responsiveness of primary health care to address mental health needs. Family health teams include multidisciplinary professionals such as social workers and nurse practitioners that add enormously to the ability to deliver primary mental health care. These teams, however, are still under development and only available in select areas of the province. Community Health Centres are mandated to address the many health and social needs of vulnerable populations, including people with serious mental illnesses. Collaborative mental health care initiatives such as shared care approaches are linking family physicians working in older practice models with mental health specialists and psychiatrists who offer advice and support to better serve patients with mental illnesses and those experiencing poor mental health. But the need is great and there isn’t adequate capacity.
Increasingly, community mental health agencies are co-locating or sharing staff with Family Health Teams. This includes having mental health specialists from community mental health agencies supervising and consulting with primary health care providers, as well as integrating services to ensure people can have both their physical and mental health needs addressed in the same setting. The funding of a satellite Community Health Centre at our CMHA Windsor branch, a community mental health agency, now provides services to a local area that includes people with and without serious mental illnesses.
Again, we have brought you a 2006 issue of CMHA’s Network magazine, which profiles many collaborative primary health care initiatives taking place in Ontario.
These type of innovative solutions and promising practices that we have profiled are not sufficiently known across sectors, and have not yet found a champion because they cross jurisdictional and funding boundaries.5 We believe this to be a result of service-led versus needs-led policy directions. We need a provincial strategy that is organized based on user needs, rather than service funders. We are optimistic that Ontario’s new Mental Health and Addiction Strategy will provide directions to address this matter in a comprehensive way; and we offer our expertise to support setting directions to develop a more accessible and responsive system for people experiencing poor mental health and/or mental illnesses.
Promoting Positive Mental Health
Now, we would like to speak on an equally important issue — what this province can be doing to promote positive mental health. Evidence is strong with respect to the factors that lead to positive mental health, as well as what governments and communities can do to promote mental health. The most significant dimensions that impact mental health are social inclusion, freedom from discrimination and violence, and access to economic resources. Mental health promotion policies and programs need to address individuals, their connections within the community and the broader environment in which they live.
Strategies that promote social inclusion create environments that foster social connections, companionship and social support. The type of strategies which promote social inclusion include: access to affordable recreation and physical activity programs in communities; creating opportunities for both youth and adults to participate in arts and cultural activities; and developing culturally-appropriate policies and programs that promote inclusion of new immigrants and refugees in Canadian society.
Discrimination and violence are risk factors for poor mental health. Discrimination and violence are often linked. Violence can take many forms, including child abuse, neglect by parents, bullying, youth violence, violence by intimate partners, abuse of the elderly, and sexual violence. Being a victim of violence is strongly associated with poor mental health. Stigma and discrimination against people with mental illness is also a major concern. And, it is important to note the people with serious mental illnesses can also benefit from mental health promotion strategies.
Access to economic resources, such as housing, education, work and income is strongly correlated with promoting mental health and reducing the risk of mental illness. Lack of access to economic resources can result in poverty and material deprivation, sustained hardship and poorer mental health. Investing in strategies that improve access to economic resources and remedy the inequalities experienced by disadvantaged populations can significantly promote positive mental health.
CMHA Ontario, together with four other organizations, the Centre for Addiction and Mental Health, Health Nexus, the Ontario Public Health Association and the Centre for Health Promotion at the University of Toronto recently prepared a report, entitled “Mental Health Promotion in Ontario: A Call to Action” that identifies a very large number of evidence-based strategies that could be pursued in Ontario to promote mental health. Our organizations are interested to assist the government in a process for taking action.
- Canadian Mental Health Association. A Framework for Support, 3rd edition, 2004.
- Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health. Mental Health Services in Ontario: How Well is the Province Meeting the Needs of Persons with Serious Mental Illness, 2004.
- System Enhancement Evaluation Initiative. Moving in the Right Direction. SEEI Final Report. Submitted to the Ministry of Health and Long-Term Care March 31, 2009.
- LHIN data report on MH&A, 2008.
- Community mental health agencies and Community Health Services are within LHINs. Physician services, Family Health Teams and Nurse Practitioner Clinics are outside of LHINs.