A report based on discussions at CMHA Ontario’s think tank on diabetes and serious mental illness. The report recommends action to improve collaboration between primary health care, diabetes education and mental health services; to advance policies to increase attention and resources for this population; and to develop strategies to expand capacity and streamline efforts.
The Ministry of Health and Long-Term Care (MOHLTC) has recently established key priorities in the area of chronic disease prevention and management (CDPM) in recognition of the increasing burden of these diseases on the health of Ontario citizens and rising costs to the heath care system. The MOHLTC is responsible for providing the policy framework to guide efforts towards effective prevention and management, and engaging stakeholders in a systematic approach to responding to chronic disease.
The MOHLTC initiated the overall implementation of the Ontario CDPM Framework (Lee, 2006) by addressing diabetes as the first priority. The driving forces were that approximately 8.8% of the province’s population currently has diabetes, and the cost of dealing with this disease and related complications annually exceeds $5.5 billion (Ministry of Health and Long-Term Care, 2008). In 2006, an Expert Panel was convened to examine research and best practices from around the world and define a strategy to focus on meeting the needs of Ontarians with diabetes. As a result, the MOHLTC made a series of announcements in both 2007 (Ministry of Health and Long-Term Care, 2007) and 2008 (Ministry of Health and Long-Term Care, 2008), culminating with the provincial diabetes strategy. Major elements of the strategy include:
- Increasing access to team-based care with an infusion of $290 million to expand current programs, align care and fund new initiatives.
- Investing $6 million in prevention programs including education campaigns to raise awareness of risk factors (e.g., physical inactivity, poor nutrition and obesity) that contribute to the onset of type 2 diabetes focusing on high risk populations (e.g., Aboriginals, Hispanics, South Asians, Asians, African-Canadians, lower income families and people aged 50 and older).
- Creating a diabetes registry that will provide instant access to information and education tools to help people with diabetes manage their care; assist physicians to check patient records, access diagnostic information and send patient alerts.
- Extending the Insulin Pump Therapy program to all adults with type 1 diabetes with a $62 million investment and reviewing the evidence to see if the pump program should be extended to adults with type 2 diabetes who are insulin dependent.
- Expanding the Chronic Kidney Disease Program with $220 million in funding to improve access to all services available under the program, focusing on early identification of kidney disease. Diabetes is a common risk factor associated with kidney disease.
- Improving access to bariatric surgery for people with obesity, with $75 million in funding in recognition of the fact that more than 50% of type 2 diabetes cases in the province are associated with obesity. (Ministry of Health and Long-Term Care, 2008)
With the shift in Ontario’s health care system towards chronic disease prevention and management, CMHA Ontario published three papers in 2008, a backgrounder on the relationship between mental health and physical illness, a discussion paper on the fit between mental health, mental illness and Ontario’s CDPM Framework, and a policy paper with recommendations to address co-morbid mental illness and chronic physical conditions. While the framework recognizes mental health elements in treating chronic physical conditions and the fact that many people with chronic diseases are at risk of depression, suitability of this approach to treating people with serious mental illness who also have chronic physical health conditions has yet to be fully tested. A strength of the Ontario CDPM Framework is “the potential for integrating physical and mental health care… [and this is of] value in improving physical health care of people with serious mental illnesses, a population whose physical health is often poor and who are at high risk of developing diabetes and heart disease” pg. 1 (Canadian Mental Health Association, Ontario, 2008 — discussion paper).
The Ontario CDPM Framework is also a potential means to address the long-standing inequities people with serious mental illness (SMI) face in accessing primary and preventative health care. Many people with SMI are orphan patients in terms of primary health care — they are treated within the mental health care stream that traditionally has not been structured or funded to support prevention and management of other health conditions. At the same time, there are people with serious mental illnesses and chronic physical conditions being seen in primary health care settings who are not connected to mental health services. Primary health care settings alone are not equipped to address the complex needs of these individuals, which usually extend beyond issues of direct health care. Diabetes education programs also need support in order to adequately address the diabetes needs of people with serious mental illnesses.
Serious mental illness is a significant risk factor for the development of a number of chronic diseases including chronic obstructive pulmonary disease, breast cancer, colon cancer, lung cancer, stroke, heart disease and diabetes. This high risk of serious health conditions among people with serious mental illness means that prevention services, health screening and regular access to primary health care should be of high priority (Bazelon Center for Mental Health Law, 2004). Increased coordination, collaboration and shared care between health care sectors will increase the capacity of each sector and will improve health care outcomes for people with mental illness and chronic diseases.
It is important to add that underlying factors that put these individuals at high risk of chronic conditions and complicate their capacity to manage these illnesses must also be addressed. This is a population living with high rates of poverty. The impact of poverty on diabetes has been well-documented. (Health Council of Canada, 2007)
Overview of the Think Tank
Under the provincial diabetes strategy, the MOHLTC provided funding to CMHA Ontario for a one-day Diabetes and Mental Illness Think Tank session to bring together representatives from primary care, diabetes, community mental health, the LHINs and the MOHLTC. The focus of the session was to identify strategies to increase collaboration and cross sectoral support to improve diabetes prevention and management for people with serious mental illnesses, and to plan action steps. Prior to the think tank, participants were provided with background reading materials related to diabetes and serious mental illness. (See Appendix 2.) Brief overviews of the issue, current policy and the Ontario CDPM Framework were provided at the outset of the think tank. Discussion groups were populated with representatives from the various sectors and asked to identify and strategize care responses using a case approach (See Appendix 3.) Continuing in small groups, participants then discussed the system level needs and potential for collaboration. The group recommendations were prioritized and shared in the larger audience.
Overall, participants were impressed with the quality of knowledge exchanged and appreciated the amount of time dedicated to discussion and strategy development. They welcomed the opportunity to have input and felt all perspectives were valued throughout the process.
There was also a great deal of sharing of information among the participants as they were encountering “new” colleagues with unique information. They also noted that their level of awareness of the diabetes and mental illness issue was appreciably enhanced as a result of their participation. One of the most valuable aspects of the Think Tank expressed by participants was the opportunity to have a meaningful exchange of information between sectors in small groups so that people could have full discussion of the issues and approaches in various sectors and organizations.
Several organizations and individuals indicated that they would be willing to continue to work with CMHA Ontario to further the action steps outlined in this report.