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Addressing Mental Health and Addictions Needs in Primary Care

March 1, 2016

Response to Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario

As the government acknowledges, the province lacks an effective, coordinated system for home and community care and this creates immense challenges that need urgent attention across Ontario1. The Ministry of Health and Long-Term Care’s proposed strategy, Patients First: A Proposal to Strengthen Patient-Centred Health Care, aims to specifically target many of these gaps and challenges identified across the health care system2. As the proposal states, “Many of these challenges arise from the disparate way different health services are planned and managed. Some — such as hospitals, long-term care, community services and mental health and addiction services — are planned and managed by the province’s Local Health Integration Networks (LHINs). Others — such as primary care, home and community care services, and population and public health services — are currently planned and managed in different ways.”3

What is Community-Based Mental Health?

Community-based mental health is defined as care provided outside of the hospital setting. It includes services and supports provided across the continuum of care, including health promotion, illness prevention, treatment and recovery. It includes not only treatment and crisis response, but also outreach, case management and related services such as housing and employment supports and court diversion programs. Community-based mental health and substance use care identifies the importance of communities in supporting recovery. This philosophy is supported by the fact that individuals receiving care generally prefer to do so within their community, and that for most individuals, formal mental health services are just one piece of the puzzle.

Every Ontarian must have equitable access to mental health and addictions services and supports across the province. To ensure that every door is indeed the right door to the mental health and addictions system, health care providers must have access to mental health and addictions resources in all health care settings, including primary care, home and community care. Mental health and addictions issues, such as depression, anxiety, and substance use, are among the most common and disabling health conditions worldwide4 . They often co-occur with acute and chronic medical problems and can substantially worsen associated health outcomes. When mental health and addictions issues are not effectively identified and supported, they can impede recovery, impair adherence to medical treatments, and are associated with increased morbidity and mortality, increased health care costs, and decreased productivity for the individual5 .

Whether at home, in a family physician’s office or a community health clinic, individuals with mental health and addictions issues must be supported with mechanisms for early identification and assessment, followed by quick referrals to appropriate services and supports. The work of community mental health and addictions service providers needs to be better integrated with home and community care.

CMHA Ontario Supports Patients First

Canadian Mental Health Association, Ontario, along with our 31 local branches, is pleased to express support and recommendations for Patients First: A Proposal to Strengthen Patient-Centred Health Care.

CMHA Ontario commends the provincial government on the proposed strategy as it focuses on attaining consistent, accountable and integrated primary care, home and community care and public health services. As a leader in community mental health and addictions, CMHA Ontario provides services across the lifespan through a health equity and social determinants of health framework. As such, CMHA Ontario is encouraged that the government’s proposed strategy is informed by the needs of diverse Ontarians who rely on our health care system, including children, seniors and people with disabilities. Furthermore, we support the fact the proposal is grounded in the principles of health equity and the social determinants of health, such as income level and geography6 .

CMHA Ontario is pleased that the government will look to Ontario’s Mental Health and Addictions Leadership Advisory Council for advice on enhancing access and improving overall performance of mental health and addiction services across the province. As such, as the planning and future direction of this work takes place at the Local Health Integration Network (LHIN) level, there must be alignment with the Leadership Council’s work as we move forward. CMHA Ontario is a member of the council and co-chairs the System Alignment and Capacity Working Group. Our organization also co-leads several initiatives including: identification of core mental health and addictions services for Ontario; development of a provincial data and performance measurement strategy; and, implementation of a quality improvement strategy for community mental health and addictions services. We also provide support to the Supportive Housing Working Group, helping to advance Ontario’s plan for ending chronic homelessness within the next 10 years.

CMHA Ontario calls for stronger collaborative partnerships between primary health care providers and community mental health and addictions agencies to ensure that Ontarians, no matter where they live, have equitable access to mental health and addictions services. Mental health is not just about specialized care – mental health is an integral part of the primary, home and community care sectors. Importantly, CMHA Ontario strongly emphasizes the need to ensure that primary care physicians – most often the first point of contact for people with mental health and addictions issues – have access to appropriate mental health and addictions resources. In order to make appropriate referrals to the mental health and addictions services and supports in the community, primary care physicians need access to screening and crisis management tools and improved knowledge about the community-based mental health and addictions resources available in their local area.

A Significant Strength: Collaborative CMHA Partnerships with Primary Care Sector

Collaborative partnerships between primary care providers and community mental health and addictions agencies, which are grounded in evidenced-based practice, are necessary to strengthen patient-centred care and ensure the seamless coordination between primary health care and community mental health and addictions services.

For many years, CMHA branches across the province have been establishing strong collaborative partnerships with primary health care providers in order to provide seamless services to Ontarians with mental health and addictions issues.

We are pleased to profile five such collaborative efforts in different regions in Ontario. CMHA Ontario and our local branches welcome the opportunity to work with government and primary health care providers to expand these initiatives across Ontario.

windsor-on-october-6-2015-dr-mohammed-hussain-sees3City Centre Health Care is operated by the CMHA Windsor-Essex County Branch and offers primary care services for the health needs of individuals and families. The centre operates under a collaborative care model where an interdisciplinary team of family doctors, nurse practitioners, and other health care professionals including a Registered Practical Nurse, dietitian, therapist, health promoter, and chiropodist, take a holistic approach to patient care addressing both the primary and the mental health needs of the population. The team assesses the needs of the clients served, and creates and implements treatment plans to effectively address the identified needs. Referrals for on-going primary and mental health support are made according to the treatment needs of the patient. The clinical team offers care using best-practice guidelines and referral processes.
For more information, visit www.citycentrehealthcare.ca.

cmha durham buildingCMHA Durham Region’s Nurse Practitioner-Led Clinic offers a full range of primary health care services to individuals and families who do not have a primary health care provider. The clinic is unique in that it offers a new way of delivering primary health care where NP s are the lead providers. Through a collaborative practice approach which includes registered nurses, RPNs, collaborating family physicians, and other health care professionals, NPs provide comprehensive, accessible, and coordinated family health care services to people who do not have access to a primary care provider. Among its array of services, the clinic addresses the primary care needs of people with mental health and addictions issues and their families, medication monitoring, referrals to community resources and health promotion to the community.

For more information, visit the CMHA Durham website.

Hamilton Primary Health Care Clinic is a collaboration between CMHA Hamilton Branch and the Shelter Health Network (SHN) and provides accessible primary care to individuals experiencing homelessness who are without a family doctor. Two SHN physicians and an SHN psychiatrist each provide services for a half-day a week at the clinic. A RN at CMHA supports the clinic by providing concurrent counselling and referrals within the community. For example, referrals may include the following: city housing and income support; addictions services; public health harm reduction; and, sexually-transmitted disease testing. OSCAR is the web-based documentation system used by all SHN clinic locations including the CMHA Primary Health Care Clinic. Any clinician at any one of several SHN locations in the Hamilton urban core can access a client’s electronic file, thereby ensuring continuity of care for this vulnerable and transient population. Other local health care providers collaborate to enhance capacity to support the care of these patients such as the SHN’s Hep C treatment team, the SHN maternity team and the Wesley Special Care Unit, an evidenced-based alcohol management program. Clinic clients can also easily access CMHA services such as court or housing support, and intensive case management. The key objective of the clinic is to provide accessible, integrated service to improve client outcomes for those experiencing homelessness in Hamilton.

For more information, visit the CMHA Hamilton website.

Rapid Assessment Intervention and Treatment (RAIT) Program is a collaborative partnership between CMHA Lambton-Kent Branch and primary health care practitioners. The RAIT program aims to remove barriers to access by offering timely mental health assessments, treatment, case management or support services. The RAIT team is multidisciplinary. Psychiatrists, nurses, social workers, psychotherapists and client care assistants work in close cooperation and communication. Services may include psychiatric consults and recommendations, nursing assessment and treatment, psychotherapy treatment, psychosocial interventions, and life skills coaching, as well as linkages and referrals to needed resources and services within CMHA or externally to other community professionals.

For more information, visit CMHA Lambton Kent’s website.

MOBYSSMobile York South Simcoe (MOBYSS) is Ontario’s first mobile health clinic for youth aged 12-25. Launched by CMHA York Region South Simcoe Branch, this innovative clinic travels areas across York Region and South Simcoe where youth have difficulty accessing services, because of travel, stigma, or other barriers. The clinic, a 39-foot RV, is wrapped in graffiti and retrofitted with medical office and other private meeting space. The bus parks where youth gather, such as malls, schools, campuses and skate parks. The model is youth driven; the support is holistic and compassionate, grounded in evidence, anti-oppression and cultural competency, following trauma-informed and harm-reduction care. Services include assessment, suicide intervention, counseling, referral, sexual health and addictions education and support, basic primary care and health screening for vulnerable youth who are facing complex issues and obstacles to accessing mainstream supports. Telemedicine services will offer a range of treatments and specialized services. The team includes an NP, youth mental health worker and peer support specialist. Visit www.mobyss.ca to learn more.

Our Responses to support Patients First

Within Patients First: A Proposal to Strengthen Patient-Centred Health Care, the government asks for feedback on four specific proposals with the goal of putting patients first. CMHA Ontario is pleased to offer the following input on each proposal:

Proposal #1

    • To provide care that is more integrated and responsive to local needs, make LHINs responsible and accountable for all health service planning and performance.

Identify smaller regions as part of each LHIN to be the focal point for local planning and service management and delivery.

CMHA Ontario supports the objective of proposal #1 to make LHINs responsible and accountable for all health service planning and performance and to identify smaller (sub-LHIN) regions as the focal points for local planning and service delivery. However, moving forward, CMHA Ontario would like to recommend that the Ministry of Health and Long-Term Care clearly define the role that the Mental Health and Addictions Leadership Advisory Council would play in the newly-envisioned LHINs (and sub-LHINs).

Although the proposal to create smaller sub-LHINs as focal hubs for local planning seems feasible, unless system coordination is paramount, there is a real risk of further fragmentation of services. Service coordination is essential for people with mental health and addictions issues across multiple sectors including health care, housing, employment and criminal justice.

To ensure coordination within and across LHIN boundaries, strong coordination mechanisms are needed. For example, increasing the use of shared electronic health records, is one mechanism that can help coordination of patient records so that patients don’t have to repeat their stories for every service provider. However, coordination must encompass not only ministry-funded initiatives but services of other sectors. Service regions and lead agencies under the Ministry of Children and Youth Services, for example, must also be considered as part of a whole-of-government approach to coordination.

Regardless of the coordinating body, the coordinating function should be considered as the most important factor. This function should remain in the community as this where the complexity of mental health and addictions is best addressed and recognizes the cross-sectoral nature of the needs and supports required.

With respect to performance of the mental health system, CMHA Ontario, in partnership with the Leadership Advisory Council, is currently helping to develop a data and performance measurement framework for the sector. One of the challenges throughout the mental health and addictions sector is that agencies often lack capacity and financial and technical resources for data collection. Data infrastructure challenges across the system are a priority that must be addressed so that we can gain a better understanding of how Ontarians are impacted by mental health and addictions services, and how we can improve those services.

Among service providers outside the mental health and addictions sector, there remains a lack of awareness about the complex health needs of people with mental health and addictions issues. In order to facilitate a seamless journey through the system, it would be useful for clients to have access to system navigators who are knowledgeable about all parts of the health care system and can help individuals and their families and caregivers in accessing appropriate resources whether at home or in the community.

To provide care that is more integrated and responsive to local needs, we advise that LHINs employ a health equity framework in all planning and service delivery. An integrated and responsive system also needs to recognize that for people with mental health and addictions issues, recovery supports and access to the social determinants of health are an integral part of the continuum of care which includes needs such as housing, employment, court support, peer support and social/recreational needs.

Proposal #2

  • Bring the planning and monitoring of primary care closer to the communities where services are delivered. LHINs, in partnership with local clinical leaders, would take responsibility for primary care planning and performance management.
  • Set out clearly the principles for successful clinical change, including engagement of local clinical leaders.

To bring planning and monitoring of primary care closer to the communities where services are delivered, CMHA Ontario advises that each LHIN and sub-LHIN develop mechanisms to help primary care physicians adequately support individuals with mental health and addictions needs. Family or community-based primary care physicians, especially solo practitioners, need access to mental health resources as they are often the first point of contact with the health care system for Ontarians. In order to make appropriate referrals to the mental health and addictions services and supports in the community, primary care physicians need access to screening tools, crisis management tools and increased knowledge about the community-based mental health and addictions resources available in their local area.

Furthermore, people with mental health and addictions issues often face discrimination and stigma from those in the system tasked with providing care. For example, primary care physicians may screen out complex care clients (who are often people with mental health and addictions issues) due to lack of time and resources. To ensure that people with mental health and addictions issues are not discriminated against, a uniform and LHIN- mandated standard of clinical care would be beneficial and should be considered by government.

Proposal #3

  • Strengthen accountability and integration of home and community care. Transfer direct responsibility for service management and delivery from the CCACs to the LHINs.

To ensure accountability, we would advise LHINs to consider applying outcome measurements to both directly operated and sub-contracted services. In addition, appropriate mechanisms at the local or sub—LHIN level would help to ensure that there is adequate case coordination between community mental health and addictions services and recovery support services, such as housing, employment, education, court support, etc.

Within the current system under the CCACs, sub-contracted services often exclude providing home care to individuals because of a mental health concern. If the service management and delivery of home care services are transferred to the LHINs, CMHA Ontario recommends that these services expand their capacity to serve individuals that have co-morbid mental health needs by enhancing mental health education, capacity and skillsets of their front-line staff . Close partnerships between home care providers and community mental health and addictions providers are essential to meet the needs of Ontarians.

Proposal #4

  • Integrate local population and public health planning with other health services. Formalize linkages between LHINs and public health units.

CMHA Ontario would welcome integration of population health and public health. Public health has always been a key stakeholder in the work we do and we partner with public health as we recognize their crucial role in prevention and promotion. However, we advise that the parameters and scope of integration should be clearly defined. This proposal is an opportunity to expand public health programming to link more closely with community mental health and addictions programs at the local level. The government may wish to integrate further planning tables province-wide so that public health programming (such as school-based mental health programs and drug treatment services such as methadone clinics) can be aligned with community mental health and addictions services and supports.


References

1 Ministry of Health and Long-Term Care. (2015). Bringing Care Home: Report of Expert Group on Home and Community Care. http://health.gov.on.ca/en/public/programs/ccac/docs/hcc_report.pdf

2 Ministry of Health and Long-Term Care. (2015). Patients First- A Proposal to Strengthen Patient-Centred Health Care in Ontario. http://www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_paper_20151217.pdf

3 Ibid. p.9

4 Patel, V., Belkin, G. S., Chockalingam, A., Cooper, J., Saxena, S., & Unützer, J. (2013). “Grand Challenges: Integrating Mental Health Services into Priority Health Care Platforms.” PLoS Medicine, 10(5), e1001448. http://doi.org/10.1371/journal.pmed.1001448 (cross references)

5 Patel, V., Belkin, G. S., Chockalingam, A., Cooper, J., Saxena, S., & Unützer, J. (2013). “Grand Challenges: Integrating Mental Health Services into Priority Health Care Platforms.” PLoS Medicine, 10(5), e1001448. http://doi.org/10.1371/journal.pmed.1001448

6 Ministry of Health and Long-Term Care (2015). Patients First- A Proposal to Strengthen Patient-Centred Health Care in Ontario. http://www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_paper_20151217.pdf

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