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Mental Health and Addictions Issues for Older Adults: Opening the Doors to a Strategic Framework

March 1, 2010

It is estimated that the prevalence of mental health problems in adults over 65 years ranges from 17 to 30 percent. This report identifies services and supports needed for older adults at risk/or living with mental health conditions.

Executive Summary

Preamble

The Canadian Mental Health Association (CMHA), Ontario is a not-for-profit, charitable organization whose vision is “mentally healthy people in a healthy society.” As a core responsibility, CMHA, Ontario develops and provides public policy advice that promotes mental health and improves the lives of people living with mental illness.

We applaud the efforts of the Ministry of Health and Long-Term Care (MOHLTC) in the development of their discussion paper, “Every Door is the Right Door” and in the directions they are taking to develop a 10-year strategy for mental health and addictions.

With this paper we hope to concentrate attention on older adults with mental health and addictions issues and underscore the necessity for a framework that is specifically focused on this group. The aging population in Ontario, the increasing prevalence of mental ill-health in this demographic and the associated human, health and social costs provide compelling reasons to establish a framework that prevents mental ill health, provides for early identification and early intervention if illness presents, and supports seniors so they can live in their homes, in communities of their choice.

Introduction

In 2008, adults over the age of 65 constituted 13.5 percent of the total population in Ontario or 1.7 million people; by 2036 that figure is expected to rise to approximately 23.2 percent or 4.1 million. Of these, it is estimated that the prevalence of mental health problems ranges anywhere from 17 to 30 percent or higher, depending on what diagnoses are included in the analysis. For example, if sub-clinical depression and anxiety are added, estimates rise to 40 percent of older adults.

In total that means that between 289,000 and 680,000 older adults are affected by mental health problems in Ontario(Ontario Ministry of Finance 2009). Mental ill health has a significant impact on our economy, health care expenditures, use of high-demand acute care beds and, of particular importance, our social fabric. The moral, economic and familial impacts of mental ill health for so many older adults make a compelling argument for government action.

A Framework for Seniors’ Mental Health and Addictions

This report will focus on services and supports needed for older adults at risk/or living with mental health problems. We also know from the literature that in many instances, addiction-related concerns are a concurrent factor. The specific groups addressed in this report include:

  • Those growing older with long-standing or recurrent mental health issues;
  • Those whose mental health problems, including depression and the dementias, which are primarily related to biological aging or circumstances associated with later life;
  • Those older adults dealing with concurrent disorders.
Mental Health Disorders in Older Adults
Depression
Suicide
Anxiety Disorders
Dementia
Delusional Disorders
Delirium
Paraphrenia, late onset psychotic disorders
Concurrent Disorders

Currently there are a lack of adequate mental health services and community supports for older adults. Instead of a mental health system, where “Every Door is the Right Door,” we find that many doors are closed to the needs of older people, and the gaps in service outweigh the opportunities for access. It is indeed an injustice to rationalize these gaps on the basis that mental health problems are a natural by-product of aging. Research shows that many so-called aspects of “normal aging” (such as depression) are preventable and treatable (Canadian Coalition for Seniors’ Mental Health, 2009).

While some supports do exist in the form of psycho-geriatric services and acute and special long-term care beds, these focus primarily on the needs of those with dementia or serious mental illness. To address the needs of all older adults, a framework must be developed that includes a continuum of education, care and support that will enable people living in the community to live their lives to the fullest in spite of the challenges of mental illness and/or addictions.


Opening the Doors

In July 2009, the Ontario Ministry of Health and Long-Term Care (MOHLTC) released a discussion paper, “Every Door is the Right Door.” Using the directions laid out in their paper as a template for discussion, we offer our insights and strategies into a senior’s framework for mental health and addictions.

Core Elements of a Senior’s Framework
Community-based care
Collaboration across all sectors to deliver a social model of care
Recovery-based approach that involves the client and family (where desired by the client)
Client and family/carer involvement in system planning, implementation and evaluation

DIRECTION #1: ACT EARLY

Prevention, early identification and early intervention are key strategies in an effective mental health system for seniors.

a) Prevention

The consequences of loss, sorrow and grief as a result of life events affect many older adults, causing ongoing negative mental health consequences. Anxiety, depression and perhaps substance abuse are just some of the mental health problems that arise as people navigate these transitions in later life. Prevention strategies can mitigate these effects from becoming permanent mental health issues.

Research has shown that psychosocial interventions such as social networks; facilitated education programs that help seniors build on their strengths, maximize their potential and optimize their physical wellness; and peer support networks play a role in preventing age-onset depression. Support for broader availability of community-based social networks is required (Psychosocial Approaches to Mental Health Challenges of Late Life, 2009).

The importance of accessible and responsive primary care is essential in the prevention of mental health problems in older adults. With the advent of Family Health Teams in Ontario, come new opportunities to prevent the incidence and impact of mental illness related to aging and loss. Home visits to the frail elderly, nurse practitioners for community-based primary care and expanded community-based supports to enable seniors to live at home are all excellent strategies for creating environments conducive to good mental health and should be expanded across the province. Examples of effective practices through cooperative and integrated service delivery are emerging for primary mental health services (WWLHIN, 2009). These models offer excellent foundations for extension to our seniors in need.

b) Early Identification and Early Intervention

There is growing statistical evidence that the incidence of mental illness is increasing in older adults. In spite of that, there is reluctance for people to self-identify or for family members or peers to mention someone who is suspected of having mental health problems because of perceptions that this is an unavoidable part of normal aging. This makes early identification and intervention extremely difficult.

Part of this reluctance is due to social stigma about ageism. To combat this, seniors-specific education is needed to decrease societal stigma, self-stigma and benign ignorance about the differences between normal aging and signs of mental illness. Resource materials for seniors’ groups, seniors’ centres, conferences and workshops would be valuable aids to increasing awareness about ageism and discrimination.

Educational support is not only needed for seniors, it is also required for all service providers involved with seniors, be that in mental health or in other parts of the public sector such as social services, housing, transportation and justice. Finally, public education on the topic of ageism is needed to reach out to family members who might inadvertently be discriminating against their own loved one by ignoring early signs of mental illness with rolling eyes, a shrug of the shoulders and “oh, he’s just getting old.”

Screening and risk assessments by primary care practitioners are invaluable in early detection of mental illness and treatment, particularly for depression. For that reason, primary care professionals should have support and access to training that enables them to recognize, address and diagnose the full range of mental illnesses and addictions and differentiate them from the signs of normal aging. In addition, primary care practitioners must have access to other expertise for consult, rapid referral and educational support. A recent study shows that only 9% of physicians routinely question or screen outpatients for depression (Williams, Rost, Ciotti, Zyzanski, Cornell, 1999) . This presents a huge opportunity for improvements in early detection and intervention.

If screening indicates that early signs of mental illness are presenting, then the involvement of the multi-disciplinary primary care team should take place, involving professionals such as a geriatric nurse, pharmacist, dietician and occupational and physical therapists. There are currently innovative models in Ontario that not only include the primary care team at this stage, but also involve a home care coordinator and specialist services such as a geriatrician, neuropsychologist and bereavement counselor (Donnely, 2005).

Key Strategies for Acting Early
Prevention:
Support for community-based social support networks by seniors, for seniors
Expand Family Health Team services to include home visits, nurse practitioners focused on frail elderly
Expand community-based supports to enable seniors to continue to live at home
Early Identification and Intervention:
Education for the public, specifically seniors and service providers on ageism, discrimination and normal aging vs. mental health problems
Primary care screening and assessment
Multi-disciplinary team support at primary care level and by specialists if early signs of disease are detected

DIRECTION #2: MEET PEOPLE ON THEIR OWN TERMS

In this section, we interpret the concept to mean “Meeting people on their own terms, in their own place, in their own way, in culturally safe and culturally competent ways.” Research has proven that treatment is more effective, clinical outcomes are more positive and client satisfaction in the experience is much greater, when the treatment approach is recovery-based and person-centred. This is equally true when we talk about an effective approach to seniors’ mental health.

Mental health service delivery must not only be oriented to recovery, but must involve seniors with lived experience, their families or carers in the planning, implementation, monitoring and evaluation of system and service change. If the changes do not make a positive impact on the people being served, then service is not person-centred but service-centred; meaningful change must be defined and determined with input from those who have the lived experience.

There are very few services focused on senior-specific addiction and/or concurrent disorders. This is particularly problematic given the fact that seniors with depression are four times more likely to have alcohol-related problems than those who are not depressed (Spencer, 2003). In addition, those who are addicted to over-the-counter and prescribed medications cannot access services when required. There are examples of seniors-specific addictions programmes in Toronto, Guelph, Ottawa, Thunder Bay and Sault St. Marie; these types of models are needed in other locations across Ontario to provide equitable access for those suffering from an addiction or concurrent disorder.

Meeting people on their own terms also requires an approach that is culturally safe and culturally competent. At present, a lack of English coupled with social isolation contribute to mental health problems in older adults of different ethnic backgrounds and add to the challenges in providing them with support. There is an absence of formal ethno-specific seniors’ mental health services. This gap leaves a large number of elderly people in Ontario stranded on islands of linguistic and social solitude. Some faith-based organizations, community centres and associations attempt to cover the gap through programming but more funding is required to ensure that the needs of these seniors are met.

Good mental health requires that the social determinants of health, including affordable and appropriate housing in their own community, adequate income, education, social networks and transportation are present. This necessitates a cross-sectoral approach at all levels, from government ministries to grass roots service delivery to ensure that the bio-psycho-social factors of mental health are balanced and available to seniors. Service by silo cannot be the way of the future. Cross-ministerial coordination and partnerships are the keys to real system transformation.

In keeping with the “whole of government” approach, it would be advantageous to apply a “Seniors’ Mental Health Lens” (MacCourt, 2005) to all government policies to assess the impact of any policy on mental health and older adults. Applicable not only to the MOHLTC but to all Ministries, this lens would ensure that policy development that would benefit one area of public service would not inadvertently be counterproductive to seniors’ mental health and addictions.

Key Strategies for Meeting People on their Own Terms
Adopt a recovery-based service culture
Involve people with lived experience in all aspects of system and service change
Establish additional centres/services for seniors with concurrent disorders
Support development of ethno-specific mental health services for seniors in the community
Cross–sectoral involvement of all relevant Ministries to ensure that the complete bio-psycho-social needs of older adults with mental illness are met
Apply a “Seniors’ Mental Health Lens” to all government policies

DIRECTION #3: TRANSFORM THE SYSTEM

Instead of a seamless system of integrated components offering comprehensive, effective, efficient, proactive and population-based services, there exists a minimal patchwork of supports. Each component struggles to provide the best service it can, yet without a cohesive structure, seniors who need mental health and addictions support find themselves shut out from the help they need. The consequences of the lack of alternatives are tremendous in terms of unmet need, extended waiting lists, escalating costs, overutilization of medication and human suffering.

a) Helping Older Adults with Mental Illness and/or Addictions Remain at Home

Most people, when given a choice, would prefer to remain in their own communities, in their own homes rather than be institutionalized. Older adults with mental health problems are no different. Supports and services that enable them to do so, in a safe, effective and holistic manner are extremely important elements in a mental health system that embraces the needs of seniors.

To support older adults in the least restrictive, most natural environment possible to achieve good quality of life, specialized case management for seniors is an ideal approach. This type of service is comprehensive, intensive and frequent, linking specialized psycho-geriatric, addiction and community support services. Case Managers would support the client and caregivers, in managing health symptoms, providing mental health and physical health information, assist with goal setting and day-to-day management of tasks.

In conjunction with that, it would also be beneficial to establish formal, collaborative relationships between psycho-geriatric services, home and community care services to ensure that the bio-psycho-social needs of seniors are met. Because the mandate of most psychogeriatric services is focused on dementia, it would also be necessary to expand their mission to include a broader range of older adult mental illnesses.

Geriatric Mental Health Outreach Teams (GMHOTs) have been identified as a major resource for transforming the mental health and addictions system for older adults (Donnelly, 2005). By providing an interdisciplinary/multidisciplinary approach to assessment, consultation, treatment and education to seniors with serious mental illness, as well as to their families and service providers, GMHOTs have been extremely effective in helping troubled seniors remain at home. The expansion of these valuable resources is needed and it is recommended that consistent mandates, increased service capacity and enhanced staffing be available across the province.

Outpatient programs (hospital-based) vary widely in mandate and function across the province. These programs enable access to services while helping people remain in their homes. There are many excellent examples of programs that could be replicated across the province to provide better opportunities for seniors who are able to travel to hospital for services. Knowledge sharing of these programs coupled with funding to support wider and more consistent delivery would be an excellent adjunct in an array of approaches aimed at helping older adults with mental illness to remain at home.

b) Avoiding Emergency Visits and Hospital Admissions

Even if all of the proposed community services for older adults were in place, there will still be times when problems could escalate and an individual will require acute care. Hospital emergency departments become the destination of last resort, however busy ER’s tend to further agitate a senior who may already be confused and aggressive. Furthermore, a senior suffering from an acute episode in an emergency department, waiting for admission to a mental health bed, becomes a resource-intensive patient as his agitation becomes a source of concern for staff. For both patient and hospital staff, it is best to avoid this situation in advance rather than deal with it escalating within the confines of the Emergency Room.

For these reasons, it is suggested that crisis-avoidance be the first step. Currently, some jurisdictions benefit from Assertive Community Treatment Teams (ACTT). This model has proven to be effective for supporting people with mental illness and avoiding emergency trips, however their mandate does not consistently extend to people over 65 years of age. Variations occur from one ACTT to another with providers making their own determination of the upper age limit, primarily because of funding considerations. It is recommended that the province establish a mandate for all ACTT services to include people over 65 years of age and provide funding to support this.

In spite of the efforts of ACTTs, some clients can enter into crisis. To manage these episodes effectively and still avoid an ER visit, it is recommended that province wide 24/7 crisis services for seniors with mental health and addictions issues be established. These services would provide immediate attention, assess client needs and provide short-term intervention. They would link clients to community support services as well as specialized psycho-geriatric services in order to help them post-crisis and assist them to stay safely at home after an acute episode.

Finally, if an emergency visit is required, the availability of Geriatric Emergency Management (GEM) nurses in the emergency department have been shown to be effective. The specialized attention and interventions of these professionals both during and after the hospital visit can decrease the negative effects of dislocation and assist in re-integration to the community after discharge. Currently most GEM nurses work during the day, Monday through Friday; it is recommended that this important service be available on a 24 x 7 basis.

c) Long-Term Care and Seniors’ Mental Health

While the major focus of this report is not on long-term care facilities, it is important to briefly touch on their role, capacity and services for seniors with mental health issues. Recent studies show that 80% to 90% of residents in long-term care settings suffer from some form of mental disorder; 15% to 25% are severely impacted by major depression. According to the Ontario Long-Term Care Association (OLTCA) almost a quarter of residents who have depression, show signs of worsening over a three month period (OLTCA,2009). In spite of the magnitude of the problem, there is a shared perception amongst staff and family members that the management and treatment of mental health issues for residents are insufficient and inadequate.

Data from the OLTCA also show that almost half of the homes in their study reported the need to call police for assistance with residents and almost the same percentage required the use of a Form 1 or associated psychiatric leave. This has prompted the OLTCA to question whether long-term care facilities are the appropriate places for older adults with mental health issues both from the perspective of care for those who suffer from the problem and for the safety of other residents. A thoughtful review of the future role of long-term care facilities and residents with acute mental health conditions is required to ensure appropriate treatment is available to these individuals and to safeguard the well-being of other residents.

There are many people living in long-term care facilities that are not in an acute episode but are suffering from some form of chronic mental health problem. The Canadian Coalition on Seniors’ Mental Health estimates that 80% to 90% of residents have some form of mental disorder and that depression is present in approximately 50% of residents. Staff are ill-equipped for the most part to adequately manage these challenges. There is a tremendous need to strengthen the capacity, knowledge and skills of the workforce in long-term care settings to better manage residents’ behaviours in a sensitive and timely fashion. The implementation of Psychogeriatric Resource Consultants has been helpful with regards to that training however there is more that needs to be done.

The alignment of Geriatric Mental Health Outreach Teams (GMHOTs) has been helpful in the Toronto region. By training staff in long-term care settings how to tap into seniors’ mental health expertise available outside the facility, the availability of a support network has become more accessible. Similar models would be helpful beyond the Toronto area to ensure equitable service provision for residents who live outside of the GTA.

Key Strategies for Transforming the System
Helping Older Adults to Remain at Home
Specialized case management
Formal relationships between psychogeriatric services, home and community care services
Expand Geriatric Mental Health Outreach Teams across the province
Support the role of primary care practitioners
Avoiding ER visits and Hospital Admissions
Establish a policy that expands ACTT service limits beyond 65 years of age
Establish crisis response service for seniors with mental health issues
Ensure every ER has a GEM nurse available for in-hospital service and post-discharge follow-up
Long-Term Care
Additional training for staff to better manage mental health problems in residents
Expand use of GMHOTs beyond Toronto region
Review the role of long-term care facilities and residents in acute mental distress

DIRECTION #4: STRENGTHEN THE WORKFORCE

Training the workforce to enhance knowledge, decrease discrimination and increase and share best practices are essential elements for strengthening the mental health and addictions workforce.

a) Training

Mental health service providers have also identified the need to enhance their skills in a number of areas; they seek training to improve their abilities and offer improved service to their clients (Peel Older Persons Mental Health and Addictions Educational Interest Group, 2009). There are a number of options that would be beneficial in creating an environment based on best practice and ongoing quality enhancement.

As a first step, it would be beneficial to enhance undergraduate professional curriculae to include issues related to aging, geriatrics and mental health. In addition, there needs to be more specialized academic training opportunities in gerontology and mental health. Furthermore, and in keeping with the vital role of primary care, build on physician training strategies that are aimed at medical students, family medicine residents and practicing family physicians to increase knowledge capacity in diagnosis, treatment and support of seniors with mental illness.

With so much of the mental health workforce in the community, it would be advantageous to enhance support to services that expand the skills and knowledge of staff. There are a number of excellent community-based organizations that provide this type of training, offering custom designed education for personal support workers and their community organizations working with seniors with mental health and addictions problems.

Additional resources and training to assist the workforce could be expanded through the use of local mental health providers, specialized centres, Psychogeriatric Resource Consultants and GMHOTs. These organizations could conduct training in:

  • Differentiation of the signs of normal aging from signs of mental ill health;
  • Understanding the process and expectations around aging and chronic mental illness;
  • Early identification of mental health problems/addictions;
  • Managing disruptive behaviours;
  • Shifting the culture of service delivery to one of recovery rather than control;
  • Effective interventions and access to resources for helping depressed or suicidal seniors;
  • Anti-stigma and ageism discrimination;
  • Helping older people overcome the barriers to seeking help.

b) Best Practice

There is widespread desire for implementing best practice for seniors as it relates to mental health. Work has begun in jurisdictions throughout Canada but much more work is required to ensure that services are effective and efficient; we need to build on this work and establish best practice for seniors with mental illness in Ontario. Government needs to provide leadership by creating a mandate for best practice for seniors with mental health and addictions issues.

Key Strategies for Strengthening the Workforce
Training
Enhance undergraduate training in all health and social service programs in aging, geriatrics and mental health
Offer more specialized academic training opportunities in gerontology and mental health
Build on physician training strategies aimed at medical students, family medicine residents and practicing family physicians to increase knowledge around older adults and mental illness
Support community-based education for workforce in aspects of seniors’ mental health problems ranging from normal aging, anti-ageism, early identification, treatment and support
Best Practices
Establish a mandate in Ontario for best practices, building on the work done in other jurisdictions

DIRECTION #5: STOP STIGMA

Ontario’s Ministry of Health and Long-Term Care (MOHLTC) has recognized the need to identify and stop stigma and end discriminatory behaviours. Stigma and discrimination can exist amongst the public, service providers, families and consumers themselves.

a) The Public

Discrimination often starts with a lack of self-awareness about personal attitudes and behaviours. In general, people do not intentionally discriminate against older people, including those with mental health problems; however lack of intent does not mean a lack of discrimination. Social media campaigns and education are needed to increase awareness of stigmatizing attitudes around ageism and to decrease societal biases towards older people with mental health issues.

b) Providers

The stigma against aging and the resulting discriminatory behaviours towards older adults with mental illness is a serious concern in the mental health workforce. While recognition of the problem is an important first step, targeted education is essential in overcoming the double dilemma of ageism and mental illness in seniors. Enhancing workforce knowledge in the understanding that many mental health problems in older adults are preventable and/or treatable and not “just an irreversible consequence of old age” is necessary if providers are to adopt a recovery-based service approach.

It is important to observe that the stigmatizing attitudes of ageism and discrimination against older adults with mental illness exist beyond the mental health workforce. At any point in the public service, be that housing, employment, social assistance, justice or any other portfolio, unconscious discrimination can pose barriers to the provision of optimal assistance. There is a need for basic understanding of seniors’ mental health for service providers who will work with older adults. This could be achieved through training to heighten awareness of latent attitudes and facts surrounding seniors, normal aging and mental illness.

c) Self-Stigma

One of the most tragic consequences of societal and provider discrimination is the development of self-stigma in those suffering from mental health and addictions issues. Self-stigma prevents people from self-identifying when they are experiencing difficulties, asking for help and maintaining their engagement in services. Their own built-in biases against mental illness and their fear of being stigmatized by others not only create barriers to treatment, but induce feelings of guilt, shame and self-loathing.

Addressing the public and provider recommendations listed previously will help in decreasing the tendency for older adults to self-stigmatize but it would also be beneficial to provide educational opportunities by seniors, for seniors, to teach about the distinctions between normal aging and the onset of mental health issues. This type of education should also be provided to the family and carers of older adults because they are key to overcoming the personal effects of discrimination and the development of self-stigma.

In addition, resource materials such as those provided by Community Care Access Centres (CCAC), the CMHA, Ontario and CAMH could be funded so that they are more broadly available in any community location where seniors are likely to frequent.

Finally, the internet has become a tremendous resource for many people seeking information; however credible sites are mixed in with sources of dubious credentials. The province needs to support and improve access to reliable, on-line information about mental health and seniors to combat misconceptions about ageism, normal aging and mental health problems.

Key Strategies for Stopping Stigma
Public awareness campaigns
Service provider training to decrease stigmatizing attitudes for mental health workforce as well as other public service sectors
Community-based training by seniors, for seniors and their caregivers, on normal aging, the effects of ageism discrimination, early signs of mental health problems
Support for printed resource materials
Support for credible, web-based information on aging and mental health

DIRECTIONS #6 and #7: CREATING HEALTHY COMMUNITIES AND BUILDING COMMUNITY RESILIENCE TO MENTAL ILLNESS AND ADDICTIONS

The approach to preventing mental illness and supporting older people with mental health issues does not start or stop within the formal jurisdiction of mental health services. The social determinants of health are broadly accepted as being relevant to physical health as well as mental health. Measures that are taken to foster the overall population health of a community must include factors that nourish social inclusion, affordable housing, adequate income, good transportation and opportunities for recreation and exercise.

a) Whole of Government

In order for this to occur, a “whole of government” approach is required to ensure that a cross-sectoral approach supports the bio-psycho-social needs of seniors. Similarly, this coordinated approach must take place for planning, implementation and evaluation of service delivery at the regional and local levels. The MOHLTC should assume leadership responsibility for establishing this multi-level, multi-sectoral approach in partnership with other Ministries such as Community and Social Services, Education and Housing.

b) Housing

Adequate and affordable housing for seniors with mental illness is a pre-requisite for successful community living. Thus, the availability of assisted living or supportive housing linked to community services for older adults with mental illness is necessary to enable them to live in their communities of their choice. Supportive housing could also relieve some of the backlog of alternate level care patients who are waiting for a long-term care bed but could actually manage alone provided there was housing and services in place to assist them.

In addition to supportive housing, there is a need for transitional services that provide interim stay beds for patients who are discharged from acute psychogeriatric care back to the community. Transitional services should include support in regaining an independent life style, getting access to community supports and finding permanent, lower supportive housing. The Stepping Stone project in Toronto offers a good model for this type of service (Loft Community Services, 2009).

c) Community Services

Support services that enable seniors to live at home contribute to the mental health and well-being of these individuals and prevent the onset of mental illness resulting from poor nutrition, social isolation, lack of stimulation and difficulties in managing activities of daily living. Services that provide peer support, caregiver support and social opportunities are vital in sustaining good mental health. We applaud the resources that have been provided to these services and encourage further support to build and expand their availability.

Community Care Access Centres (CCAC) assist older adults to live in their homes. Currently however, the appropriate policy mandate for CCACs and other community mental health resources is unclear with respect to seniors and mental illness. Government needs to define and fund a consistent mandate for seniors’ mental health and addictions that builds on the strengths and capacities of the community mental health services sector in cooperation with CCACs.

Community services linked to supportive housing are an essential component of this strategy. Typically these services are only offered to those in supportive housing, however it should be considered that these be extended to vulnerable older adults who are at home but at-risk for homelessness. Services should offer daily visits from staff who help older adults manage challenges such as limited income, no family support, cultural isolation, poor physical health, mental health and addictions issues. They would also assist seniors with mental health issues in transition from acute care back to the community.

d) Transportation

Transportation to services is a particular concern for seniors due to problems relating to physical ability or financial hardship. This creates barriers to service for those living in their own homes or in long-term care facilities. Affordable transportation that ensures accessibility is a requirement if mental health services are to be available to seniors.

Key Strategies for Communities and Mental Health for Seniors
Whole of government approach:
Cross-sectoral involvement, led by the MOHLTC care, to address the health and social factors of mental well-being
Housing:
Expand available supportive housing for seniors with mental illness
Establish transitional services to facilitate re-integration of seniors from hospital back to the community
Community Services:
Extend services linked to supportive housing into the community to prevent at-risk seniors from becoming homeless
Expand community services for seniors with mental illness and/or addictions to assist them in living at home
Define and fund the role of CCACs in caring for older adults with mental ill health at home
Transportation:
Affordable, available transportation is necessary to enable seniors to access mental health services as well as social and recreational activities

In Conclusion

This Executive Summary is meant to provide an overview of the many issues related to the effective support of senior citizens that are living with mental health and/or addiction issues, as well as some broad-based actions and strategies for a provincial implementation framework. CMHA Ontario will be issuing a full report with greater detail on best practices and experience in the sector from people with lived experience, providers and family perspectives.


Partial List of Information Sources

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