Download PPT - OPOP

Jill Sherman, Bob Swenson, Robert Cooke, Abraham Rudnick, Paula
Ravitz, Fernande Grondin, Phyllis Montgomery, Raymond Pong,
Margaret Delmege, and Patrick Timony
September 16, 2010
Thunder Bay, Ontario
Disclosure
 Nothing to disclose
2
Learning Objectives
 Explore the continuum of mental health services in
representative small northern Ontario communities
 Understand unmet needs for mental health services from
the perspectives of smaller communities
 Identify and discuss the implications of the findings for
medical education
3
How do smaller, remote communities provide
access to psychiatric and mental health services
in Northern Ontario?
Five interrelated themes:
 Service delivery context
 Community context
 Service delivery models
 Collaborative care
 Innovations
4
Research Methods
 Study Area: NE / NW LHINs, excluding NURCs
 Multiple Case Study Approach
 Trade-off between breadth (number of cases) and depth
(level of detail possible for each case)
 10 Case Study Communities
 Purposive sampling, maximum variation
 Stratified on OPOP services, non-OPOP services
 Other variables of interest: Language
(Anglophone/Francophone), NE/NW LHIN
5
Characteristics of Communities
LHIN OPOP
LANG
C1
14
Y (but)
EN
<6,000
97
6 >60
C2
14
N
EN
<10,000
91
6 40-60
C3
14
N
EN
<1,000
95
5 <20
C4
14
Y
EN +
<6,000
79
6 40-60
C5
13
N
EN
<2,000
100
C6
13
N - Other EN
<4,000
68
5 20-40
C7
13
Y
<10,000
70
6 >60
C8
13
N - Other FR
<4,000
55
5 0 (but…)
C9 *
13
Y
FR
<6,000
95
6 20-40
C10 * 13
Y
EN/FR
<12,000
71
3 40-60
EN/FR
POP
RIO
SAC
# Acute
Beds
6 <20
6
Primary data collection
 Key Informant Interviews with health and social services
providers, community representatives, and other interested
(November 2009-September 2010)








Mayor / Town official
Hospital, FHT, CHC, other Primary Health Care Providers
Designated mental health care providers (e.g. CMHA, others)
Public Health Units
Social Service Providers (e.g. CCAC, Housing, CFS)
Schools, Churches, other Community Services
Police, EMS, Pharmacies, Legal Services
Support Groups, Volunteer Groups (e.g. VCARS)
7
Definitions of “mental health”
 Mental illness – focus on Disease / Disorder
 Psychiatric / neurological disorders, SMI
 Developmental / intellectual disorders
 Medical problems with mental health consequences
 “Social disorders”

Behavioral problems, interpersonal violence, “bad parenting,”
inability to care for one’s self, vulnerability
 Alcohol / drugs / addictions – ambiguous status
 Mental wellness – Capacity, QOL focus
 Ability to care for one’s self, enjoy life, participate in
community life
8
Definitions of “mental health services”
 “Counseling”
 “Medical mental health” – treatment focus
 Hospital, ER, psychiatrists, social workers, (pharmacists)
 “Social mental health” – treatment/recovery focus
 “Holistic mental health” – wellness focus
 “Everything designed to enhance individual and
community wellbeing” (e.g. recreation)
 Public Health, Schools, other community services –
 Sometimes included as preventive services
 “Family Physicians” usually included when prompted
 associated with medications, ER treatment, referrals
9
Role of family physicians?
 Multiple jobs  Family Practice
 ER coverage
 Outreach - satellite clinics in surrounding communities
 In context of
 Multiple vacancies
 High proportion of locums
 “Shared care may work in some communities, [but
here] it would be a waste of my physicians’ time” (Chief
of Staff)
10
Overlooked as frontline providers -1
 Pharmacists
 Serve as de facto “walk-in clinic” in small communities
 Play key role in coordinating / managing medications, esp.
in communities relying on “Dr. of the Day” (locums)
 Mediate between the clinical goal of a physician, the
demands of a drug regimen, and the realities of the patient
& community context
 Are strongly affected by changes in demand for
prescriptions (e.g. narcotics, methadone clinics), but
frequently left out of policy, planning, and communication
networks
11
Overlooked as frontline providers -2
 Dentists
 Also prescribe narcotics, but left out of planning,
communications
 Dental health reveals patient drug use, other mental health
issues (particularly in children), but dentists are not able to
refer patients to services that require a physician referral
 EMS
 Lack of training for mental health emergencies
 ‘Vicarous trauma’ – lacked access to employer-provided
mental health services
12
Overlooked as frontline providers -3
 Indian/Native Friendship Centres
 Provide a variety of health, support, and advocacy/legal
services
 Often invited to “participate” at the table, but …
 Legal Services
 Often perceive hostility rather than partnership from
health care providers (even when on the same side)
 View themselves as advocates for those who cannot help
themselves – incl. “system navigation”
 Want more education on mental health conditions,
medications
13
Unmet needs - 1
 ALMOST ALL COMMUNITIES –
 (Economic supports)
 Family physicians
 Transportation services
 Supported living / housing services
 Senior’s services
 School-based counselors
 Services for men
 Detox –


Alcohol – emphasized in NW LHIN
Drugs – emphasized in NE LHIN
14
Unmet Needs – 2
 NW LHIN –
 FASD Diagnosis
 NE LHIN  Parenting education / assistance
 Critical incident stress debriefing

VCARS services - highly valued, where they existed
 Prevention services  Difficult to define, generally deemed absent / lacking
 Some notable exceptions (e.g. Public Health Units)
15
Unmet Needs - 3
 Community-specific needs
 Counselors
 Psychiatrist
 Homeless shelters, temporary housing, family-friendly
shelters (problems with gender-segregated shelters)
 Services for domestic violence, sexual abuse, incest
 Walk-in clinic
 Minority services (French, English, Native)
16
Unmet needs: Information and Communication
 Overreliance on informal networks, interpersonal networks
Belief that “everyone knows everything” in small communities
 Information shared through (closed) provider networks

 Many community leaders lacked full or accurate knowledge of
available mental health services

Contributed to community conflict over controversial issues
 Key community members did not know where to get
information on mental health services



Lack of awareness of MHSIO, even among providers
Lack of community directories of services, or awareness of …
 “There used to be…” - problem of constant change
Communication challenges reaching low-income audiences
17
Service Models = Ethical Dilemmas
 Insufficient resources  rationing – How?
 Service intensity – Equity or efficacy?


Extensive services – emphasis on access
Intensive services – emphasis on recovery
 Spatial concentration or dispersion?

Most communities with visiting psychiatrists – 2 or more
 Service “duplication” or service diversity?
 Prioritizing among acute treatment, rehab, health
promotion/prevention?
 Service threshold / critical mass  Effectiveness
18
Typical “Success Stories”
 Recruiting service providers (family physicians, social
worker/counselor, psychiatric nurse) or developing new
services (FHT, CHC).
 “Any time we help a client to remain in the community” –
struggle to make system work for each individual
 Own program
 One or two programs were typically recognized by all or
most community informants as a success, e.g.
 Food bank, community garden, food box programs
 “Drop-in” centres, where they existed
 Senior’s programs
19
Less typical success stories
 Community fundraising initiatives, cost-sharing,
creative funding
 VCARS and/or community-wide critical incident
interventions
 Collaboration – community-wide, between
“competing” agencies, or between Native (Federal) and
Provincial services
20
“Success” stories?
 The Angry Community:
 “Getting the client OUT of the community, so that they can get the
help they need.”
 The Depressed Community:
 “Can’t think of any”
Very small / remote
21
Contextual factors
 Community factors
 Size / dispersion
 Proximity to other services

Between two centres
 Location in transportation networks
 Industry / Economy


Service Centre
Transportation Centre / Resource-dependent
 Stage in boom-bust cycle
 Leadership interest in health
 Unique characteristics
22
Contextual Factors -2
 Impact of other research –
 Hill ME, Pugliese I, Park J, et al. 2008. Forestry and Health: An
Exploratory Study of Health Status and Social Well-Being
Changes in Northwestern Ontario Communities. Centre for Rural
and Northern Health Research, Lakehead University, Thunder Bay, ON.
 The Agora Group. 2010. Together: A report from the Agora Group on
the development of an integrated model of addiction and mental
health service delivery throughout Algoma District. North East
Local Health Integration Network, Sudbury, ON. (March 2010)
 Select Committee on Mental Health and Addictions, Legislative
Assembly of Ontario. 2010. Navigating the Journey to Wellness: The
Comprehensive Mental Health and Addictions Plan for
Ontarians. (Interim Report, March 2010; Final Report, August 2010)
23
For discussion…
 What are the implications of these findings for
medical education?
 Role of family physicians in mental health?
 Interprofessional education?
 Distributed model of education?
 Health education / capacity building?
24