Mississauga LHIN Mental Health and Addictions

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					Mississauga Halton LHIN: Mental Health & Addictions
Detailed Planning and Action Team Report

May 2008

Mississauga Halton Local Health Integration Network:

2 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Table of Contents
Executive Summary:.................................................................................................................... 7  Our Methodology:......................................................................................................................... 9  Team Membership: ................................................................................................................ 10  Quantitative Team Task Group................................................................................................ 11  The Approach: ........................................................................................................................ 11  Focus and Objectives: ........................................................................................................... 11  Data Sources used for the Data Collection:....................................................................... 11  Limitations: .............................................................................................................................. 12  Population: .............................................................................................................................. 12  History and Trends:................................................................................................................ 13  Age Distribution: ..................................................................................................................... 14  Limitations: .............................................................................................................................. 16  Diversity in Mississauga Halton LHIN ................................................................................. 17  Explanatory Models: .............................................................................................................. 21  Barriers: ................................................................................................................................... 23  Limitations: .............................................................................................................................. 23  Usage Statistics - Statistics and the Hospitals ................................................................. 24  Limitations: .............................................................................................................................. 25  Statistics and the Community Services .............................................................................. 27  Limitations: .............................................................................................................................. 28  Prevalence and Determinants of Health............................................................................. 28  Concurrent Disorders............................................................................................................. 31  Co morbidity ............................................................................................................................ 32  Special Populations ............................................................................................................... 32  Acquired Brain Injury: ............................................................................................................ 36  Suggestions: ........................................................................................................................... 37  Dual Diagnosis:....................................................................................................................... 37  Key Determinants of Health: ................................................................................................ 38  Staffing:.................................................................................................................................... 39  Limitations ............................................................................................................................... 39  Recommendations ................................................................................................................. 39  Inventory of Services Task Group .......................................................................................... 41  The Approach: ........................................................................................................................ 41  3 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Focus and Objectives: ........................................................................................................... 41  What we learned: ................................................................................................................... 43  Discovery:................................................................................................................................ 50  Limitations of the Data:.......................................................................................................... 51  Summary: ................................................................................................................................ 51  Recommendations: ................................................................................................................ 52  Capacity Comparison: ........................................................................................................... 53  High Level Financial Analysis Task Group ............................................................................ 67  The Approach: ........................................................................................................................ 67  Focus and Objectives ............................................................................................................ 67  High-level Financial Findings ............................................................................................... 68  Other Key Findings: ............................................................................................................... 71  Recommendations: ................................................................................................................ 74  Considerations of an Analysis of Three Groups: .............................................................. 75  Community Engagement Task Group: ................................................................................... 77  The Approach: ........................................................................................................................ 77  Focus and Objectives ............................................................................................................ 78  Who Responded? .................................................................................................................. 79  Community Recommendations............................................................................................ 81  Summary of SWOT Findings................................................................................................ 84  Data Analysis from Surveys and Community Meetings:.................................................. 91  Community Engagement Task Group Activities – November 2007 to March 2008... 91  Recommendations for Continuing Community Engagement .......................................... 92  Best Practice for Service Integration Task Group................................................................. 94  The Approach: ........................................................................................................................ 94  Focus and Objectives: ........................................................................................................... 94  Enablers and Barriers to Service Integration ..................................................................... 96  Early Wins Task Group ............................................................................................................. 98  The Approach: ........................................................................................................................ 98  Focus and Objectives ............................................................................................................ 98  Strengths, Weakness, Opportunities and Threats: ............................................................. 100  The Approach: ...................................................................................................................... 100  Task Group: Best Practices................................................................................................ 100  Task Group: Community Engagement ............................................................................. 101  4 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Task Group: Financial Analysis ......................................................................................... 102  Task Group: Inventory of Services .................................................................................... 103  Task Group: Qualitative Data ............................................................................................. 103  Task Group: Early Wins ...................................................................................................... 104  Summary ............................................................................................................................... 105  Best Fit Exercise: ..................................................................................................................... 107  The Approach ....................................................................................................................... 107  Summary ............................................................................................................................... 108  Current LHIN Wide Integration Projects: .............................................................................. 110  The Mental Health and Addictions System Framework for Mississauga Halton: .......... 111  The Logic Model and its Application to the Work of the Mental Health and Addiction DPA Team ................................................................................................................................. 114  Continuum of Care................................................................................................................... 114  Our Recommendation: An Integrated Service Delivery Model ........................................ 120  Year one work plan for a Co-location Multidisciplinary Model .......................................... 124  Conclusions:.............................................................................................................................. 126  Acknowledgments: ................................................................................................................... 128 

** Appendices under separate cover **

5 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

6 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Executive Summary:
The Mental Health and Addictions Detailed Planning and Action (DPA) team was formed in September 2007 and officially launched it’s activities at the first Working Group meeting in October 2007. The 66 member team is comprised of health care leaders and professionals, community members, families, clients, LHIN staff and guided by shared leadership from two senior executives from the Mental Health and Addictions Agencies. Over the past 6 months the DPA team has met collectively and as task teams to address our mandate of developing and integrated service delivery model for mental health and addictions for the Mississauga Halton Local Health Integrated network. Clients and families are at the centre of our investigation and our recommendations. The process followed by the DPA team was detailed in the Health System Integration Methodology or “Toolkit” focusing on Step 2, building the case for change. Each of the six task teams concentrated their efforts on specific goals and deliverables producing an environmental scan of inventory of services, financials, quantitative data, best practice research, community engagement and early win opportunities. The teams reported their activities and findings to the DPA team at large on 3 occasions to “check –in” and ensure that the collective team was headed in the right direction in terms of meeting our mandate. Each task team produced a report detailing their approach, findings and recommendations for the development of the integrated service delivery model. To that end a recommendation of the integrated service delivery model was created, supported by a continuum of care, a logic model, a thorough assessment of the strengths, weaknesses, opportunities and threats, the determination of key components and framework that a model should embrace and a forward looking one year plan to kick start the activities and deliverables necessary to meet the long term vision. This recommendation encompasses a co-location, multidisciplinary model supported by a central hub for system administration and management, with satellites centres strategically located within the Mississauga Halton LHIN. The DPA team created the model on behalf of the community that the LHIN serves. The dedication and effort of each member of the team is reflected in the quality and sensitivity of the model’s design and implementation. Building the case for change was both challenging and rewarding for the benefits of this model are many for the client, for family members, for the professionals delivering service, for the community and for the advancement and transformation of how mental health and addictions services are delivered today and in the future. Team members “left their hats and coats at the door, concentrating their efforts on the good of the whole and not a single agency or organization. Through this collaborative philosophy a determined team delivered on their mandate.

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Mississauga Halton Local Health Integration Network:

This report details the journey the DPA team has travelled. This recommendation will “make a difference”.

Our VISION of Integration:
“A community of clients, families and service providers working together across and between the continuum of care, ensuring that services are accessible and coordinated within a seamless unified system with optimal health outcomes for all."

Our Recommendation:

8 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Our Methodology:
An “open call to action” inviting community members, organizations, various sectors, and health service providers to get involved on the Detailed Planning & Action (DPA) Team for mental health and addictions was issued from the Mississauga Halton LHIN to the community at large in the summer months of 2007. The Mississauga Halton LHIN received an overwhelming response. Sixty six responses were received and the Mental Health and Addictions (MH&A) DPA team was formed with the mandate of developing an Integrated Service Delivery Model for Mental Health and Addictions. The DPA team was composed of two groups, the working group and the resource panel. The working group was responsible for developing various components of the work plan and accepting tasks and challenges to deliver on these components. Working group members worked closely with members of the resource panel to facilitate the development of the work plan and the achievement of top quality deliverables. The resource panel was engaged on an as needed basis to provide input to and development of various deliverables. The two groups worked closely and over time established dedicated bonds with incredible commitment to moving forward on the mandate. Active participation and attendance at meetings were the norm with this team. The MH&A DPA team was lead by two co-leads, Sandy Milakovic, the CEO of CMHA Peel and Ian Stewart, the Executive Director of ADAPT, and supported by Diane Koz, Acting Director Planning and Community Engagement, the Mississauga Local Health Integration Network. The DPA team aligned their activities to the process outlined in the Health System Integration Methodology, better known as the “toolkit”, concentrating on Step #2, Building the Case for Change. To accomplish our goal members of the working group determined a task team approach, with an identified leader, would be the best method to address the deliverables of an environmental scan and assigned themselves to one of the following task groups: community engagement, quantitative data, current state of inventory of services, high level financial analysis, best practice research and early wins. Members of the resource panel also assigned themselves to a specific task group or groups where their skills and interest best fit. Each team established their goals and objectives, determined their work plan and achieved significant results over a very short period of time. These activities and results are highlighted in this report detailing their findings, recommendations and summaries. In addition the team completed a SWOT Summary through a qualitative lens for contribution to the DPA team SWOT summary and workshop. At each stage of this work, a report was made to the full MH&A DPA team to ensure that this work was in synch with the other task groups and sharing learnings that were

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Mississauga Halton Local Health Integration Network: pertinent to the work of the other groups, in particular the inventory, quantitative and financial analysis task teams. Team Membership: Working Group Gina Matesic Nora McAuliffe Karen Parsons Mary Quartarone Laurie Ridler Rex Roman Dr. Colin Saldanha Michele Singleton Charlene Winger Carol Wilkinson Resource Panel Evelyn Adams Sirel Ali Lydia Baksh Jason Barr Julia Baxter Purnima Bhardwaj Garth Buckley Jill Carlyle Mitsy Clennon Emily Collette Bonnie Cowan Lisa Cowley Susan Downing Scott Farraway Thomas Hall Donna Hart Dr. Roman Jovey David Klarer Kathryn Lynch Shelley Marshall Larry Masson Terry McGurk Al McMullan Susan Morris Joan Patrick Michele Patterson Dr. Louis Peltz Lynda Perry Dr. Nabil Philips Colin Pryor Arran Rowles John Reynolds Vanessa Sairsingh Muriel Scott Ehsan Sharif Willemien Stanger Heidy Steinback Donna Sverdrup Merlaine Tapang Neil Tarswell Judy Tyson

Ean Algar Peter Andruski Dr. Alison Arnot Tonya Castle Purvis Kay Davison Vivian Demain Diane Doherty Steven Farstad Lee Helmer David Jewers

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Mississauga Halton Local Health Integration Network:

Quantitative Task Group
The Approach: The Team: Membership included Rex Roman ( task team lead), Neil Tarswell, Muriel Scott, Thomas Hall and Lydia Baksh. Focus and Objectives: Focus: Conduct in-depth analysis and synthesis of the data that is required to understand the current state and the potential future population heath needs and issues. Objectives: • Ensure that the recommendations are grounded in appropriate quantitative data. • To demonstrate through data both the demand and supply side information needed to support the future state recommendation.

Data Sources used for the Data Collection: Please note that the team was not involved in direct data collection nor did it have direct access to raw data. The data for this portion of the report was drawn from these primary sources; i) NACRS (the National Ambulatory Care Reporting System) is the data source for the ambulatory visits. NACRS was developed by the Canadian Institute for Health Information (CIHI) and the Ministry of Health and Long Term Care (MOHLTC) for Ontario and has been in place since July 2000. The NACRS system reports on patient level data on visits to a hospital’s ambulatory services. DAD (the Discharge Abstract Database) is the data source that provides the information for the Inpatient Discharges in the PHPDB (Provincial Health Planning Database). The DAD was developed in 1974 between CIHI’s precursor, the Hospital Medical Records Institute and the Ministry of Health. Statistics Canada provided the population demographic data, including population counts, socio-economic and gender data. Furthermore, provincial and LHIN based population projections and estimates were provided by the Ontario Ministry of Finance (MOF). For the Ontario Health Insurance Plan (OHIP) data, the OHIP billing database was used. This is an extremely large database holding a multitude of records 11 Mental Health and Addictions Detailed Planning and Action Team Report

ii)

iii)

iv)

Mississauga Halton Local Health Integration Network: including those of service and payment for fee-for service physicians and other health professionals. MIS is the database that is used to collect Community information about services which are outside the hospital setting and are strictly out-patient services. All of these databases were accessed via the Provincial Health Planning Database (PHPDB) BI structure.
LHIN NAME 1986 ERIE ST. CLAIR SOUTH WEST WATERLOO WELLINGTON HAMILTON NIAGARA HALDIMAND BRANT CENTRAL WEST 564,614 767,098 490,365 1,120,306 428,930 1991 584,702 847,158 562,783 1,210,578 504,999 1996 606,276 878,183 601,058 1,252,271 570,513 2001 634,212 907,476 659,109 1,318,486 653,864 POPULATION ESTIMATE 2006 2011 647,633 931,097 708,445 1,371,282 779,205 663,797 961,160 752,612 1,432,115 875,787

v)

vi)

Table 1- Population Projection by LHIN
2016 683,439 997,764 800,644 1,501,604 969,464 2021 704,423 1,035,443 848,778 1,573,629 1,054,129

MISSISSAUGA HALTON
TORONTO CENTRAL CENTRAL CENTRAL EAST SOUTH EAST CHAMPLAIN NORTH SIMCOE MUSKOKA NORTH-EAST NORTH-WEST TOTAL

619,039
1,016,774 938,951 1,088,113 402,495 921,657 252,095 585,069 242,626 9,438,132

729,365
1,035,283 1,110,019 1,223,480 441,172 1,019,074 305,973 603,777 249,769 10,428,132

819,206
1,083,580 1,226,954 1,307,681 461,572 1,077,183 342,985 603,180 252,410 11,083,052

937,838
1,142,073 1,410,696 1,402,898 471,244 1,147,095 391,185 576,729 244,722 11,897,627

1,092,237
1,159,438 1,604,943 1,484,277 482,360 1,188,793 431,448 567,762 238,037 12,686,957

1,208,284
1,198,428 1,769,379 1,572,916 495,520 1,234,965 474,110 556,310 230,783 13,426,166

1,324,951
1,245,050 1,933,914 1,674,739 513,791 1,302,417 519,603 551,854 228,834 14,248,068

1,433,001
1,287,525 2,092,251 1,775,292 532,127 1,372,831 564,302 549,307 227,655 15,050,693

Limitations: NB: Unless otherwise specified, numbers refer to 2006 census. Population: Current State: As of 2006 the population of: • • • • The Mississauga-Halton LHIN was 1,092,237 people. MH-LHIN contains 8.6% of Ontario’s population. As of March 2008, our current population is 1.1 million people. The Mississauga Halton LHIN is the 6th largest LHIN 1

1

It is worth noting that as of 1986, it was only 7th largest in population. 12 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

History and Trends: Growth: Population is one thing, growth is quite another. The most significant aspect of population trends in the MH LHIN is the effect of tremendous growth over the last twenty years. Between 1986 and 2006 the region almost doubled (a staggering 43.32%) in population, going from 619,039 to 1,092,237 people. That makes the MH LHIN the 2nd fastest growing LHIN in Ontario, with an average yearly growth of 15.3%. This growth is expected to be sustained at an average 12.1% until 2026. By 2026, the Mississauga Halton LHIN will be the 4th largest LHIN in terms of population. This increase in people brings with it a concomitant increase in dwellings, vehicles, shopping outlets, services, and increased social interaction with diverse groups. All these factors are inevitable stressors on the residents and may result in an increase in need for mental health and addiction services. The other inevitable result of rapid group is the disconnection between supply and demand. As in any free market system, the supply of goods and services is usually dictated by demand and therefore supply always follows demand. This means that in a rapidly expanding population we will inevitably find that supply is trying to catch up with demand. This is particularly true in situations where creating the supply is itself a long and expensive procedure, such as the building of hospitals and training qualified practitioners. Another attendant consequence of rapid group is the often haphazard and crisis driven response by governments to the needs of the community. Aside from the aforementioned gap between supply and demand, there is often an insufficiently developed infrastructure to maintain good governance, effective communication and adequate education. It is therefore perhaps fortuitous that ‘Integration’ is precisely what is needed at these times. Integration provides a way of coordinating efforts, mandates, and goals so that health care can be delivered most effectively and efficiently.

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Mississauga Halton Local Health Integration Network: Age Distribution: The composition of the population depends on many factors. Chief among these are age and growth of the population. Mississauga Halton is remarkable in its rapid growth. Now growth can occur as a result of natural births (fecundity) or as a result of immigration. Each type of growth may result in a different demographic. In order to review this, we will compare MH with other LHINs and make some remarks on the differences.

Population Trends
160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 0-4 5-9 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 8589 90+

ERIE ST. CLAIR WATERLOO WELLINGTON CENTRAL WEST TORONTO CENTRAL CENTRAL EAST CHAMPLAIN NORTH-EAST

SOUTH WEST HAMILTON NIAGARA HALDIMAND BRANT (HNHB) MISSISSAUGA HALTON CENTRAL SOUTH EAST NORTH SIMCOE MUSKOKA NORTH-WEST

Figure 1 - Population Trends

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Mississauga Halton Local Health Integration Network:

MISSISSAUGA HALTON Population by age group
120,000

100,000

80,000

60,000

40,000

20,000

0 0-4 5-9 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 8589 90+

Figure 2 - Mississauga Halton LHIN Population by Age Group (2006)
SOUTH WEST 80,000

70,000

60,000

50,000

40,000

30,000

20,000

10,000

0 0-4 5-9 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084 8589 90+

Figure 3 - South West LHIN Population by Age Group (2006)

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Mississauga Halton Local Health Integration Network:

A look at the population by age group, divided into 5 year cohorts. There are several very interesting aspects which should be noted. a) Fewer Baby Boomers: There is a definite peak which is associated with the baby boomer generation, that is, those born 1946-1964. This would make these individuals 60 and 42 years old as of 2006. This does not coordinate perfectly the MH chart (although, as we will see, it does with others.) This anomaly can be explained by the fact that most of the growth over that last 200 years has been due more to immigration 2 rather than fecundity. Note in particular that there is no sustained plateau in the 40-60 year old range, as compared to the southwest. b) Small Echo: While the baby boomers in turn had children, they never had as many as their parents and generally had them much later in life. 3 Thus we would expect to see another group cresting at around the 20-24 year old age group. While this is very clear in the southwest group, there is only a very small rise in the MH chart. Thus this group accounts for considerably less of the total. c) More Youth: What is quite remarkable in the MH chart is that there is a definite peak at the 10-14 year old age and that there is no dramatic drop-off at the 1-4 year old age. This makes clear that these children were born to much younger (immigrant) parents and that there a great many more of them than in other regions. It should be noted here that we were not expressly looking at children and youth. We have included them here in our analysis because we must view the numbers as dynamic and predictors of future states. Without the inclusion of children statistics, we would be unable to predict the composition of future adult populations. d) Fewer Seniors: Another remarkable aspect of this chart is the dramatic drop in numbers of those 50 years old and over. Although a decline is expected, the rapid decline here adds credence to the idea that the LHIN is inhabitant by a much larger younger group. It is reasonable to believe that, given the number, the younger group does not have as many familial ties to the older group as one might expect in a steady-state population. Limitations: Population statistics from StatsCan are very reliable and historically useful. The limitations arise because LHIN boundaries have shifted—making historical comparison inaccurate—and data must be translated in LHIN-specific sets.
2 3

Of course, there was also quite a bit of emigration, but the point still stands. As David Foot made clear in his famous book ‘Boom, Bust, and Echo,’ 16 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Diversity in Mississauga Halton LHIN Demographic Trends: The Social Planning Council of Peel provides a detailed and useful summary of the 2006 population demographics of Halton Region, City of Mississauga, Peel Region and other geographical areas 4 . The table below presents a picture of the 3 main areas which overlap the boundaries of the Mississauga Halton LHIN (MH LHIN). The actual demographic profile of the LHIN will be different in numbers but presumably with similar makeup in each category.
Table 2 – Immigrant demographics of overlapping regions of Mississauga Halton LHIN

Population Growth, 2001-2006 Total Immigrant Population % of Total Population Total Immigrants by Place of Birth (top 5)

Halton Region 17.1% 107,920 24.8%

City of Mississauga 9.1% 343,245 51.6% N Asia – 24.7% N Europe – 11.8% SE Asia – 11.1% E Europe – 10.3% E Asia – 9.6% N Asia – 43.3% E Asia – 11.1% SE Asia – 10.6% Middle East – 9.6% E Europe – 6.4% 193,140 people (29.0%) Chinese – 4.3% Urdu – 3.1% Polish – 2.9 % Punjabi – 2.8% Tagalog – 1.5% Others – 14.4%

Peel Region 17.2% 561,235 48.6% N Asia – 30.1% N Europe – 11.3% SE Asia – 9.5% Caribbean – 9.3% E Europe – 7.6% N Asia – 51.3% SE Asia – 9.2% E Asia – 7.8% Middle East – 7.1% E Europe – 4.7% 314,610 people (27.3%) Punjabi – 6.5% Chinese – 2.8% Urdu – 2.6% Polish – 2.0% Spanish – 1.3% Others – 12.1%

N Europe – 25.2% S Europe – 14.1% E Europe – 10.1% S Asia – 9.5% WEurope – 7.3% Recent N Asia -19.0% Immigrants by E Asia -12.4% Place of Birth E Europe -10.8% (top 5) [2001- Middle East – 8.7% 2006] N Europe – 8.6% Home/Non34,510 people (7.9%) Official Chinese – 0.8% Language Polish – 0.8% Spanish – 0.6% Punjabi – 0.6% Portuguese – 0.5% Others – 4.6%

Even though Table 2 is not based on exact MH LHIN boundaries and population, it demonstrates that:
4

(The Social Planning Council of Peel. January 2008. Immigration and Language: Peel Region, Halton Region, & City of Mississauga) 17 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

• • • •

There is a large number of immigrants in the MH LHIN The top 5 places of birth for new immigrants (2001-2006) have changed considerably during recent years The first language for many immigrants is not English and there are many different languages spoken by this group. We can assume that the MH LHIN has a large multicultural population that has been growing quickly in recent years and that this will impact greatly on mental health and addiction services.

Prevalence in Ethnic Populations: With these observations in mind, we turn to the research and literature concerning the prevalence of mental health and addiction issues as well as the use of services by people of various ethnic and cultural groups 5 One way to investigate this is to understand how many doctor visits are related to mental health and then correlate that with the population.

LHIN - Total Population ERIE ST. CLAIR SOUTH WEST WATERLOO WELLINGTON HAMILTON NIAGARA HALDIMAND BRANT (HNHB) CENTRAL WEST MISSISSAUGA HALTON TORONTO CENTRAL CENTRAL CENTRAL EAST SOUTH EAST CHAMPLAIN NORTH SIMCOE MUSKOKA NORTH-EAST NORTH-WEST Grand Total
Figure 4 - 2006 Census Population Comparison between LHINs

Total Percent 647,633 5.10% 931,097 7.34% 708,445 5.58% 1,371,282 10.81% 779,205 6.14% 1,092,237 8.61% 1,159,438 9.14% 1,604,943 12.65% 1,484,277 11.70% 482,360 3.80% 1,188,793 9.37% 431,448 3.40% 567,762 4.48% 238,037 1.88% 12,686,957 100.00%

5

. It must be noted that none of the information is specific to the MH LHIN locality. While there have been some relevant studies completed for mental health and ethnicity, there is little mention of addictions. 18 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Toronto Central Anxiety Disorders Cognitive Disorders Disorders Usually First Diagnosed in Childhood Mood Disorders Other conditions Personality Disorders Schizophrenia and Other Psychotic Disorders Substance-Related Disorders

9.14% 7.36% 10.21% 9.01% 10.88% 9.39% 11.74% 18.43% 14.53%

Mississauga Halton Anxiety Disorders Cognitive Disorders Disorders Usually First Diagnosed in Childhood Mood Disorders Other conditions Personality Disorders Schizophrenia and Other Psychotic Disorders Substance-Related Disorders

8.61% 4.70% 4.78% 3.36% 6.47% 4.09% 3.04% 5.37% 4.95%

Figure 5 - Comparison of Mental Health Visits between Toronto Central and Mississauga Halton LHIN

The point to make here is that we would expect that the number of visits to a doctor involving mental health should correlate with the population. Thus, if your region has 10% of the population, then you would expect that 10% of all visits related to any particular matter—say depression—were seen in your region. One would assume that this is true no matter what the mental health or medical issue. Any statistically relevant difference would have to be explained. For example, a region with a disproportionate great number of highways might experience a higher rate of visits relating to motor vehicle accidents. When we compare MH with the Central Toronto has a significantly more visits which have to do with schizophrenia. This is not surprising since CAMH (Toronto) is a wellknown centre where schizophrenia has long been treated. Thus we have a good explanation.

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Mississauga Halton Local Health Integration Network: What is surprising is that is that while MH has almost 9% of Ontario’s population, it only has half as many visits! In fact, in none of the categories which relate to mental health or addictions does the number of visits even approach 9%. This cannot be attributed to chance or error. There is a statistically significant difference.

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Mississauga Halton Local Health Integration Network: Explanatory Models: The conclusion here is that this anomaly needs to be researched and answered. It may be that the services are not required, but it is more likely—given that a great proportion of the population are new immigrants—that the service is not being sought. This would seem to indicate that great effort needs to be made to serve the needs of the ethnic population. From this review, different themes have emerged. Some ethnic groups have lower rates of reported mental health needs and also utilization of services. Different studies have provided varying explanations: 1) The explanatory model of illness, i.e. different ethnic groups may explain symptoms, causes, illnesses and treatment in other ways and this influences whether they access treatment and what treatment is acceptable to them. Alternative explanations may be in a context of a religion or supernatural beliefs, Western medicine versus non-Western, factors within the individual or the environment, etc. 6 Factors Influencing Attitudes towards Seeking Professional Help among East and Southeast Asian Immigrant and Refugee Women. 7 2) Perceived service accessibility – Do people feel that they can access culturally, gender and language appropriate services? Wong and Fung’s study indicated that people from mainland China and Korea did not feel they had access to appropriate services. Another study found that there is a “perception that available care providers would not understand or be prejudiced against the respondent’s culture and that professionals from their cultural background were not available” 8 3) A “healthy immigrant effect” is in evidence in Canada but it is not consistent for all groups ( 9 ). It is suggested that the variables may not only include genetic tendencies but also the social and cultural identity, and the well documented reality that these people may be underemployed and impoverished, social determinants of health.
6

(Wong, R., & Fung, K. International Journal of Social Psychiatry, Vol. 53, No. 3, 216231 (2007 7 www.intl-isp.sagepub.com/ ). ( Kirmayer, L., Galbaud du Fort, G., Young, A., Weinfeld, M., & Lasry, J. 1996. Pathways and Barriers to Mental Health Care in an Urban Multicultural Milieu: An Epidemiological and Ethnographic Study. www.mcgill.ca/files/tcpsych/Report6.pdf) 9 Hyman, Ilene. 2007. Immigration and Health: Reviewing Evidence of the Healthy Immigrant Effect in Canada. www.ceris.metropolis.net
8

21 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: 4) Other factors that may precipitate mental health decline: displacement from family, friends and community; homelessness; post-traumatic stress as a result of war and violence in the home country or refugee camp; and, loss of status. 10 Jennifer Ali summarizes the main results of her study which compared immigrants with Canadian-born population in terms of depression and alcohol dependence: Immigrants had lower rates of both depression and alcohol dependence than the Canadian-born population. This “healthy immigrant effect” was strongest among recent immigrants and among immigrants from Africa and Asia. These two trends are related, since recent immigrants have tended to come from Africa and Asia, whereas the majority of long-term immigrants came from Europe. Long term immigrants have similar rates of depression as the Canadian-born. The lower rates observed for immigrants were not due to demographic or socio-economic differences (age, sex, marital status, income, and education) between immigrants and the Canadian-born population. After adjustment for all of these factors, recent immigrants still had the lowest risk for both depression and alcohol dependence. Furthermore, language barriers, immigrants’ higher unemployment rates, and their lower sense of belonging to the local community did not diminish the gap between immigrants and the Canadian-born population. 11 Some of Ali’s findings are contradictory to the results of other studies and many common assumptions, specifically, that language barriers or social determinants of health such as employment and belonging did not contribute to more depression and alcohol dependence. It is important that we begin to identify ethnic groups and individuals within them who are at the highest risk for mental illness and addiction problems. We also need to develop and ensure access to services for new immigrants and refugees who “find themselves barred, either because the rules make them ineligible or because they cannot prove that they are eligible”. 12 (Zine, Jasmin. 2002. Informal Housing Network Project. Living on the Ragged Edges: Absolute and Hidden Homelessness among Latin Americans and Muslims in West Central Toronto. http://ceris.metropolis.net/Virtual%20Library/housing_neighbourhoods/Ragged%20Edge s%20031113.pdf 11 (Ali, Jennifer. 2002. Supplement to Health Reports, volume 13, Statistics Canada. Mental Health of Canada’s Immigrants http://www.statcan.ca/english/freepub/82-003SIE/2002001/pdf/82-003-SIE2002006.pdf )
12 10

(Comments on Settlement and Integration to the Standing Committee on Citizenship and Immigration, April 2003. http://www.ccrweb.ca/settlementcomments.html)

22 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Barriers: In July 2006, Access Alliance Multicultural Community Health Centre facilitated meetings with immigrants and refugees to discuss the new LHIN model of healthcare planning and delivery. While the meetings were held within the Toronto Central LHIN, it was Access Alliance’s intention that the report would help to inform all LHINs regarding the diversity of needs from the experiences of immigrants and refugees. Their feedback to the LHINs was grouped within these themes which are also applicable to mental health and addiction service streams: 1. 2. 3. 4. 5. 6. Wait Times Language Barriers Access to Healthcare Concern about Changes to Existing Healthcare System Expense of Healthcare Issues for Non-insured Immigrants and Refugees 13

Limitations: • • • • • • • • What will the future cultural composition be of Mississauga Halton LHIN? What awareness, education, resources and services are needed to provide MH & A supports to a culturally diverse population? Are prevalence rates the same across cultural and ethnic populations and also considering gender and age? What treatments and therapies are most acceptable and effective with specific cultural groups? Are MH & A issues under reported in some population groups? Do we need to more clearly define PTSD, its prevalence among newcomers; and what approaches will be most helpful? What is the impact of poverty, housing, unemployment, traumatic and violent experience, language, and ethnicity on who seeks and receives mental health or addictions services? How best to consistently collect statistical information about ethnicity, mental health and addictions plus other factors having an impact on health without “racial profiling”?

13

(Access Alliance Multicultural Community Health Centre. 2006. Immigrant and Refugees Engagement Summary, Toronto Central LHIN. http://www.accessalliance.ca/media/LHINProjectFinalReport3.pdf )

23 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Usage Statistics - Statistics and the Hospitals
Table 3 - Ambulatory Care Episodes under Major Ambulatory Cluster for Mental Health: Mississauga Halton LHIN (2005/6)

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Original Ministry ICD Codes converted by DPA Quantitative Data Task Group * Small cell counts less (<5) were suppressed in original document DSM-IV Diagnostic Categories – ICD-10 Codes in brackets Disorders Usually First Diagnosed in Infancy; Childhood or Adolescence (F70-F79; F80-F89; F90-F98) Delirium; Dementia and Amnestic and Other Cognitive Disorders (F00-F09); Schizophrenia and Other Psychiatric Disorders (F20-F29); Substance Related Disorders (F10-F19); Mood Disorders (F30-F39) Anxiety Disorders (F40-F49); Personality Impulse Control and Sexual Disorders (F60-F69); Sexual, Eating, Sleep and Other Conditions that may be of clinical focus (F50-F59); Unspecified Mental Disorders (F99-F99)

The preceding chart is indicative of the statistical information that we have developed from the available statistics. In order to obtain this information we had to convert existing statistical information because the ministry requires coding to be done in ICD10 numbers. These numbers are accepted in Canada for coding and are used by other parts of the world. However, most practitioners are more familiar with DSM IV codes, since the classifications used are those prescribed in the DSM IV. Thus the codes do not conform to the language and concepts used in Mental Health and Addictions practice in Ontario. These numbers, we are told, are valid in terms of the quantitative 24 Mental Health and Addictions Detailed Planning and Action Team Report

In fa nc y; A Chi d l D oles dren el iri cen or um ce ;D Sc eme n h Su izo tia ph bs r ta nc enia er el at ed M oo A d nx Pe iet y Se rson xu al ity al , Ea ti Su n g b To -To t ta l H al id G de ra nd n To ta l
6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 * * * * * * * * * * 6 14 20 39 29 14 30 110 88 65 94 103 123 36 12 * 5 * * * * * * * 7 29 31 30 16 6 7 * * * * 2 * 105 48 52 99 77 167 62 74 63 21 22 19 17 * * * 38 36 13 25 19 32 16 14 10 12 13 14 29 13 11 * 6 * * * * * * * * * * * * * * 5 * * * * * * * * * * * * * * * 184 59 243 194 88 282 153 109 262 196 71 267 219 69 288 333 61 394 231 71 302 140 83 223 91 88 179 40 72 112 28 74 102 51 61 112 51 51 102 68 44 112 44 34 78 25 17 42 2048 1052 3100

DSM IV

Mississauga Halton Local Health Integration Network: assessment. In other words, we can be sure that these were, in fact, the number of events which occurred in the hospitals for that particular period. Yet, we cannot be nearly as sanguine about the actual classifications. Did someone who today presented with a delusion receive a classification of bipolar, or schizophrenia or personality disorder. We have no way of independently verifying the efficacy of the coded diagnosis as the currently is no system in place.
Table 4 - Inpatient Care in Mississauga Halton LHIN by ICD10 Code (2005/06)

INPATIENT CARE in the Mississauga Halton LHIN 2005/6
ICD 10 Most Responsible ICD10 CA Short Description Diagnosis F322 SEV DEPRESSIVE EPISODE WO PSYCH SYMPTOMS F432 ADJUSTMENT DISORDERS F329 DEPRESSIVE EPISODE UNSPECIFIED F200 PARANOID SCHIZOPHRENIA F259 SCHIZOAFFECTIVE DISORDER UNSPECIFIED F209 SCHIZOPHRENIA UNSPECIFIED F102 MENT/BEH DISRD DT ALCOHOL USE DEP SYNDR F339 RECURRENT DEPRESSIVE DISORDER NOS F29 UNSPECIFIED NONORGANIC PSYCHOSIS F319 BIPOLAR AFFECTIVE DISORDER UNSPECIFIED F323 SEV DEPRESSIVE EPISODE W PSYCH SYMPTOMS F03 UNSPECIFIED DEMENTIA F103 MENT/BEH DISRD DT ALCO USE WITHDRAWAL ST G309 ALZHEIMER'S DISEASE UNSPECIFIED F332 REC DEPRES DISRD CURR SEV WO PSYCH F205 RESIDUAL SCHIZOPHRENIA F312 BIPOL AFF DISRD CURR MANIC W PSYCH SYM F311 BIPOL AFF DISRD CURR MANIC WO PSYCH SYM F314 BIPOL AFF DISRD SEV DEPRES WO PSYCH SYM F500 ANOREXIA NERVOSA F059 DELIRIUM UNSPECIFIED F220 DELUSIONAL DISORDER F341 DYSTHYMIA F333 REC DEPRES DISRD CURRENT SEV W PSYCH SYM F239 ACUTE & TRANSIENT PSYCHOTIC DISRD NOS F100 MENT/BEH DISRD DT ALCOHOL USE AC INTOX F431 POST-TRAUMATIC STRESS DISORDER F313 BIPOL AFF DISRD CURR MILD/MOD DEPRESSION R410 DISORIENTATION UNSPECIFIED F104 MENT/BEH DISRD DT ALCO USE WITHDR W DEL F316 BIPOLAR AFFECTIVE DISRD CURRENTLY MIXED F310 BIPOLAR AFFECTIVE DISRD CURR HYPOMANIC F051 DELIRIUM SUPERIMPOSED ON DEMENTIA It should also be noted that although we knowDEP SYNDR F142 MENT/BEH DISRD DT USE COCAINE the number F208 OTHER the number of individuals.SCHIZOPHRENIA F419 ANXIETY DISORDER UNSPECIFIED F101 MENT/BEH DISRD DT HARMFUL ALCOHOL USE F192 MENT/BEH DIS MULT DR & PSYACT DEP SYNDR Limitations: F251 SCHIZOAFFECTIVE DISRD DEPRESSIVE TYPE F603 EMOTIONALLY UNSTABLE PERSONALITY DISRD Total Top 10 Count % Top 10 to 40 252 206 201 169 142 137 136 105 100 98 89 85 79 77 73 67 66 65 48 48 46 46 46 44 43 39 37 36 35 33 32 30 28 events, 27 we 27 27 25 25 24 23

1546

Top 10 43.9%

2243

Top20 63.7%

2648

Top30 75.2%

of

do not know

2916

Top40 82.8%

The last chart—Inpatient Care in MH 2005/6—is coded in ICD-10 codes. In this chart we have taken the liberty of highlighting the most common coded admissions. We could code these for both inpatient stays and for emergency visits. These would seem to be useful in determining the most prevalent codes and, therefore, the most prevalent conditions. Unfortunately, this is not an extrapolation we can make with any degree of 25 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: confidence at this time. The inability to extrapolate with confidence exists for the following reasons:

a. Not enough years of data We have only received 2 years of data and understand that there is no more another 2 years available. This is an insufficient number to develop any trends. Therefore we cannot know whether the numbers presented are consistent with the services currently in place. Certainly we cold predict the future service requirements. b. Inability to coordinate with population Since we do not have historical information, it is impossible to correlate the services currently being used with the population. As the population changes, for example gets older or younger, there will be different needs predicted by prevalence rates. Since we do not have the historical usage statistics, this correlation cannot be performed. c. Lack of comparison with other LHINs We do not currently have data from other LHINs or expertise from other LHINs by which we could determine the real needs, and the relationship between needs and services. d. No established method to validate the data There is currently no method in place to independently validate the data we have. Independent validation is important because the data is not collected passively, but rather requires skilled active intervention by an entry person. We cannot be sure that everyone is trained in the same way, that the same person is inputting, or that there are mistakes being made in the entry of data. e. Unclear how co morbidity and special cases are captured A situation where the same person uses the same service is not readily captured. More importantly, situations where there is more than one condition, and especially where one condition affects the other, are not captured. Conditions such as Acquired Brain Injury are captured by symptoms and not by condition.

26 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Statistics and the Community Services COMMON DATA SET (CDS) Mental Health: CDS-MH is the administrative/clinical data standard for community mental health reporting to MOHLTC. It is a semi-annual and annual submission of aggregate data only, with a focus on basic demographic data. It links to the MIS Financial & Statistical data. It is intended to answer the following questions: 1. Who is providing community mental health services? 2. How many service users are utilizing how much of what services? 3. Who is using the services? (e.g. age, gender, location, language, broad diagnostic category, legal status) 4. Why are individuals seeking the services? 5. Who refers the service recipients to the function? 6. How do service recipients exit the function? 7. What is the impact of these services on hospitalization? 8. Are there changes in service recipients’ housing status and living arrangement? 9. Are there changes in service recipients’ source of income? 10. Are there changes in service recipients’ involvement in meaningful daytime activity? 11. How are organizations evaluating their functions? Such data would provide meaningful reporting to the LHIN and to the Ministry. The data would provide for accountability and performance measurement as well as facilitate appropriate and equitable funding decisions. This would support informed strategic planning, policy and operational decision making. It would also: • Ensure consistency and comparability of data reported • Substantiate operating plan submissions with meaningful CDS-MH data • Ability to benchmark with peers based on provincial feedback reports • Facilitate equitable and appropriate funding decisions • Demonstrate effectiveness of CMH&A services • Streamlined reporting • Contribute to program evaluation and research CDS-MH Link to MIS: The structure of the data set and the types of reports available were impressive. Had we some years worth of verifiable and consistent data, then we would be in a strong position to make important decisions about the needs of the community and the deployment of resources. In addition we would be closer to understanding the efficacy of the services provided. Community data linked with hospital data would mean an ability to track people and services throughout the life cycle. It would also mean the ability to plan with confidence the services of the LHIN.

27 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Limitations: • • • • • • • • • • Lack of standards and definitions Various applications and tools across the province Need for defined, consistent and meaningful data collected provincially across all functions for: accountability for performance measurement for funding Information is available on the MOHLTC website but it is outdated (last updated Oct./06; Q2 2006/07) Varying degrees of report information and analysis, e.g. higher for ACT High agency reporting compliance (91% submission rate 2006/07 year-end) Data quality issues: - Inconsistent interpretation of definitions - High rate of “Other” presenting issues - High rate of diagnosis “Unknown” - High rate of clients who were not uniquely identified - High level of unreported and unknown values in baseline and current

Prevalence and Determinants of Health Demographic Considerations: In recent years, there have been intensified efforts to understand the magnitude, distribution, and impact of mental health and substance use disorders. Many of these endeavours suffer from the following limitations: • • no inclusion of those residing in a rural environment/children/aboriginal/homeless; those admitted to psychiatric institutions, prisons or general hospitals.

As well, experienced clinicians may not have been used to assess the mental health/addiction disorders relevant to the study. As well, depending on the research study design, diagnoses such as schizophrenia and anorexia nervosa may be excluded from the results due to the perception that prevalence rates are too low to be reliable (Goldner 2000). This underscores the lack of uniformity and comparability that exist in epidemiological studies, and emphasizes the need for comparable, uniform basic data on prevalence and service use. However, the Quantitative DPA Team was charged with the task of trying to develop some insight into the breadth and scope of mental health issues within our LHIN. Despite the issues noted above the following is an attempt to provide a point of departure regarding some demographic considerations with regard to the prevalence and incidence of mental health and addiction issues within the MS-LHIN.

28 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:
Table 5 - Population Projections: Mississauga Halton LHIN by Age Group

Year 1996 2001 2006 2011 2016

15-19 54,957 65,213 75,342 84,026 82,771

20-24 56,652 63,623 76,046 83,555 91,941

25-29 65,245 64,770 74,780 84,183 91,760

30-34 78,760 74,865 81,564 87,645 98,430

35-39 75,047 88,198 91,830 93,908 100,928

40-44 65,634 84,215 100,559 99,498 101,404

45-49 61,237 71,974 91,304 104,199 102,302

50-54 47,171 62,943 74,238 91,136 103,376

55-59 36,368 45,849 61,883 72,310 88,599

60-64 29,890 34,660 43,817 58,832 69,094

Total 570,961 656,310 771,368 859,294 930,605

Source: STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007
Table 6 - Estimated Lifetime Prevalence Mental Health Population Projections: Mississauga Halton LHIN 1564yrs

1996 Population Life time prevalence 25% 570,961 142,740

2001 656,310 164,077

2006 771,368 192,842

2011 859,294 214,823

2016 930,605 232,651

Source: STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007

Where Lifetime prevalence (LTP) is the number of individuals in a statistical population that at some point in their life have experienced a disorder. According to the World Health Organization’s Global Burden of Disease study “of the ten leading causes of disability and premature death world-wide five are psychiatric conditions • • • • • Major Depression alcohol use Bipolar Disease Schizophrenia Obsessive Compulsive Disorder

Major depression takes an enormous toll on functional status, productivity, and quality of life, and is associated with elevated risk of suicide and stress related illnesses such as heart disease. The WHO suggests that in some countries suicide is greater or equivalent to death by traffic accidents. According to The Lancet an estimated 14% of the global burden of disease is due to neuropsychiatric disorders (NPDs). As noted above studies showed markedly different prevalence rates (due to their markedly different designs; varying objectives and age-groups etc.). A number of epidemiological studies suggest that the lifetime prevalence rate of suffering from any mental health disorder is from 20%-30% of the population. 14 The Qualitative DPA reviewed the
14

The Lancet Global Mental Health Group; The Report of the Surgeon General (1999); Narrow et al (2002); Kessler et al (1996); Kessler & Zhao (1999); Government of Canada 2006 29 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: literature and felt that a conservative percentage of 25% for a lifetime prevalence rate was reasonable. 15
Table 7 - Projected One Year Incidence of Mental Health Population: Mississauga Halton LHIN 15-64yrs

Population 18.5% (Clinical) 5.4% (SMI) 2.6% (SPMI)

1996 570,961 105,627 30,831 11,761

2001 656,310 121,417 35,440 13,519

2006 771,368 142,703 41,653 20,055

2011 859,294 158, 969 46,401 22,341

2016 930,605 172,162 50,252 24,196

S o u r c e :

STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007

The above chart uses incidence as a measurement of individuals who contract a disease during a specified time interval. In 2002 Narrow et al reviewed a number of studies regarding the prevalence and incidence rates for mental health and addictions, noting their discrepancies and limited usefulness for service planning. As a result their attention was turned to those persons who have mental health issues of “clinical significance”. The review resulted in a revised prevalence rate for any disorder to 18.5%. Based on other reviewed documentation and practice wisdom, the DPA committee felt confident that this number would reflect an upper range for those with mental health and addition issues. Kessler (1999) found that 5.4% of the general population is considered to have a Serious Mental Illness (SMI) in any given year. About half (approximately 2.6% of all adults) with SMI were identified as being more seriously affected having a Serious and Persistent Mental Illness (SPMI). This category includes schizophrenia, bipolar disorder, severe forms of depression, panic disorder and obsessive-compulsive disorder. Recent analysis and evaluation of the Ontario population of individuals with a serious mental illness have recommended that, for the purposes of planning, the figure of 2.5% be used as a prevalence rate for people with serious mental illness among the adult population. This rate is based upon the prevalence rate of 2.0% for serious mental illness which was derived from an analysis of survey data in the Mental Health Supplement of the Ontario Health Survey (1990) plus an additional 0.5% to account for the institutional population which was not included in the survey sample. It has been postulated that 60% (one sixth of the population) of individuals who have been diagnosed with one disorder, in fact have more than one mental health disorder –
15

It should be noted that 50-70% may not seek treatment due to a lack of resources (personally/systemically); stigma and accessibility or service delivery issues (transportation, geographic issues and/or service criteria) (Lesage 2006). 30 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: other mental health diagnoses as well as substance abuse is noted as part of this co morbidity (Kessler 1994).

Concurrent Disorders Concurrent or Co-occurring Disorder refers to those persons who are experiencing a combined mental health and substance use disorder. The table below shows the estimated prevalence rates of a substance use disorder with individuals diagnosed with a mental health diagnosis. As noted by Minkoff et al (2004) “dual diagnosis [concurrent disorders] is an expectation [not an exception]” in care delivery to individuals accessing either a mental health or addictions organization. In general the overall prevalence of a substance use disorder with someone with a mental health disorder is approximately 29% compared to 16% in the general population. For those with an existing substance use disorder approximately 43% may have a cooccurring mental health issue. Furthermore, persons with mental health issues are more likely to be involved with tobacco, as per above, abuse of both drugs and alcohol leading to a greater risk of medical illness; poor adherence to medical/mental health treatments; increased risk of domestic violence; family problems and homelessness (Health Canada 2001). 16
Table 8 - Prevalence of Combined Mental Health and Substance Use Disorders

DIAGNOSIS Schizophrenia Anxiety Disorders Phobias Panic OCD Major Depression Bipolar Disorder

ALCOHOL 33.7% 17.9% 17.3% 28/7% 24% 16.5% 46.2%

DRUGS 27.5% 11.9% 11.2% 16.7% 18.4% 18% 40.7%

Source: Dr. Wendy Tolme unpublished presentation – CMHA Guelph (2005)

The reader is advised to review Health Canada’s Best Practices: Concurrent Mental Health and Substance Use Disorders document.

16

31 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Co morbidity There is overwhelming evidence that mental disorders and medical illnesses are strongly linked. Sederer et al (2006) suggests that persons with depressive disorders are two times as likely to develop coronary artery disease and to have a stroke (depression is a frequent post-stroke condition). Furthermore, these persons are more than four times as likely to have a myocardial infarction and die within six months of the event as those without a depressive disorder. Health care expenditures are more than four times higher for persons with co morbid diabetes and depression. The Surgeon General (1999) suggests that “nearly 15% of individuals exhibiting a mental disorder in 1 year prevalence have a co-occurring [medical] disorder, compared to 3% of the general population”. In their Series on Global Mental Health the Lancet suggests that the true burden is likely to be underestimated because of inadequate appreciation of the connection between mental disorders and other health conditions.
Table 9 - Prevalence of medical disorders in patients who have mental health disorders

DIAGNOSIS Hypertension Heart Disease Gastrointestinal Asthma Diabetes Malignancy Respiratory

COMMUNITY 9.2% 5.6% 7.6% 5.5% 5.8% 2.1% 26.3%

MENTALLY ILL 10.0% 8.8% 12.1% 8.5% 7.4% 1.5% 32.8%

Source: Kathol, R. M.D., Saravay, S.M. et al (2006)

Special Populations Incidence and Prevalence of Mental Health Issues in the Older Adult 17 : Mental health problems are an important contributing factor to the disease burden of older adults. The prevalence and severity of mental health issues combined with physical conditions have major implications for the provision of services to assist older adults cope with “life’s contingencies” and maintain an acceptable quality of life (AgeInfo.). Quality of life has been defined as “a person’s subjective valuation of the degree to which his or her most important needs, goals, wishes have been fulfilled” (Scogin, et al. 2001 pg. 271). It is estimated that over 44% of the province of Ontario’s health budget is utilized by those over 65 years of age. As well, this age group represents 50% of acute hospital days and by 2026/27, when seniors comprise about 21% of the population, approximately 60% of health care spending could be devoted to caring for this age group (Ministry of Health and Long-Term Care, 2002).
17

(the following section on Older Adults is an amended excerpt from Tarswell 2005): 32 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Table 10 - Older Adult Population Projections: Mississauga Halton LHIN

Year 1996 2001 2006 2011 2016

65-69 25,217 28,457 33,357 41,324 55,550

70-74 20,202 23,572 27,249 31,206 38,580

75-79 12,842 17,751 21,564 24,380 27,931

80-84 8,289 10,197 15,043 17,840 20,191

85-89 3,999 5,322 7,610 10,817 12,872

90+ 1,913 2,380 3,348 5,193 7,542

Total 72,462 87,679 108,171 130,760 218,216

Source: STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007

33 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Table 11 - Older Adult Population Projections by Gender: Mississauga Halton LHIN

Year 65-69 70-74 75-79 80-84 85-89 90+ Total 1996 Female 13,049 11,365 7,537 5,238 2,758 1,446 41,393 Male 12,168 8,837 5,305 3,051 1241 467 31,069 Total 25,217 20,202 12,842 8,289 3,999 1,913 72,462 2001 Female 14,673 12,575 10,274 6,242 3,560 1,772 49,096 Male 13,784 10,997 7,477 3,955 1,762 608 38,583 Total 28,457 23,572 17,751 10,197 5,322 2,380 87,679 2006 Female 17,331 14,411 11,876 9,072 4,931 2,470 60,091 Male 16,026 12,838 9,688 5,971 2,679 878 48,080 Total 33,357 27,249 21,564 15,043 7,610 3,348 108,171 2011 Female 21,287 16,462 13,180 10,144 6,781 3,632 71,486 Male 20,037 14,744 11,200 7,696 4,036 1,561 59,274 Total 41,324 31,206 24,380 17,840 10,817 5,193 130,760 2016 Female 28,668 20,143 15,024 11,231 7,625 5,104 87,795 Male 26,882 18,437 12,897 8,960 5,247 2,438 74,861 Total 55,550 38,580 27,931 20,191 12,872 7,542 162,656 Source: STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007

Risk factors for mental health problems that have been identified include: recent bereavement; social isolation; physical disability and/or poor health; low socio-economic status; stressful life events; long-term hypnotic drug use; sensory deficits and genetic vulnerability all of which complicate the assessment and treatment of older adults (Morris, 2001). In fact, co-morbid medical conditions are the “rule rather than the exception” as older adults have at least 3 or more medical conditions when compared to younger people (Okereke, 2005). According to the National Advisory Council on Aging approximately 46% of those over the age of 65 have a disability and by age 85 the disability rate was 70% (NACA, 1991). The year 2011 is of particular interest, as the first of the “baby boomers” will reach 65 years of age (Hopkins 2002). It has been postulated by Knight (1999) that, as “baby boomers” age over the next several years - and in that Baby Boomers are more psychologically minded than previous generations - one can expect that the demand for mental health services will increase (La Rue & Watson, 1998). Numerous documents suggest that Depression, Dementia and Delirium are the most common mental health disorders among older adults 18 . Dementia is due to cognitive deficits, including memory decline caused by brain dysfunction, with social, functional
18

Wasylenki, et. al., 1990; Hall, & Hassett, n.d. 34 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: and/or occupational decline. Depression is a group of symptoms with depressed mood, including a combination of the following: decreased, or changes in, any of the following: sleep, interest, energy, excessive guilt, irritability, appetite, concentration, and suicidal thinking lasting more than two weeks. Delirium is a rapid onset of decline in attention or thinking combined with a disturbance of consciousness (Litchenberg and Duffy, 2000 & DSM IV, 1994). Health and Welfare Canada's report, Mental Health Problems Among Canada's Seniors(1991), suggests that a figure of 25% be used when estimating the total prevalence of mental health disorders in older adults. Abraham (1994) suggested a prevalence rate for mental health issues among older adults has been estimated to be as high as 15% – 25%. These estimated prevalence rates were supported by the Ontario Ministry of Health and Long Term Care (1998; 1996) as they represent both the lower and upper limits for those with geriatric mental health concerns accounting for the “multiple diagnostic features of this illness”. The Canadian Medical Association (CMA, 1987) states that at “any given moment, approximately 30% of Canadian Seniors require mental health services”. The Mental Health Report of the Surgeon General (1999) documents a prevalence rate of 4% for SMI and 1% for SPMI for older adults. Using these estimates, along with the above population projections, the table below outline the prevalence for previous and projected mental health issues for older adults in the Mississauga Halton LHIN.
Table 12 - Projected One Year *Incidence of Mental Health Population 65+: Mississauga Halton LHIN

Population over 65 25% 18,115 21,919 27,042 32,690 40,664 15% 10,869 13,151 16,225 19,614 24,398 4% 2,898 3,507 4,326 5,230 6,506 1% 724 867 1,081 1,307 1,626 Source: STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007

1996 72,462

2001 87,679

2006 108,171

2011 130,760

2016 162,656

As one ages the prevalence rate of dementia increases from 1.4% at age 65 to 6.5% at ages 75-79 and eventually 38.6% for the over 90 age bracket (Canadian Study of Health and Aging 1994). It is estimated that the prevalence of dementias range from 5 to 11% of the general population over the age of 65 in western societies. (Goering, et al., 1998). As many as 70 – 90% of all residents residing in a Long Term Care facility suffer from some sort of mental health disorder, with depression and dementia being the most frequently encountered disorders 19 A more recent study suggests that the prevalence (Smith, Buckwalter, & Mitchell, 1993; Conn, 2002). This is supported by Zimmer, who noted that 65 percent of nursing home residents have behavioural problems [defensive
19

35 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: rates of all mental disorders among nursing home residents in Ontario are between 80% and 90% (Conn, 2002). It is estimated that 60-80 percent of individuals in long-term care facilities in Ontario have a DSM-IIIR diagnosis (LeClair et al., 1997). The Ontario Ministry of Health estimates that the percentage of persons within Long-Term Care facilities with mental health issues is 64% (Ministry of Health and Long Term Care, 2004). Given the accumulation of literature on this topic it is interesting to note that Long-Term Care facilities have been termed “the modern mental institutions for the elderly” (Lichtenberg, 2000; Conn, 2002).
Table 13 - Estimated Demand Population of Older Adults with Mental Health Problems Residing in LTC Facilities

# of Facilities MississaugaHalton 27

# LTC of beds 2007 – 2008 4,099

Mental Health Problems with 64% prevalence rate 2,623

Source: STATCAN, accessed via Provincial Health Planning Data Base, Ver. 17.07, Dec. 03, 2007 Prevalence Source: Ministry of Health and Long Term Care (2004)

Acquired Brain Injury: Persons with Acquired Brain Injury may currently be captured under diagnostic headings such as depression, cognitive impairment, impulse disorder, substance related disorders or other conditions. There is currently no way of isolating ABI within the diagnostic groups. The lack of data has serious implications both in the current reality and future planning. In Peel/Halton there are many gaps in the system for the ABI group: • There is currently a five year wait for an ABI residential bed in the Peel/Halton area. • Long Term Care (Nursing Homes) beds are housing the young ABI. • There are limited resources and programming which serves the young brain injured i.e. 20’s group. • Available programming is limited to the low functioning ABI population. • People with Acquired Brain Injury often end up in the mental health system; unfortunately, the expertise of psychiatrists is in psychiatry, rather than in the treatment of persons with an Acquired Brain Injury, therefore, their specific needs are not met. • Access to behavioral therapy is expensive since it is available only thru the private sector. • There is no support/respite for caregivers. behaviours], including sexually inappropriate activities, depressive symptomatology and wandering (Zimmer et al., 1984). 36 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Suggestions: • • • There is a high need for Supportive housing. Review funding to the Non-Profit Community Based ABI Agencies so that they can provide quality programming for clients. A review of Transhelp admission criteria. There is a serious transportation issue. Transhelp will allow only those with physical limitations to access their service. Public transit is not a safe mode of transportation for a large number of people with ABI. . Communication needs to improve between CCAC and community agencies in order to better serve ABI clients. When ABI patients are discharged from hospital they are admitted to CCAC on a short term basis; they fall thru the gaps if the referral process from CCCAC does not occur. Establish an ABI network in Peel/Halton. Brain Injury should be identified / diagnosed in Emergency by the attending physician (brain injury as opposed to head injury). Development of a behavioral therapy program. Review respite services for caregivers. Support for caregivers.

•

• • • • •

Dual Diagnosis: “Dual Diagnosis refers to individuals with a developmental handicap as well as mental health needs. The true prevalence of developmental disabilities in Ontario [is unknown] but is estimated to be 1% - 3% of the general population. A conservative estimate of 38% has been used in Ontario as the prevalence rate for dual diagnosis (Yu D, Atkinson L. Developmental disability with and without psychiatric involvement: Prevalence estimates for Ontario. Journal on Developmental Disabilities 1993;2(I):92-99). Based on these figures it is estimated that there are 247,000 individuals with developmental disabilities in Ontario (based on 2.25%) and 93,000 individuals with a dual diagnosis (based on 38%)”. Some mental health providers continue to exclude these individuals for reasons that include lack of a diagnosis, knowledge and/or skill gaps. Families today are the majority of primary caregivers and consistently report difficulties in accessing the supports that they need when they need them (Dual Diagnosis Implementation Committee of Toronto, Action Steps for 2002/2003: Moving Toward the Vision). Long waiting lists (years) in the developmental sector for community-based housing, day and case management supports exist. Staffing of specialized dual diagnosis resources and the developmental sector remains a significant challenge due to serious gaps in formal training and education, lack of a career path for the field and low salary levels. Individuals with a dual diagnosis remain one of the most marginalized groups in our community today”

37 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Key Determinants of Health: Although there have been some progressive reforms in mental health care over the last three decades (such as the introduction of Recovery and empowerment models, mechanisms to involve consumers and families in care decisions, etc.), the mental health care system continues to be bio-medically and clinically focused with an emphasis on symptom management and psychopharmacology with much less attention on addressing the social determinants of mental health (Morrow 2006). Failure to pay attention to these threatens our ability to maintain an educated and well-functioning citizenry and workforce. Costs such as increased use of unemployment, welfare and other societal costs need to be taken into consideration in policy evaluations of the societal cost-benefit ratio of mental health and addiction organizations. The social aspect of any person is key to understanding his or her health status and liabilities. Social supports and social issues should therefore be included in any efforts to support people with mental health and substance use issues. The emotional side of social supports can boost self-esteem, lower anxiety, minimize stress, increase the sense of security, build strengths, empower, and create hope. When seen from a Population Health perspective the table below reveals both the Risk Factors and the Protective Factors for the increase and reduction of mental health and substance use disorders (WHO 2004).
Table14 - Risk and Protective Factors for Mental Health and Substance Use Disorders

Risk Factors Caring for Chronically Ill or Dementia Patients History of Abuse or Neglect Excessive Substance Use Exposure to Violence/Trauma Loneliness Medical Illness – Pain Neurochemical Imbalance Parental Mental Illness Stressful Life Events

Protective Factors Adaptability Problem Solving Skills Positive Self-Esteem Skills of Life Social and Conflict Management Skills Socio-emotional Growth Stress Management Skills Social Support of Family and Friends

Risk/Protective Factors for Mental Health and Substance Use Disorders. Adapted: WHO Prevention of Mental Disorders: Effective Interventions and Policy Options/Summary Report (2004)

38 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Staffing: Within Ontario there are essentially three different groups of care providers (hospitals; physicians and community organizations) for those with mental health and addiction services. As the result of varying funding, administrative and, at times, philosophical treatment views they are commonly referred to as being in different silos or chimneys. There are also providers outside of the Ministry of Health and Long-Term Care such as the Ministry of Family and Youth Services and the Ministry of Community and Social Services. These latter two are beyond the province the LHIN reform process which adds to the complexity of “costing” services. It is a paradox that though substantial information with its noted limitations is available on the incidence, prevalence, course, diagnosis, classification, disability and burden of mental disorders, hardly any information is available on the resources that exist to respond to this burden. The information that does exist often cannot be compared across “silos” because reports use varying definitions and units of measurement. This imbalance between “disease information” and “resources information” is a major impediment to planning mental health services (World Health Organization [Atlas] 2004). According to the Canadian Collaborative Mental Health Initiative (Lesage 2006) the most commonly used providers by sector for mental health issues were (in descending order): general practitioners; social workers/nurses/counselors/psychotherapists; psychiatrists; psychologist and selfhelp groups. Limitations With regard to the above section the reader should be aware that the data may include information regarding diagnosed conditions which retrospectively may not have been the correct diagnosis. As well, Quantitative data does not “tell us why” we observe certain patterns needing Qualitative research to triangulate the data to get a fuller picture. Recommendations What we have discovered is that communication and education between institutions, agencies, the LHIN and the ministry need to improve in order to improve the data and its use. 1. Make LHIN-based data, reports widely available. 2. Work with other LHINs to develop conformity and consistency in data analysis. 3. Develop a set of comparative statistics between LHINs. 4. Develop a system—including technology, policies and protocols—to make Quantitative data easy to enter, transfer and retrieve. 5. Ensure that proper education be mandatory for all those involved in statistical entry, transfer or retrieval. 6. Ensure that there is a comprehensive system of checking the validity of the data used to develop reports. 39 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: 7. Develop a set of standard reports which are used to evaluate the performance of the LHIN. 8. Develop a model which integrates Mental Health, Addictions, acute care medicine, and the determinants of health to assess outcomes. 9. Focus on the needs of ethnic populations including, (i) to increase awareness and skills at the level of primary care; (ii) to support community services and improve liaison with professional mental health care; and, (iii) to provide specialized teams with cultural knowledge and language skills essential to work with patients who require a high level of expertise to diagnose and treat their problems. 20 10. Qualitative and quantitative data needs to account for the complexity of client/patient intensity of distress and client-defined needs.

20

(Kirmayer, L., Galbaud du Fort, G., Young, A., Weinfeld, M., & Lasry, J. 1996. Pathways and Barriers to Mental Health Care in an Urban Multicultural Milieu: An Epidemiological and Ethnographic Study. www.mcgill.ca/files/tcpsych/Report6.pdf

40 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Inventory of Services Task Group
The Approach: The Team: Membership included Tonya Castle Purvis ( task team lead), Julia Baxter, Jill Carlyle, Scott Farraway, Terry McGurk, Lynda Perry, John Reynolds, Arran Rowles and Ehsan Sharf Focus and Objectives: The objectives of the Inventory of Services Task Team are as follows: 1. Compile an inventory of mental health, addictions, problem gambling and special populations services across the LHIN 2. Develop a high-level mapping of services 3. Identify gaps in services 4. Adopt a client-focused approach To meet these objectives, the Team: • • • • Assumed the perspective that we knew nothing initially, in order to avoid personal biases influencing the information-gathering process Met with representatives from ConnexOntario three times to establish accuracy, scope and limitations of the data Linked with Halton Information Providers to do same Requested and received 12 reports from ConnexOntario, which we narrowed down to: a. 3 reports, one each for addictions, mental health and gambling, identifying all services across the LHIN, organized by municipality b. 3 reports, one each for addictions, mental health and gambling, identifying all available services that welcome or specifically target special populations, organized by municipality * Special populations are those indicated by ConnexOntario, and include Methadone Maintenance Clients, Dual Diagnosis Clients, Eating Disorder Clients, Forensic Clients, Women, Native Peoples, People with Disabilities, Concurrent Disorder Clients, HIV/AIDS Clients, Families, Ethnocultural Communities, Gay/Lesbian/Bisexual Clients, Acquired Brain Injury Clients and Homeless Clients Reviewed the information provided by ConnexOntario, Halton 211 and PIEnet and determined first cut of data, including gaps in service Made a call-out to members of the Working Group, Resource Panel and the community to update their services’ information with the information providers, and

• •

41 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: to forward to us any perceived gaps in service; perceived either by the service providers themselves, or by families and clients Collated information and discussed limitations of that information Identified gaps in services specifically for long term care, concurrent disorders, addictions and dual diagnosis Identified geographical gaps in services for communities in the northern areas of the LHIN Partnered with Maternal/Newborn, Child & Youth Team Lead, Quantitative Data Analysis Team Lead and High Level Financial Analysis to establish open communication and exchange of information and to identify future areas of collaboration Completed SWOT Summary

• • • •

•

Figure 6 - Sample ConnexOntario Report

This is an example of the most basic type of report we generated from the ConnexOntario website. The information can include wait times for specific drug/alcohol programs, the funded capacity of programs across all 3 sectors, the number of referrals each program received through ConnexOntario’s referral system, 42 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: age range of programs, specific diagnosis or substance use reported, etc. In keeping with the priority of a ‘high-level analysis’, we determined that detailed information was better suited to Step 3 deliverables. Consequently, we sought the more fundamental information that pointed to available agencies and programs and the populations they serve. What we learned:

Figure 7 - Program Counts in the Mississauga Halton LHIN

43 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: • At the time this report was generated, there were 75 identified drug and alcohol programs, 9 problem gambling programs, and 79 mental health programs offered in the LHIN, for a total of 163 programs.

Figure 8 - Drug and Alcohol Program Service Locations

The above diagram plots drug and alcohol program across the LHIN and services outside the LHIN that are accessed by LHIN residents. While it appears there are an equal number of programs in the north and south, this map does not identify the quantity of services within each program, thus skewing the observable data. In this map, and the two that follow, services are designated by colour. Blue represents a drug and/or alcohol services, red represents problem gambling and green represents mental health.

44 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 9 - Available Problem Gambling Services

This map plots the available problem gambling services across the LHIN.

45 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 10 - Mental Health Services Availability

Finally, this map plots the available mental health services. The orange represents confidential site locations.

46 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 11 - Drug and Alcohol Programs by Type

•

• •

•

Peeling back a layer to analyze gaps in service within specific sectors, we start with the programs for addiction services. As demonstrated in the chart above, there are 67 programs covering case management, community treatment, residential treatment, community day/evening treatment, community medical/psychiatric treatment, and initial assessment/treatment planning. When this range of services is compared to the addictions treatment continuum, one realizes there are gaps in residential withdrawal management programs. Specifically, there are no such programs in the Mississauga Halton LHIN. By way of comparison, two neighbouring LHINs, Hamilton Niagara Haldimand Brant and Toronto Central have 4 and 10 Level 2 withdrawal management services, respectively. Further, the Toronto Central LHIN has a Level 3 withdrawal management service. This data matches the feedback we received from service providers and families, who identified the need for local, accessible detox services.

47 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 12- Problem Gambling Programs by Type

• •

•

Looking at the problem gambling services, the most easily identifiable gaps in services are residential treatment and community day/evening treatment programs. These services are limited in the surrounding LHINs; Hamilton Niagara Haldimand Brant has a 5-day day treatment program with a funded capacity of 15 clients, and Toronto Central has a 3-week day treatment program and a residential treatment program, both for women only, and with a total funded capacity of 8 clients. This sector also illustrates the complication of the LHIN boundaries in accessing data. For example, all but 3 of the services in the above chart are offered by ADAPT (Halton Alcohol, Drug and Gambling Assessment Prevention and

48 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: • Treatment) however, the day treatment program listed in the Hamilton Niagara Haldimand Brant LHIN, which is also offered by ADAPT is not included as a service in the Mississauga Halton LHIN. This is because the location of the service is in Burlington, which, while definitely located in Halton, is not in the Mississauga Halton LHIN.

Figure 13 - Mental Health Programs by Type

49 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Discovery: • The category of Mental Health Services is certainly the one with the greatest numbers of programs, however, that information can be misleading when one considers the partnerships, educational initiatives and other collaborative endeavors that are not reflected in the provided categories, eg. The Concurrent Disorders Partnership (Health and Hope Team) that is comprised of several clinicians from across Halton Region, but only two of whom have their roles counted as clinical contact. • The distribution of the above services is concentrated in the southern portion of the LHIN, creating a lack of services in the north – a situation that is further complicated by a lack of public transportation. • Services that address the needs of special populations and that are considered strengths in this category include: o Crisis services such as COAST and Peel Crisis Capacity Network that provide specialized crisis intervention and support services for individuals with mental health issues. o Concurrent disorders partnership and the initiatives and services they promote o Dual diagnosis service (Central West Specialized Developmental Services, formerly Oaklands) o Court diversion programs that catch mental health issues and redirect suitable individuals to treatment instead of incarceration • Specific gaps in service include: o Concurrent Disorders resources such as a psychiatrist for the Health & Hope program, day treatment programs, CD friendly housing, tobacco cessation programs (including subsidized NRT), adequate transportation, and sufficient CD programs in North Halton. Further they are consistently under-funded and over-capacity, and “borrow” from other agencies and programs. o Transitional Age Youth services lack psychiatric inpatient beds, and a day treatment program. Other issues include long waitlists to access case management services, limited vocational/specialized educational programs, limited shelter space, limited dual diagnosis services, and long waitlists for counseling services. o Geriatric Mental Health service providers have identified insufficient psychiatric services in Long Term Care facilities, especially for clients under 65 as well as insufficient therapeutic recreation services for this population. Further, clients with psychiatric or behavioural issues are hard to place in Long Term Care, and there exists no suitable unit with sufficient and appropriately trained staff for residents whose cognitive impairments lead them to be volatile. o Also within Geriatric Mental Health, it has been reported that Community Care Access Centres do not provide services to clients if the main diagnosis is psychiatric. Further, transportation to programs and

50 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: appointments is needed, as are day programs with transportation included, supportive housing that is affordable for people on pension, o friendly visiting programs, addiction services, in-home respite, access to family physicians, affordable dental care, home-based foot care, psychotherapeutic support, and caregiver support groups. o Identified gaps in Dual Diagnosis services include behaviour services, crisis response services, specialized day treatment programs, specialized residential options, and tertiary care for inpatient and outpatient day treatment services. Limitations of the Data: The above information as provided by ConnexOntario is considered to be 95% accurate. However, their information is only as good as that provided by the services and agencies themselves. By the very nature of our scan, we assumed diligence and accuracy on the part of the agencies and services regarding the information they submitted. In order to optimize the precision of our report, we sent out 3 requests to community services and agencies to update their information with ConnexOntario and other information providers. Further complications of the data include: • • • • • Role drift as a result of responsiveness to client needs leads to camouflaged gaps Demand for service not accurately identified due to staff taking on large caseloads (funded capacity vs. actual capacity) Funding for consultant positions provide some support but also hide actual gaps MIS/CDS do not identify or count community development initiatives and therefore stats do not accurately reflect work accomplished Division of roles across locations and consequential loss of time due to travel

Summary: Even with the high-level mapping of the inventory of services, some recurring themes regarding under funding, role drift, gaps in programming and inconsistent data are obvious. Data is inconsistent across the sectors, across services and across clinical/consultation roles. Finally, north of the LHIN is consistently under serviced – a situation further complicated by the lack of available public transportation and the lost clinical hours of service providers due to their travel time. While we readily identified weaknesses in the system, we feel it is also important to highlight the broad range of services available across sectors and special populations. These services and programs exists thanks in large part to the ingenuity and dedication of front-line workers and forward-thinking partnerships. The very problem of role drift exists because clinicians are responding to the needs of their clients, and are attempting to fill that need in the absence of an organized, funded alternative. Kudos are deserved to those staff and programs who are demonstrating such initiative. 51 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Recommendations: Given the restrictions in the available data and the varying levels of accuracy of that data, it is recommended that the information in the Inventory be synthesized with that of the Quantitative Data Analysis Team and the High Level Financial Team in the next step toward service integration. By amalgamating these teams and the results of their respective efforts, we can gain a clearer understanding of the supply and demand of services in the LHIN. Further, patterns can be identified as to the frequency with which individuals and families who reside in the LHIN travel outside the LHIN to seek services, and the nature of those services. We also recommend a revision of the current reporting structure to better capture the clinical services currently offered, as well as the non-clinical services that are necessary to establish full integration. For example, educational initiatives, community-building, consultation, participation in partnerships and establishing networks are aspects of the service delivery that are largely overlooked by the current reporting strategies. The ramifications of these exclusions involve financial and funding disadvantages, as well as compromised ability to provide comprehensive client-focused services and interventions. Such non-clinical initiatives are crucial in the development and maintenance of an integrated service delivery model, and should be considered and counted as such.

52 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Capacity Comparison: On the next page you will find a set of graphs (Figures 14 - 26) that compare capacity for Mississauga Halton LHIN, Hamilton Niagara Brant Haldimand LHIN and the Toronto Central LHIN. The data in the capacities charts underlines the need for increased diversity in the Mississauga Halton LHIN’s treatment programs, as well as the need for increased funded capacity. For example, in the Drug and/or Alcohol Treatment charts, Mississauga Halton has the fewest treatment options (as determined by provincial service categories) as well as the lowest capacities, when compared with the neighbouring LHINs. The Problem Gambling Treatment charts are somewhat more encouraging at first glance. However, the data for the Mississauga Halton LHIN identifies the gambling treatment program offered by ADAPT, which is actually located in the Hamilton Niagara Haldimand Brant LHIN. Again, the scope of treatment options is very limited in our LHIN. Finally, the Mental Health Services capacities identify relatively comparable numbers between the LHINs, however, the scope of the treatment options in the Mississauga Halton LHIN is less than half that of the Hamilton Niagara Haldimand Brant and Toronto Central LHINs. Clearly, our LHIN requires greater funded capacity in the programs we do have, and an increase in treatment options across Substance Abuse, Problem Gambling and Mental Health services. When one considers the speed with which the population of this LHIN is growing, and is expected to continue to grow, the need for increased services and capacities becomes that much more urgent. Regarding the data contained in these capacity charts, please note the total capacities are calculated only for the services that have reported capacity to ConnexOntario. Those organizations that have unlimited or unidentified capacities are not represented in the totals. Consequently, the capacity charts may not match the program charts found elsewhere in this report. These discrepancies have been considered in the analyses of the data.

53 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 14

54 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 15

55 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 2

Figure 16

56 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 17

57 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 18

58 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 19

59 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 20

60 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 21

61 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 22

62 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 23

63 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 24

64 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 25

65 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Figure 26

66 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

High Level Financial Analysis Task Group
The Approach: The Team: Membership included Karen Parsons (task team lead), Ean Algar, Vivian Demian , Ian Stewart, Charlene Winger, Kay Davison and Diane Koz Focus and Objectives The objective of the High Level Financial Analysis Task team is as follows: 1. To provide a profile of the current costs in the existing system for the program or population across the local health system (Source: Mental Health & Addictions DPA Team Step #2 Health System Integration Methodology) To meet this objective, the Team: Given the confidential nature of such information, the Local Health Integration Network (LHIN) initially conducted a review of available financial materials, selected relevant data, and provided the lead of the High Level Financial Analysis Task Group with a summary of this data (aggregated to avoid identifying any one individual agency) Please note that the team did not have access to raw data. We decided to base our data analysis on the last full fiscal year for which data was available: 2006/07. A review of the MIS figures (obtained from the MOHLTC FIM website) determined the data was not sufficient for our evaluation. Largely through trial and error, and consultation with the Ministry’s MIS department, various reports from MIS were analyzed to test for validity. In the end, only one report, the LHIN’s WERS report of budget allocations for the 2007/08 fiscal year, proved to provide the most accurate and consistent source of information for Fund Type 2 revenue, although we found some discrepancies in this data as well (for example, one agency has noted a discrepancy in the “Paymaster” line, specific to their revenue.) During our review of data sources, we found no source that passed all validity tests. Comparing information at a more detailed level indicated even greater discrepancies. While limited in scope, the LHIN’s WERS data most accurately met our purpose, which is to provide to the review committee a profile of the current costs in the existing system for the program or population. While the Step 2 worksheets provided an excellent place to start, the nature of the data available did not permit us to include capital costs or thorough Type 3 funding information. As well, obtaining Fund Type 1 data (global hospital funding) proved to be a significant challenge, and we were unable to match categories to Fund Type 2 data in order to accurately aggregate data. Therefore, we have approached the analysis of Fund Type 1 and Fund Type 2 separately. 67 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

In our search, we discovered that there are literally hundreds of reports available for review. The following is a sampling of the reports we reviewed: • • • • • • • Administration Functional Centre Reporting Bricks and Mortar and Homeless Functional Centre Reporting Statistical Reporting in Residential Functional Centres Statistical Reporting by Non-Residential Functional Centres Community Mental Health and Addictions – Global Indicators, LHIN Comparison 2007/2008 Q2 Community Mental Health and Addictions – Functional Centres, LHIN Comparison 2007/2008 Q2 Community Mental Health and Addictions – Functional Centres, LHIN Trend Results

Please note one challenging restriction: some organizations outside of the MHLHIN provide service within, and some organizations within the MHLHIN serve clients outside of the MHLHIN. At this time, we have limited our financial review to those agencies that are funded directly by the MHLHIN, which include nine community organizations and three hospitals. High-level Financial Findings Profiles of revenue and current costs in the existing mental health and addiction systems, for Ministry or LHIN-funded agencies can be found in Appendix 1. While the worksheet data is reported in aggregate form, the information represents revenue and costs for nine community agencies and three hospitals. Excluded are organizations providing mental health and addiction services that are funded by other Ministries and receive no MOHLTC or LHIN funding, services that are funded by other LHINs, and those that are private (fee for service or using fundraising dollars.) In Appendix 1, Fund Type 2 revenue (that includes funding directly from the LHIN, MOHLTC, one-time payments, paymaster flow-throughs, service recipient revenue, donations, and other funding/revenue sources) for community based programs totalled $15,257,489, and $8,828,632 for hospitals. Total expenses did not match revenue in community programs, which is not unusual given high vacancy rates in a time when recruiting qualified staff is difficult. As well, measuring expenses during a period when new programs are in “start-up” phase is not indicative of the true cost of the program when fully operational. Therefore, at this particular time, operating expenses is not an adequate indicator of the cost of providing services. The total Type 2 revenue for both community and hospital programs totals $24,096,121, while fund Type 3 (funding other than LHIN or MOHLTC, such as United Way, MCSS, etc.) revenue to community programs contributed $1,526,370 to mental health and addiction serves. In addition, hospital global budgets (Type 1 funding) support mental health and addiction services in the amount of $22,294,802. A combined total of fund

68 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Type 1, 2 and 3 for mental health and addiction services for MHLHIN-funded agencies is $47,917,293. (Sources: Type 2 and 3 community and hospital – WERS Budget 2007/08; Type 1 Global hospital – HAPS 2006/07. Please note that obtaining data for the same fiscal year was not possible, as WERS budgets were not available for 2006/07, and HAPS budgets were not available for 2007/08 at the time of our data review.) WERS was not a reliable source of information related to number of FTEs or for total patient activity for hospital-based programs. In fact, information related to FTEs from hospital-based programs was unobtainable by the LHIN. The WERS report indicates that Type 2 funding for community and hospital programs, and Type 3 funding for community programs supported 292.72 FTEs, of which 49.47 were management and operational support staff and 240.25 were unit producing personnel (front-line staff.) Not surprisingly, the number of hospital staff supported by the revenue to hospital programs is fewer than the number of community staff supported by the revenue to community programs. We must exercise caution when determining the reasons for this difference. While we can accurately assume that salaries and benefits are higher in hospitals than they are in community programs, we must also consider that the most acute and complex cases are treated in hospital settings. Still, the disparity between the salaries and benefits of hospital and community programs has long been a challenge. Anecdotally, we know that community programs lose staff to hospital programs once they are trained and experienced in the community setting, as staff seek better pay for similar work. The WERS report also indicates that Type 2 funding for community and hospital programs, and Type 3 funding for community programs, served 17,811 individuals, with 133,575 face-to-face visits and 70,570 telephone visits. Appendix 2 illustrates the total Type 1, 2 and 3 revenue as a pie chart, as does Appendix 3, which illustrates fund Type 1 mental health costs in hospital programs. An outstanding question remains regarding hospital global funding for an existing addiction program (has it been missed or rolled into the costs labelled mental health?) Appendix 4 compares revenue, staffing and selected service recipient activities across all 14 LHINs for the 2006/2007 fiscal year at year end. (Source: MOHLTC FIM website.) Please note: We know that the LHIN 6 information provided in this summary is not sufficient for our evaluation, as it includes at least one organization that is outside of LHIN 6 and excludes two, possibly three, organizations that are in LHIN 6. For example, when the same report is downloaded using individual agencies, the total revenue for LHIN 6 equals $25,420,165, versus the $21,117.036 shown. However, the information contained in this report is not sufficient for our evaluation, as information is missing for individual agencies (either not submitted or retrievable by F.O.I. only.) For example, the detailed report indicates that three hospitals had ‘0' management staff assigned to mental health and addictions, one hospital indicated ‘0' staff of any kind assigned to mental health and addictions, and two hospitals had no information 69 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: indicated for ‘cost per individuals served.’ Therefore, we must exercise caution when using the data in this report. Despite these challenges, the report offers some interesting data, and might be valuable when further analyzed by population per LHIN to determine per capita spending for mental health and addictions across all LHINs. Also interesting is the ‘average MOS/UPP hourly rate,’ which is not significantly lower in areas where the cost of living is significantly lower. Also notable is the ‘administration %,’ which ranges from 6.10% to 14.20%; however, the ‘Administration Function Centre Reporting’ document, based on 2006/2007 compliant budget submissions indicates an average ‘admin expense as a % of total org expense’ as 27.73% for LHIN 6. Interestingly, that same report indicates a range from zero percent to 61.36% across the province. MIS staff has documented their concerns with the data from this report. Average Costs for CMH&A Service Recipient Activity (budget year 2006/07) by functional centre is summarized in Appendix 5. Again, we must exercise caution when reviewing this report, as one organization appears to be missing completely, while other organizations are only partly represented. As well, not all organizations reported similar activities in the same functional centre. Much discretion was exercised when choosing functional centres and interpretation of reporting both financial and client data information is largely at the discretion of the current program manager. Reporting structure might change mid-year, based on a change in management or on experience with the MIS system, allowing for more informed decisions. Given the information on functional centres we have, we can determine that the ‘cost per unique individuals served’ within functional centres varies considerably. For example, the cost per unique individuals served for the functional centre ‘Case Management – MH’ ranges from $1,537 to $4,089, with an average of $2,865, considerably higher than the provincial average of $1,705. Likewise, the range for the functional centre ‘MH Counselling and Treatment’ is $465 to $8,979, with an average of $606 compared with a provincial average of $779 (these examples have been used because these functional centres contain many agencies, so as to avoid identifying any one.) Again, we must exercise caution when comparing such variances, as the data does not capture complexity or quality, and, as mentioned above, we know that the most complex and acute client cases will be served by acute care centres. This particular report also contains provincial information on functional centres that are identified as having no services in LHIN 6. This does not mean that these services do not exist in LHIN 6; they may be provided by an organization outside of LHIN 6 or the organization may have reported the activity under a different functional centre. As well, we know that information is simply missing from this report.

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Mississauga Halton Local Health Integration Network: Other Key Findings: • MIS data was found to be insufficient for our evaluation. Reports from MIS revealed that agencies located in LHIN 6 were omitted from the reports, and agencies located outside LHIN 6 were included. We investigated which agencies were affected and notified MIS; these inaccuracies were promptly corrected. However, we do not know how far these corrections reach, as subsequent data reviews still contain significant inaccuracies and omissions. • MIS data is difficult to analyze. For example, using one agency as a guide, comparisons were made with data entered to MIS and data appearing on various reports. While some data was recognizable, much was not, and large portions of data entered seemed to be missing altogether. Consultation with MIS staff did not resolve this concern. As well, some agencies were in the early stages of becoming MIS compliant during the period reviewed (2006-2007 fiscal year), the most recent year for which data was obtainable. As a result, there were inaccuracies in the data as agencies gained proficiency with the new reporting system. We discovered that more detailed reports produced more frequent and greater discrepancies, and maintaining a higher level view of the data produced more accuracy. In addition, MIS data specific to administrative costs, as reported by organizations, was highly variable, and MIS staff questioned the validity of the submitted data. • Analyzing data by functional centres did not provide an accurate picture, and did not match WERS data. While some information in the functional centre summary report was identifiable and accurate, other information appeared to be missing, and one organization, identified by its organization number only, was listed in LHIN 6 but was not identifiable as any of the existing agencies. As well, agencies were able to link activities to function centres at their discretion; therefore, two agencies performing very similar activities may have chosen to link these activities to different functional centres. • An analysis of data by functional centres did produce one interesting finding: the wide discrepancy in “cost per unique individuals served” for various organizations reporting on the same functional centre. For example, within the “Mental Health Counselling and Treatment” functional centre, cost per unique individuals served ranged from $495 to $8,979. Many other functional centres showed similar variances. There are many reasons for these variances, such as: costs of operation tend to higher in hospital settings (higher salary and benefit costs, for example,) service users with the most chronic and complex issues tend to be served in hospital settings, some programs serve only those service recipients with the most complex needs, requiring much longer periods of care. Therefore, comparing individual organizations by “cost per unique individuals served” would produce inaccurate conclusions. • Analyzing “cost per unique individuals served’ does not take into account hours that are provided by staff outside of regular working hours, such as unaccounted overtime and forfeited lieu and vacation time (data is based on standardized operating hours). Therefore, the “true” cost of providing service is not obtainable. 71 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

• Analyzing operating costs during periods of growth produce inaccurate conclusions. The mental health sector has experienced several years of intense growth, and not all operating dollars are used during start-up or the phased in operation of a program. Therefore, caution must be exercised in interpreting surpluses identified. • Revenue reported does not take into account organizations located in LHIN 6 that provide service outside the LHIN, and organizations located outside of the LHIN that serve regions within the LHIN. Therefore, revenue identified as allocated to an agencies located in LHIN 6 may be used to provide service to service recipients residing out of LHIN 6. Conversely, organizations funded by other neighbouring LHINs are providing service to service recipients residing in LHIN 6. As well, organizations identified as provincial resources (such as residential treatment centres) may be located within our LHIN but serve individuals from across the province, and individuals living within the LHIN boundaries attend residential programs (up to one year in duration) outside of our LHIN boundaries. • As noted above, MIS and WERS reports, when cross-referenced, are not comparable. • Analyzing numbers of service recipients seen does not take into account client complexity or intensity or quality of service delivered. A singular focus on increasing numbers of service recipients seen has the potential to reduce the quality of service provided, thereby compromising “best practice” service provision. • Operating budgets are restrictive. Surpluses may be identified in some areas while deficits are experiences in other areas, all within the same organization. While best efforts are exercised to accurate projections, unexpected events, such as an unexpected staff vacancy or loss of equipment, for example, create a need for flexibility with ease of process. Similarly, surpluses in one program cannot be re-allocated to fill a need in another program. Therefore, an organization might appear to have a surplus in one area while lacking resources in another, which may or may not be temporary conditions. Current budget restrictions interfere with optimal fiscal stewardship. • In order for the financial data to be meaningful, it needs to be linked to the number and type of services available and the number of service recipients served. As noted above, however, caution must be exercised to avoid reaching for a goal of serving the largest number of clients with fewest dollars, as quality would be severely compromised. Current functional centre categories are confusing and do not accurately describe the services or programs provided. • We know that demand for mental health and addiction services is outstripping supply, and we know that this gap will continue to broaden. Population-based studies conducted by the Social Planning Council of Peel and the former District Health Council in our region, and other provincial organizations, clearly and consistently indicate that mental health and addiction services cannot meet the need with current resources. 72 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: Based on research that suggests that one in four or five individuals will be affected by mental health and/or substance use and/or problem gambling concerns, we can project that, with a population of 1,092,237 in LHIN 6 (based on 2006 Stats Can data,) 43,689 individuals are affected, based on a conservative 4% of population. Our data suggests that we expect to serve approximately 17,000 individuals in the 2007/08 fiscal year; therefore, we will have reached only 39% of the in-need population, demonstrating severe incapacity. That figures does not take into account the critical activities associated with prevention and promotion, for which we are largely not funded. • An analysis of financial data related to a combined average hourly rate of both MOS and UPP staff indicates a range from $23 to $43. There are currently no suggested ranges of remuneration in the mental health and addiction sectors. Unlike regulated health professions, such as nursing, mental health and addiction workers are unregulated, and therefore come from a broad range of backgrounds with respect to training and experience. As a result, there are often great inconsistencies in the rates of pay provided to workers in these sectors, creating difficulties recruiting and retaining skilled employees. Community agencies tend to experience a talent drain as they train workers who then move on to higher paying positions in larger institutions. This situation often creates frequent vacancies with frequent need to recruit.

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Mississauga Halton Local Health Integration Network: Recommendations: 1. Standardize data collection across LHIN 6 and then across other LHINs. In order to accomplish this, functional centre descriptions and options need to be reviewed and revised, and organizations given an opportunity to adjust their reporting by functional centre to better capture their activities, resulting in consistency across the system. As well, data collection systems must be consistent, so that collection of data is reliable and usable. 2. Create an accurate method of easily capturing revenue for all types of funding (types 1 – hospital global funding, 2 – MOHLTC/LHIN funding, and 3 – other funding) that is readily retrievable and reliable. 3. Avoid focus on quantitative-based comparisons and goals only. Consider outcome indicators that capture qualitative data. 4. Permit organizations to re-allocate dollars between budget lines to respond to pressures and arising needs. As well, provide opportunities to redirect funds from one program to another within organizations to respond to emerging needs (for example, two separate programs at one hospital can share resources should one experience reduced need while the other experiences increased need.) These internal program reallocations can be temporary or permanent. This will result in better stewardship of funds, reduced surpluses in areas where savings are realized (unexpectedly and through fund management) and reduced deficits in areas where unexpected expenses arise. 5. Establish multi-year funding, which would allow for optimal fiscal stewardship, as organizations can spread costs over a longer period of time, “save” for large cost purchases, and adjust for in-year operational changes. This, combined with recommendation #4, will allow for “in the moment” responses to financial opportunities and challenges, stretching our revenue dollars and resulting in peak efficiency of spending. 6. Advocate for levels of funding for mental health and addiction sectors that more closely align with population needs and provincial averages (Mississauga and Halton are among the most poorly funded areas when compared with other regions in Ontario.)

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Mississauga Halton Local Health Integration Network: Considerations of an Analysis of Three Groups: High Level Financial Analysis, Quantitative Data Analysis and Inventory of Services A review of the results of an environmental scan in these three areas indicates the following opportunities for a merged analysis: • to match revenue to population-based spending within several categories, such as age, gender, ethno-cultural, and specialized population-based programs • to link dollars spent in each functional centre to current population (per capita spending) and projected population (which, when compared over years, will indicate whether spending is keeping pace with population growth). Since each group experienced challenges with the efficacy of data collected, the value to linking data for further analysis is questionable. These challenges are summarized below: • We know that our client population is not representative of our community (for example, 51.6% of Mississauga’s population is “immigrant” with approximately 40% identifying as visible minority, yet our client base does not reflect similar statistics.) The report on Quantitative Data Analysis states “that we would expect that the number of visits to a doctor involving mental health should correlate with the population.” The report also states “that while MH has almost 9% of Ontario’s population, it only has half as many visits.” Using this example, using our current data research as a foundation for future comparison and planning ignores systemic qualitative and quantitative challenges. • We have evidence that many or most services are already working over funded capacity, and our data collection does not capture this. • Our current inventory of services does not align with our designated functional centres, rendering any comparable links impossible. • Reporting to DATIS is not currently mandatory in a manner that is consistent and reflective of the actual state of affairs. • During the data collection phase, we discovered that agencies that are not in LHIN 6 were included in the data summaries, while two LHIN 6 agencies were not included at all, as they were originally designated as being located in other LHINs. While this has been corrected in some areas, we do not know the extent of the correction (there are hundreds of reports in MIS a correction in one area may not translate to a correction in another.) • Mental health and addictions report different types of data to different systems. 75 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

• Interpretation of reporting is left largely to the current management of the service; if that service has only one or two managers, then the reporting might be somewhat more consistent than a service with multiple managers with flexibility for interpretation. Therefore, consistency of reporting within organizations is not reliable, let alone between organizations. • Activities that are crucial to the integration of mental health and addiction services, such as consultation, education and networking, are not captured in the current reporting structures. Consequently, they are not encouraged, yet they are critical components, and they add to the hidden role drift phenomenon that is pervasive across the sectors. The leads of the three groups agreed that a merged analysis is best considered in Step 3, given the limited scope of Step 2, depending upon the recommendations adopted by the larger group to address the challenges, especially as they relate to accuracy and relevance of the data collected and reported.

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Mississauga Halton Local Health Integration Network:

Community Engagement Task Group:
The Approach: The Team: Membership included Mary Quartarone (Task Team Co- Lead), Peter Andruski (Task Team Co-Lead), Heidy Steinback , Judy Tyson, Lisa Cowley, Garth Buckley, Dr. Alison Arnot, Mitsy Clennon, Kathryn Lynch, Vanessa Sairsingh, and Diane Koz Findings: Several themes were repeated many times by people who participated in the meetings or completed the survey. These can be summarized and conceptualized in the following graphic. It illustrates key characteristics from the community’s perspective if the system is seen as a Circle of Care, with the Client at the centre:

Common Goal

Consistency

Coordination

Clients

Creativity

Collaboration
Figure 27 - System Circle of Care

Communication

A successful program depends on connected and integrated services that share knowledge and information. The key indicators for success are a client-centred and client-directed approach, which demands both acute care and flexible care, for as long as a client may need it. Many of the respondents noted that their experiences with a psychiatrist-centric (provider dependent), top-down system, resulted in long waiting times. The system is vulnerable to failures in individual communications and planning. Stigma is a major issue that needs to be addressed. Goals for the Circle of care: Client-centric, Coordination, Consistency, Collaboration, Creativity, Common goal.

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Mississauga Halton Local Health Integration Network: Focus and Objectives The aim of the CE Task Group was to plan and operationalize community engagement strategies to support planning efforts of the Mental Health and Addictions Detailed Planning and Action Team with the implementation of the IHSP. Goal: To augment community input gathered during the development of the IHSP by inviting ideas from clients, consumer/survivors, health service providers and related partners around building a more client-centred, effective and efficient mental health and addictions system. Mississauga Halton LHIN has been a leader in effectively engaging clients, patients and communities in the creation of a healthcare system that meets local needs. The Integrated Health Services Plan (IHSP, 2006) clearly identifies that, for the Mental Health and Addictions priority area, the needs of clients and families are paramount. The MH LHIN has prioritized two key objectives that require optimum community engagement in order to create a truly effective mental health and addictions system: 1. Placing individuals with mental illness and their families at the centre of the system; and, 2. Focusing on streamlining access by improving consumer choice and access. These objectives were the driving principles behind the work of the CE Task Group. In shaping our approach to engaging communities, we agreed on a number of starting assumptions and objectives namely, to: • Build on community engagement work that has been done previously by the MH LHIN in order to update current knowledge and input from communities. • Acknowledge that our work is a beginning – the start of a long-term, process of engaging community. This means that we involve communities in an ongoing manner, through mechanisms that provide space for all stakeholders to actively participate with us by providing input at all stages of system model development and implementation. Recognize the need to broaden our outreach efforts from family members and those using or providing services to include those who are not using the system because they have not been able to access it. Our challenge and privilege was to gather significant feedback from key groups – service users, family members, service providers, related health and social service providers and the general public. We decided to work through existing networks and agencies, a process facilitated by the relationships developing within the LHIN DPA teams, to reach service users, clients, consumer/survivors and family members. Additional notices to the general public about the opportunity to get involved in this consultation were presented through local newspapers that responded to our request to publicize both the community meetings and the survey.

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Mississauga Halton Local Health Integration Network: To gather input from key audiences and the general public, we used an online survey that accepted responses from December 21 to January 18. In addition, two community meetings were held in early January. In the course of that four-week period, 589 survey responses were recorded and 60 people attended the communities meetings. The data from both of these activities were analyzed by the CE Task Group. Who Responded?

A total of 589 people completed online surveys. Here are the key quantitative results: • • • • 46% were currently using mental health and addictions services Of the respondents currently using services, 69% were using mental health, 13% were using addictions and 18% are using both 79% had used services in the past 34% were family members of someone with a mental health or addictions problem and only a third of family members were currently or have in the past attended a family support program • • • • • • 47% were employed in the mental health and addictions field; 53% were not 15.1 % were aged 16 – 29 53.5 % were aged 30 – 49 30.9 % were aged 50 – 69 Two thirds of respondents were women; one third was men. 54% live in Mississauga; 26% in Oakville; 10% in Halton Hills; 6% in Milton; 4% in South Etobicoke (of 330 who responded to this question).

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Mississauga Halton Local Health Integration Network:

Figure 28 - Past and Present Mental Health and Addictions Services Used

Figure 29 - Percentage Service Area Employment in Mississauga Halton LHIN

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Mississauga Halton Local Health Integration Network:

Community Recommendations Although some shaping of the language was involved in writing these recommendations, they are, in essence, drawn from the collective input of the key target groups and over 600 individuals who contributed their experiences, thoughts and suggestions for an ideal service delivery system in Mississauga Halton. It is important to note that members of the committee were also members of the target group. Mental Health and Addictions System Integration The Community Engagement Survey results and the feedback received at community meetings offered up a number of key themes that generated significant comment from the respondents and meeting participants. The Community Engagement Task Team has developed these themes into the following list of recommendations. Although we recognize this list does not include all topics that were discussed, we feel these topics provide an accurate representation of the events most frequently tabled. In general, the feedback received indicates that mental health and addiction services, as a whole, are experienced as being fragmented and difficult to access. Although it has been recognized that there are many effective and valued programs in place, these programs are often difficult to find or not coordinated with other services available in the LHIN. There is the perception that even after the system has been accessed it can be very difficult to navigate. Given this perspective, the following recommendations have been compiled in an effort to identify focus areas for the LHIN: 1. Create 360 Access – The Right Door, Anytime, Anywhere • Regardless of the where individuals enter the system, connect them immediately to a service that is appropriate for their needs. People do not want to have to visit numerous services looking for assistance and having to repeatedly explain the same situation to various service providers. The immediately accessed service may be transitional, with a particular agency responding to a situation and then facilitating the transition to more appropriate care. • Develop an easily accessible, single list of all mental health and addictions services available in the MH LHIN, including a description of these services and how to access them.

2. Offer a Continuum of Care with a Holistic Focus • Integrated mental health and addiction services in the LHIN should incorporate a holistic approach to health where all facets of the individual’s recovery are taken into account, rather than focusing predominantly on the medical component. • Services should be available to individuals, on a consistent basis, throughout the course of their recovery and for a duration that is jointly determined by the client and the service provider, based on the clients’ goals and needs.

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Mississauga Halton Local Health Integration Network:

3. Ensure Flexible Care Pathways to Recognize Diverse Needs across the Population • In developing an integrated health services plan the LHIN should make every effort to ensure that “care pathways” can be tailored to the needs of the individual. Available services should be offered in such a manner that they can be combined in varying combinations that focus on the needs of the client. • It should be recognized that the needs across the population are expected to vary significantly.

4. Strengthen the Connection between Mental Health and Addictions Agencies • Strong leadership is required to ensure the co-ordination of services in order to avoid duplication of programming in the same geographic areas. This same leadership is necessary to ensure that services that are working well are propagated across the LHIN.

5. Provide Community and Professional Education • Provide education for service providers, individuals and family members as an integral component of mental health and addiction service provision and planning. 6. Take Action on Significant Barriers to Service • Lack of accessible transportation is a key barrier for many community respondents. • • Affordable and appropriate housing where the supports offered in the housing environment are synchronized with the level of support needed by the individual. Access to supported employment. As in the housing recommendation, the supports offered in the work environment should align with the support required by the individual.

7. Make Reaching Diverse Communities/Clients a Priority • It has been recognized that there is a challenge in reaching a number of demographic groups within the LHIN (e.g. youth, the elderly, those managing addictions, ethnic communities). Specific strategies and partnerships are required to provide service to, and solicit feedback from, these groups.

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Mississauga Halton Local Health Integration Network: 8. Continue to Build Many Positive Strengths • While there were many well-deserved comments about existing programs, two overarching themes struck a note as areas for continued and expanded support: • Positive feedback has been received with regards to Peer Mentors/Peer Support, both for individuals accessing services and their family members. This should be an expanded focal point of service provision. The services offered by caseworkers also received positive comments along with the assertion that more case workers are needed. This has been identified as an area where resource should continue to be applied and expanded.

•

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Mississauga Halton Local Health Integration Network: Summary of SWOT Findings • • • What worked well for you? What didn’t work well for you? If you could change one thing about the mental health and addictions system, what would it be?

These questions formed the basis of our inquiry with community stakeholders through the survey and community meetings. A thorough and systematic process of grouping individual survey responses yielded the following key messages and content areas, summarized here under the SWOT categories of Strengths, Weaknesses, Opportunities and Threats.
STRENGTHS • Caring providers • 1 to 1 interaction – quality, consistency, flexibility • Holistic / client centered health focus • Peer support • Family involvement • Diversity of services • Psycho-Ed programs (support, prevention, promotion) WEAKNESSES OPPORTUNITIES • Centralized • Wait times Access: Single • Barriers to Common Intake access – no (one door) & information, central contact inflexible hours, criteria, • Partnerships with existing transportation services to • Assessment & facilitate access discharge revolving door, • Develop care pathways for not flexible, mental health detailed or longand addictions term • Partnering with • Ethno cultural other DPATs relevance • Integrate • Housing primary and psychiatric care • Health promotion / prevention • Guiding Principle: Never abandon or isolate a client THREATS • Fragmentation • Record Keeping - lag in adopting EHR (electronic health records) • Societal devaluation of caretakers • Poor remuneration for many workers • Demographic and population fluctuations change demand for services

The remainder of this section highlights findings from the theming process and our SWOT analysis. By anonymously quoting direct comments from the survey respondents’ answers, we have tried to pass on just a taste of the passion and emotions, and the numerous ideas and strategies offered by the community – from both

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Mississauga Halton Local Health Integration Network: those who use the mental health and addictions system as clients or family members, and those who work within itas staff and/or clients and/or family members. . Strengths: There are many success stories to celebrate. Some clients, families and providers discovered “connections” from one network to the next. However, finding good care was reported as an ‘ad hoc’ experience. Despite pockets of excellence, a service that was strong in one community was considered weak in another. Access: Time is of the essence. Immediate response to persons in crisis was critical. Since initial experiences are vital to long-term trust in the system, the survey lauded frontline crisis and caseworkers who were caring, qualified and vigilant. “Start the intake process immediately…would allow the clients to feel as though their situation is being taken seriously.” Assessment: When an assessment from a psychiatrist was achieved, clients reported quick access to services. Providers listened and accommodated individual needs. “I required the least medication possible to function well.” Services: A good range of services exists once clients gained access. They benefited from language/culturally specific support, easy referral, a long term plan, affordable & available housing, evening appointments to accommodate employment, proximity, sensitive triage workers, court-ordered care, treatment at home, social discourse and medications management. “With concurrent disorders…the ‘one-stop-shopping’ approach, without having to refer them out…having an in-house expert is helpful, since training alone is not adequate…make ongoing consultation available, to support acquired knowledge.” Treatment: The winning formula had three components: 1) a continuous collaboration of knowledgeable providers with focus on counselling 2) supportive family/friends and 3) a welcoming peer group. What worked best for clients was one-on-one interaction. The survey credited programs that were flexible, frequent and consistent. Ongoing sessions with a counsellor or psychiatrist were vital to wellness, but not a magic bullet. Clients enjoyed a structured environment, work ordered day, job skills retraining, CBT, AA residence, a12-step program, long-term aftercare and a holistic ‘mental & physical fitness’ approach.

“If you drink every day, you need a meeting instead, every day.” 85 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

Education: The “ripple effect”, a burden of care that paralyzes families, was mitigated by workshops at various hospitals, like CVH. Clients’ understanding of their own illness was a step toward self-help and compliance. Re-training and employment assisted in client recovery. “…A live person answering the telephone when I called for help.”

Weaknesses: Access: Clients complained about finding and navigating resources in time of crisis. First access could occur through a physician, police, support services or EMS, but not all practitioners were trained to manage - or sympathetic to - mental illness. Other barriers included GP’s refusal to manage complex care, patients and/or partners unwilling to seek help, ineligible criteria (i.e. not stable enough) and long wait times. Access to information was a weakness, because there is no EHR and no patient history. The time used to collect information was regarded as robbing time from direct service. “Trying to obtain help for a suicidal client…a psychiatrist told me he could not get her admitted. I was horrified…I took her myself and had her admitted.” The following two pie charts graphically illustrate responses to two survey questions that probed existing barriers to the system, as experienced by the respondents, further rounding out the information gathered around access.

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Mississauga Halton Local Health Integration Network:

Figure 30

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Mississauga Halton Local Health Integration Network:

Figure 31

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Mississauga Halton Local Health Integration Network: Assessment: A lack of vision or ‘collective will’ was apparent. Family doctors delayed proper treatment, or their assessment caused complications. Too few specialists meant long wait times for appointments. There were inconsistencies in treatment from one doctor to another. Assessment was not substantiated by a support team. Assessing client competence to perform daily tasks (financial affairs or driving) affected compliance and family involvement, but these details were ignored. Ethno-cultural and language factors were roadblocks to communications and seeking care, as was sensitivity to the LGBTTTIQQ community. “My family doctor diagnosed depression…antidepressants put me into a manic state. The psychiatrist diagnosed me correctly and gave the right medication… just one appointment changed my life. Treatment: For many, the system is a revolving door of unintended consequences. The crisis-driven system results in programs that are too short, not customized to individual needs, and clients having no discretionary power. “Because I was so depressed, I had little ability to advocate for myself…I wanted to scream ‘Don’t you see? I’m bleeding inside just as much as someone who has cut themselves’.” Medications management is a calamity of drug interactions, complex schedules, conflicting diagnoses and double scripting. Housing is inadequate for long-term illness or transition, with reports of unhealthy food and a deficiency of knowledgeable support workers. Assistance with job search after discharge, especially for stabilized clients out of work, was not forthcoming. Policies for financial support, transportation and co-ordinated after-care were nonexistent. “We need a home…that recognizes the symptoms of trauma and doesn’t punish people for their pain. The system hurt this woman as much as the abuse itself.” The privacy issue conflicts with best care in some cases. Families need to be in the loop during treatment, and frequently need to override client confidentiality in order for the family to provide adequate support. Referrals: Finding the appropriate program was a challenge. The existence of services is not known by providers, wrong services are recommended or there is inconsistent information. Agencies don’t provide the service for which they are funded or their mandate is publicized incorrectly. Counselling is available privately to those who can afford it, but the two-tier system is not equitable for clients of modest incomes.

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Mississauga Halton Local Health Integration Network: Youth services were flagged as troublesome, due to lack of definitions, transition to adult service, standardization and assessment tools. “Young individuals require more intense intervention…Need better screening for high-risk clients and families for drug abuse, criminal activity, poverty, problems with school system.” Opportunities: Promotion & prevention: Advocacy with the help of schools, workplaces and medical professions could lead to better understanding and respect for mental health. Integrating services into mainstream walk-in locations in the community might increase public awareness. Greater public awareness and acceptance would allow users to be confident in providing testimonials and disclosure without recrimination. “Not able to get help in an abusive relationship. The police only told me to settle down and for my husband to behave himself, then left us both together.” Business and government are discovering the hard costs of mental illness, stress and anxiety. Corporations should be encouraged to develop guidelines for healthy work/life balance and to provide mentoring for re-entry to the workforce. Pharmaceutical companies should be encouraged to be more involved in promoting wellness and prevention. Police and the justice system can be a model for assistance and promote advocacy within their profession. Constituency offices should have information about crisis agencies. “More prominent individuals i.e. big business, to support those stigmatized…not just throwing money at the cause…they are vulnerable as well. It is not only the low-earners affected.” Threats Trends: Changes in demographics will affect demand for services. The growth in eating disorders, addictions and discovery of child/youth early onset will require reallocation of budgets and services. Costs of drugs and some treatment programs are prohibitive. Stigma or stereotyping in the workplace and medical field is a barrier to care. Business is increasing demands on employees, but not supporting life balance. “The stigma against drug users is preventing people from understanding the dynamics of substance use in a human and compassion context…prevents them from seeking support.” Fragmentation of records and indiscriminate system networking discourages information sharing.

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Mississauga Halton Local Health Integration Network: Lack of a centralized communications plan and a strategic plan is a barrier to integration. Data Analysis from Surveys and Community Meetings: The CE Task Group was gratified that such a wealth of qualitative data was received from the community. Our challenge was to find ways to adequately encapsulate the essential meanings of the ideas offered. Because there were no readily available electronic coding tools to determine themes from the data, we employed a “hands on” approach. This meant that each comment from respondents who answered the key questions was assigned a theme by our task group members. We worked collectively on naming the themes. The total number of individual comments made in response to each question was: 96 responses to the question “What worked well” 481 responses to the question “What did not work well” 334_responses to the question “If you could change one thing about the system, what would it be”. When all the comments were categorized according to a theme, we then were able to manipulate the data to see which themes came up the most often. The comments from the key themes were then reviewed again and collectively we analyzed the data according to our SWOT model. Additionally, the collective comments from over 60 people who attended the community meetings were also themed and compared against the survey data for similarities and additional themes. From there, we were able to develop the key recommendations. Anonymous quotes were taken from the surveys and are used to give emphasis to the points made repeatedly by respondents. The design for this report evolved over the course of several Community Engagement Task Group meetings and was guided by the SWOT analysis process and the reporting requirements set out in Step 2 of the LHIN, Health System Implementation Methodology. Community Engagement Task Group Activities – November 2007 to March 2008 November - December 2007 • Initial discussion of possible means of effective community engagement in the available time frame. • Identification and planning of agreed on community engagement activities – online survey and community meetings. • Development, testing of the survey instrument. • Launch of Community Engagement Survey on the Mississauga Halton LHIN web site – December 21, 2007. • Distribution of the Community Engagement activities through Mental Health and Addictions DPA team, Working Group member networks and a general e-mail broadcast from the MH LHIN. 91 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network:

January 2008 • • • •

Community engagement event in Milton – January 14 Community engagement event in Mississauga – January 16 Initial analysis and compilation of data gathered from Community Engagement Survey and Community Engagement events – January 28 SWOT analysis of community engagement data developed and presented to DPA working group and resource panel. – January 31.

February – March 2008 • Analysis of data to identify and shape community recommendations. • Preparation of Community Engagement Task Team Final Report to the MH LHIN. • Submission of completed report – March 11, 2008. Recommendations for Continuing Community Engagement The position of the Community Engagement Task group is that engaging the community in an ongoing manner is essential to developing and maintaining an effective integrated mental health and addictions service system in Mississauga Halton. It is necessary to provide the means to generate ongoing feedback from the community regarding the services provided and the accessibility of those services. Combined with this, is the need to provide ongoing communication to the community regarding the activities of the LHIN as they pertain to the development, provision, integration and access to mental health and addiction services. The value in providing quality feedback to the community regarding the status of LHIN initiatives cannot be underestimated. In order to keep the community engaged it is necessary for them to believe their input is valued and being acted on. From this perspective the following strategies may prove useful: • Continue ongoing community engagements throughout the LHIN ensuring events are well publicized, easily accessible and offered at appropriate times for those in the community to attend. • Move forward with the concept that communications planning and strategic planning work hand in hand. • Initiate a LHIN advisory group to coordinate community engagement across Priority Area teams • Identify with the philosophy of “creative destruction” model where the process is under continuous evaluation in an effort to maintain the most effective service possible at any given time. • Utilize service agencies to collect information from and communicate information to clients 92 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: • • • • • • Create partnerships with organizations representing diverse communities to broaden outreach “Piggyback” on focus groups or meetings that are happening with other groups, in particular with organizations representing diverse groups Actively use the LHIN website to post community specific LHIN information Distribute community specific LHIN information through email Implement a method to reach those that do not have access to electronic media. Implement a strategy to educate the community about the LHIN, why it is important, and why input from the community is important.

See Appendix 6-10, respectively, for: • Complete survey results • Summary of community meeting results • Newspaper coverage of community meetings • Survey instrument • Community flyer

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Mississauga Halton Local Health Integration Network:

Best Practice for Service Integration Task Group
The Approach: The Team: Membership included Nora McAuliffe (task team lead), Ian Stewart, Michele Singleton, Gina Matesic, Kay Davison, Heidy Steinback, Al McMullen, Carol Wilkinson, Dr. Nabil Phillips, Dr. Roman Jovey and Diane Koz. Focus and Objectives: This 12 member task team comprised of both DPA Working group and Resource team members met every two weeks over a three month period and conducted a literature review of best practices in the area of service integration. Initially, the team defined their topic as ‘what system of services best support an individual who has mental health or addictions which limits their quality of life?’ The topic was later refined to ‘what are the key components for mental health and addictions service integration model?’ To meet this objective, the Team: The team reviewed over one hundred and fifty articles which were not limited to Canadian literature but included articles from the US, Australia, England and Scotland. Eighty-one articles were identified as contributing to this task and included the Government of Ontario’s Integration, A Range of Possibilities, the health planners toolkit; Sewing the seams, Report for service integration for Children Division; Brown, G et al; Setting the Course, A Framework for Integrating Addiction Treatment Services in Ontario and British Columbia’s government document, Establishing Collaborative Initiatives between Mental Health and Primary Care Services for Seniors, Canadian Collaborative Mental Health Initiative (Appendix 11, Literature Review). The literature also included recognized leaders in the field of service integration, Keith Provan and H. Brinton Milward from the US, Chris Miller and Yarsah Admad, England and closer to home Alan Cudmore and Janice Durbin, CAMH, Gina Browne and Valarie Grdisa. Valarie also met with the task group and was instrumental is helping the group focus their work. To date, no model of service integration for mental health and addictions was found in the literature. There are many examples where aspects of service integration exist. For example, within our own jurisdiction, the use of the Community Support Agreement by seven mental health and one addiction services promotes service integration for the client but does not impact integration at the systems level.

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Mississauga Halton Local Health Integration Network: With this finding, the task group proceeded to review the literature using the following criteria/guiding principles as a filter: • Client and family focused • Focused on population health • Evidence based practice • Promotes integration innovation • Promotes sustainability • Supports the health system • Demonstrates partnerships • Aligns with provincial directives The team used a 3 stage process to analyze the learning from this literature review and develop a report for each stage of the process: 1. A summary document (Appendix 12) of the analysis of each article, under the heading of the source and study location, the purpose and methodology used, key findings, limitations of the study and most importantly, what worked and what didn’t work. 2. A roll-up of the key components identified in the literature. This step helped in the process of the initial identification of common themes and clarifying what are the possible components of a service integration model. 3. Key Component Summary (Appendix 13) This document lists the key component, the pertinent details and the literature which support each component. This process helped to validate the findings under each heading. At each stage of this work, a report was made to the Mental Health & Addictions DPA team to ensure that our work was in synch with the other task groups and sharing our learning that was pertinent to the work of the other groups, in particular Service Inventory and Early wins. The initial components identified were: • Client and Family Centred • Collaborative Structures and Richness • Dynamic, flexible, includes community, physicians and hospitals • Process • Values/norms/cultures • Funding and Governance • Dimensions of Health • Clinical Outcomes

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Mississauga Halton Local Health Integration Network: As the literature review processed, these were expanded to include: • • • • • • • • • • • • • • • • Leadership Culture Values Social Capital Accountability Service Structures Measurement and Evaluation Legal Agreement Determinants of Health Re-engineering Protocol Roles and Responsibilities Education and training Linkages, networks and strategic alliances Shared services and Resources

At a full meeting of the MH&A DPA meeting, these components were reviewed and each component was assessed by individual team members to determine if the component was essential. This exercise narrowed the list of components through a best fit exercise. Enablers and Barriers to Service Integration The literature review also identified enablers and barriers to service integration and potential outcomes and deliverables. Enablers Communications Resources – staff, funding Sharing resources psychiatrist, HR Barriers Resistance to change Silos – hospitals, physicians, community services Philosophical differences Bureaucracy Competitive mind sets Outcome/deliverables Seamless service Client centered MH &A system: Timely access and appropriate use of a full range of services Fewer service interruptions Increased continuity of care Focus on client resilience and assets Client choice and satisfaction

Transportation

Fear of loss of autonomy, power, jobs, identity

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Mississauga Halton Local Health Integration Network: Enablers Education and training – collaborative skills, team building, engaging staff Information Technology Barriers Time to implement and create real shift the system Secure information – sharing info, confidentiality Geographic – large, diverse area (urban/rural Lack of evidence that integration results in improved client outcomes Current relationships and past history Can’t be forced, must have buy in Outcome/deliverables Demonstration projects to test components Common record and documents

Family doctors and Family Health Teams as possible hubs Health Promotion and Advocacy Dimensions of Health – Housing, income Current networks and linkages - relationships and past history

In addition, the Best Practice task group reviewed Ontario’s Chronic Disease Prevention and Management Framework to determine the synergy between the components. Many similarities were noted and there are opportunities to promote further alignment with the use of the logic model developed by the Centers for Disease Control.

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Mississauga Halton Local Health Integration Network:

Early Wins Task Group:
The Approach: The Team: Membership included Lee Helmer (Task Team Lead), Sandy Milakovic, Charlene Winger, Diane Doherty, Laurie Ridler , Susan Downing and Sherry Woods. Early Wins are defined as early integration opportunities or ideas that may or may not require additional resources, leveraging successful ideas or pilot projects in the community and exploring their expansion across the LHIN. Early wins advance the work of the DPA teams and are tangible and achievable within 6 months of approval to proceed. Proposals must demonstrate measurable outcomes that make a difference with respect to improved access, availability of services, quality improvements, sustainability, and/ or improved co-ordination and communications. Focus and Objectives Our goal was to review opportunities based upon ideas/pilot projects that presented indicators of successful integration (not duplication) of mental health and concurrent disorder services, that would: • place individuals with mental illness and their families/significant others at the centre of the system, • focus on streamlining access, and • • create greater accountability. Early Wins were to be considered on the basis of leveraging current partnerships, or to develop new ones to enhance coordination of services. Coordination, partnering, and integration were key objectives when considering ideas and pilot projects. Process: A series of Task Group meetings were held between November 07 and February 08 with five specific ideas being highlighted. These were : • Community information packages regarding mental health services for family members and consumers in crisis; said packages to be automatically provided by Emergency Room staff, and also distributed through physicians, mental health service providers, etc. Formal identification of funded Committees/Networks within LHIN6 within the existing data base of mental health and addictions

•

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Mississauga Halton Local Health Integration Network: • • Implementing a Common Recovery Approach Peer Support - establish means to enhance collaboration/coordination of Peer Support Services through the development of comprehensive services throughout LHIN6, with common expectations of the credentials/expertise of peer support. Implement a common screening tool across LHIN6 for Concurrent Disorders. Addictions - To increase the profile of addictions and its relation to mental health through the inclusion of addiction-specific groups, services and information in as many other general mental health initiatives as possible.

• •

As a result of these discussions the following Early Wins will be directed to the Mississauga Halton LHIN for their review and consideration: • Concurrent Disorders Partnership • Back Room Function Partnership • Community Information Packages for family members and consumers in crisis • Mental Health and Addictions Training and Development for Family Physicians (See Appendix 14-17)

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Mississauga Halton Local Health Integration Network:

Strengths, Weakness, Opportunities and Threats:
The Approach: Each of the task teams conducted their own assessment of strengths, weaknesses, opportunities and threats (SWOT’s) from the lens of their team’s objective. It was decided that completing this task on a per team basis would ensure that we looked at our SWOT’s in a more refined manner rather than a full team crating the list of SWOT’s. The following summarizes those discussions. Task Group: Best Practices From the perspective of Best Practices, the group highlighted the important influences affecting the Mississauga Halton LHIN Mental Health and Addictions Services.
STRENGTHS
•

WEAKNESSES
•

OPPORTUNITIES
•

THREATS
•

•

•

• •

LHIN Structure to provide leadership Monitoring processes in place LHIN in position to create local policy Willingness for cooperation Signed agreements with MOHLTC

•

•

•

•

Silo mentality at the leadership and board level Lack of consistent definitions – MIS, WERs No provincial or local connection to the MH Commission of Canada Competition for funding undermines collaboration Long waitlists for case management services

•

• •

•

Develop Leaders / change agents at all levels of MH&A organizations Develop a balanced score card Develop local policies Reward collaborative initiatives Exchange of resources and participation in joint ventures

•

•

• •

Silo mentality across Ministries and LHINs Lack of resources to evaluate measurement and evaluation tools Policies could be imposed at the Provincial level Privatization of health care Lack of funding to promote integrated services

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Mississauga Halton Local Health Integration Network: Task Group: Community Engagement Using inputs from across the community, including 589 completed surveys; the group presented the key factors affecting the Mississauga Halton LHIN Mental Health and Addictions Services.
STRENGTHS
• •

WEAKNESSES
• •

OPPORTUNITIES
•

THREATS
• •

•

• • • •

Caring providers 1 to 1 interaction – quality, consistency, flexibility Holistic / client centered health focus Peer support Family involvement Diversity of services Psycho-Ed programs (support, prevention, promotion)

•

• •

Wait times Barriers to access – no information, inflexible hours, criteria, transportation Assessment & discharge revolving door, not flexible, detailed or longterm Ethno cultural relevance Housing

•

•

• •

• •

Centralized Access: Single Common Intake (one door) & central contact Partnerships with existing services to facilitate access Develop care pathways for mental health and addictions Partnering with other DPATs Integrate primary and psychiatric care Health promotion / prevention Guiding Principle: Never abandon or isolate a client

•

•

•

Fragmentation Record Keeping - lag in adopting EHR (electronic health records) Societal devaluation of caretakers Poor remuneration for many workers Demographic and population fluctuations change demand for services

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Mississauga Halton Local Health Integration Network: Task Group: Financial Analysis The following key points highlight those variables affecting the Mississauga Halton LHIN Mental Health and Addictions Services from a financial perspective.
STRENGTHS
• • •

WEAKNESSES

OPPORTUNITIES
• • •

THREATS
•

People • Willingness to do • the work MIS compliance •
• •

Data integrity Lack of consistency Lack of human resources Comparisons not possible Cross boundary reporting

•

•

Standardize data collection Define functional centres Create easily retrieved data system Allow reallocation of dollars between budget lines Multi-year funding

•

•

•

•

Analysis during growth period not reflective Vulnerability re MIS staff leaving (MIS is complex) Quantitative data does not capture complexity Inaccurate data prevents accurate analysis / advocacy Service demands outstripping supply

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Mississauga Halton Local Health Integration Network: Task Group: Inventory of Services Using an Inventory of Services perspective, the group highlighted the important influences affecting the Mississauga Halton LHIN Mental Health and Addictions Services. These included:
STRENGTHS
•

WEAKNESSES
•

OPPORTUNITIES
•

THREATS
•

•

• • •

Values and attitudes of frontline staff Availability of specialized programs Use of recovery model principles Collaborations and partnerships Wealth of information and knowledge

•

•

•

Municipal / LHIN boundaries complicate inventory process Role drift / working above funded capacity camouflages gaps Community development initiatives not counted in MIS / CDS stats Clarification required for transfer payment agencies located in other LHINs

•

•

•

•

Standardize service descriptions across continuum Co-sharing of physical sites / program space Advocate new reporting requirements / categories Develop expertise in clinical intake / referral process Ensure services described reflect services delivered

•

• •

•

Gaps in services or gaps in information? Inconsistent maintenance of service information (eg. with ConnexOntario) Population growth Difficulty retaining staff w / expertise in special populations Stretching services beyond capacity is unsustainable

Task Group: Qualitative Data The following key points highlight those variables affecting the Mississauga Halton LHIN Mental Health and Addictions Services from a Qualitative Data perspective: STRENGTHS GREAT Team! Solid Population Stats • Good Hospital Stats • Community stats beginning • CIHI - Canada • LHIN personnel
• •

WEAKNESSES More Time No direct access to data • Only 2 years of data • No expertise • Missing Data • Gaps in data
• •

OPPORTUNITIES To develop system • To provide knowledge transfer • To ensure consistency • Eliminate error and bias • Prevalence data
•

THREATS • TIME! • Unreliable data • Force required to make changes • Mental Health and Addictions not a priority

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Mississauga Halton Local Health Integration Network: Task Group: Early Wins Viewing the SWOT analysis from the perspective of Early Wins, the following points are those key highlights identified as affecting the Mississauga Halton LHIN Mental Health and Addictions Services. STRENGTHS Existing resource information • Existing research data • Partnerships
•

WEAKNESSES Under-staffed Under-funded Philosophical conflicts • Silos
• • •

OPPORTUNITIES Greater collaboration • Engage multiethnic communities • Expand knowledge base
•

THREATS • Ensuring adequate staff training • Ensuring open dialogue • Existing stigmatization

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Mississauga Halton Local Health Integration Network: Summary To develop a summary of the SWOT’s and our assessment of those that demanded our attention, the full DPA team met to review all SWOT’s and assess their priorities. Fifteen themes emerged. All of the strengths, weaknesses, opportunities and threats were then aligned by theme using an affinity exercise approach. The group discussions resulted in the following consolidated list of key themes found within the SWOT affinity exercise that participants agreed were most important, and which will be used as direct inputs into the Key Components phase of the Best Fit Model. The following table summarizes the Strengths, Weaknesses, Opportunities and Threats (SWOT) in 15 fundamental themes. These themes suggest those factors affecting the effective and efficient delivery of the Mississauga Halton LHIN Mental Health and Addictions Services. The table categorizes the aggregate number of inputs from the affinity exercise and further highlights (in orange) those areas with the highest number of inputs within each theme. Themes Information Technology & Management Cultural Diversity Evaluation Accountability Existing Infrastructure / Methods Leadership Structure Strengths 1 2 3 1 10 8 2 4 Communication Partnerships / Collaboration Access to Resources People Resources Services Processes / Model / Policy / Procedures Innovation 15 8 8 8 10 11 Weaknesses 25 4 6 5 5 7 10 7 10 15* 16 8 0 11 13 10 11 10 7 13 5* 13* 7 12* Opportunities 9 7 1 Threats 3

8 4 8* Overriding theme (all inputs)

*Those themes that were consolidated into larger groupings are represented in the above table through the use of merged cells.

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Mississauga Halton Local Health Integration Network:

Figure 32 - Mississauga Halton LHIN Mental Health and Addictions SWOT Summary

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Mississauga Halton Local Health Integration Network:

Best Fit Exercise:
The Approach Once the Best Practice Task Team identified the proposed components of an integrated service delivery model each member of the DPA working group assessed each component to determine if they were indeed essential to a mental health and addictions model or important. The results of the assessment are as follows:

Component Assessment
Component Leadership Culture Policy, Protocol, Procedures, Processes Education and Training Determinants of Health Linkages, Networks, Strategic Alliances Measurement and Evaluation Accountability Service Structures Values Agreements Shared Services and Resources Legal Social Capital Re-engineering + Service Structure Protocol Roles and Responsibilities Essential 18 18 16 16 15 15 15 14 12 12 12 10 10 7 6 5 3 Important 1 0 2 1 4 3 3 4 9 7 7 9 9 11 13 14 15

It was agreed that the model must include those components that received high essential scores. It was also concluded that several of the components could be combined. To further understand the importance of the proposed components the team determined the effect each component would have on addressing the identified strengths, weaknesses, opportunities and threats (SWOT). Each component was scored using the following grades: • 3 = essential • 2 = important • 1 = needed but not that important 107 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: • 0 = no relationship

The SWOT lists used in this evaluation reflect the results of the SWOT exercise - See Figure 3 - Mississauga Halton LHIN Mental Health and Addictions SWOT Summary

STRENGTHS
PARTNERSHIPS AND COLLABORATIONS ( 15 ) PROCESSES, POLICIES & PROCEDURES (11) EXISTING INFRASTRUCTURE AND METHODS ( 10 ) L E A D E R S H I P SERVICES (10) ACCESS TO RESOURCES (8) PEOPLE (8) LEADERSHIP (8) RESOURCES (8) COMMUNICATION (4) EVALUATION (3) STRUCTURE (2) CULTURAL DIVERSITY (2) IT AND MANAGEMENT (1) ACCOUNTABILITY (1) INNOVATION (0)

3,2,1

0

For example: A score of 3 for partnerships and collaborations meant leadership was essential in the model for the identified strength of partnerships and collaborations to be effective and result in them actually occurring. This was a tedious exercise for each component was evaluated by all 15 strengths, weaknesses, opportunities and threats. Summary The summary of this evaluation, of each component, as it relates to supporting strengths, addressing a weakness, taking advantage of an opportunity and mitigating threats is as follows: The top 5 most essential components, based on their ranking are: • Leadership – mindset, at all levels, focused on positive outcomes, influential ability, champions, will carry out the mandate • Culture – top down embrace the concept of integration, trust, respect, welcoming, building relationships, collaboration, recovery oriented, key determinants of health • Service structures - meet specific population needs, not overly complex, shared services and resources, reduce exclusionary criteria, accessibility, streamlined access, comprehensive continuum of services and care 108 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: • • Shared services – client driven, shared care model, managing data, inputting data, analyzing data Social capital – shared knowledge, being part of the design, relational ties, recognizing people as a resource, strength from informal ties

These should be included in the design of our recommended model of service integration.

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Mississauga Halton Local Health Integration Network:

Current LHIN Wide Integration Projects:
There are a number of significant virtual integration projects already underway in our LHIN. The Mental Health and Addictions DPA team can learn a great deal from what is working and what is not working from these projects as it relates to moving forward with the Co-location Multi Disciplinary pilot and Virtual Integration Pilots. To say that we are not providing integrated services today would be inaccurate. We should expand these where possible and continue to integrate additional services where and when appropriate. Examples of some virtual integration projects are: 1. 2. 3. 4. 5. 6. 7. 8. Early Intervention in Psychosis Halton Concurrent Disorders (CD) Program Concurrent Disorders (CD) and Seniors Central West Eating Disorder Program (CWEDP) Halton Homes Program Intensive Case Management and Dual Diagnosis Housing and Support Peel / Supportive Housing Etobicoke York Region of Peel Street Outreach

(See Appendix 18-25)

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Mississauga Halton Local Health Integration Network:

The Mental Health and Addictions System Framework for Mississauga Halton: A Dynamic Framework
The goal of this framework is to illustrate the key concepts, principles and overarching operations that will be used to provide a seamless, accessible and responsive mental health and addictions system in Mississauga Halton. The framework captures ideas from the work of the Detailed Planning and Action Team (DPAT) of the MH LHIN including the development of the Project Charter, Vision, Mission, Logic Model and Best Practice Components. Our framework of the Mental Health and Addictions system in Mississauga Halton is one of an integrated, comprehensive, dynamically evolving system of service that revolves around the goal of positive client outcomes and recovery. The graphic representation of our system then, is shown as a disc circling an axis that represents positive client outcomes and recovery. Action on any of the segments of our system generates movement of vertical fluctuations of the various pie segments and rotations of the various layers that encircle the disc resulting in positive or negative vertical movement along the axis. If the overall movement of the framework is upwards on the axis, this indicates an increase in positive client outcomes and recovery. System Components are those that affect the entire system. Organization, Education, System Supports and Evaluation were identified from a list of over 15 key components explored in the literature. They represent the technical aspects of the system. The entire disc encircled or “held together” by a band that represents Leadership. Leadership is identified in the literature as crucial to successful systems, and is seen as integral to all system components. As such, it surrounds and permeates the entire framework. This Framework operates in an environment composed of four domains – Client, Family, Service Providers and Community. Functional Components represent relational aspects of the system – Trust, Choices, Respect, Equity, Opportunity, Inclusion and Support. Not only these values but the behavioural modes they lead to must be present in interpersonal relationships as well as in program and service outputs in order for energy to be generated within the framework. It is this energy that will fuel positive movement of the system.

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Mississauga Halton Local Health Integration Network:

Figure 33 – Mental Health and Addictions System Framework

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Mississauga Halton Local Health Integration Network:

Framework for Mental Health and Addictions System Integration

System  Components •Leadership •Organization •Education •Evaluation  •System Supports •Policies

Functional   Components •Inclusion •Choices •Supported •Respect •Trust •Equity •Opportunity

Figure 34 – Framework for Mental Health and Addictions System Integration

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Mississauga Halton Local Health Integration Network:

The Logic Model and its Application to the Work of the Mental Health and Addiction DPA Team
The Mental Health and Addictions DPA Team used a logic model to assist in the process of planning for an integrated mental health and addictions integrated service system. The logic model helped to develop a logical understanding between the functions in our system and changes we expect to see as a result of these functions. It also helped the DPA Team in developing a common understanding of mental health and addictions integrated service system. Finally, the logic model helped identify key issues and questions with respect to the mental health and addictions system that need to be evaluated.

Continuum of Care
A Continuum of Care for Mental Health and Addictions Services across the Mississauga Halton LHIN was also created. The Continuum is based on best practices for system level delivery, as defined by the Canadian Council on Health Services Accreditation (CCHSA). The CCHSA defines a continuum of care as "an integrated and seamless system of settings, services, service providers, and service levels to meet the needs of clients or defined populations". The Continuum provides a framework to match resources to need, foster continuity of care, and identify opportunities for service improvement. This framework is in part based on the services and programs identified by the Inventory of Services Task Group, and can be beneficial in guiding system level service planning.

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Mississauga Halton Local Health Integration Network:

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Mississauga Halton Local Health Integration Network:

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Mississauga Halton Local Health Integration Network:

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Mississauga Halton Local Health Integration Network:

Mississauga/Halton LHIN MENTAL HEALTH and ADDICTIONS CONTINUUM OF CARE
Prevention & Promotion Early Intervention
Youth Substance Abuse Program (Peel) Rainbow Adult Day Centre Peel Children’s Centre FACT Peel (CAMH) Shared Care, Child and Adolesent; Adult FACT Peel+ CMHA Addiction & Concurrent Disorder Centre (CVH) Peel Children's Centre (Children Mental Health) Assessment Clinic (THC) Resource Centre, CMHA Peel PAARC ADAPT CWEDP-HHS Phoenix ProgramEIP SHIP

Crisis Intervention
Mobile Crisis of Peel Crisis Response Service (PCC) Gerstein Centre (E) Reconnect Mental Health Services Crisis Intervention Team, CVH, HHC, THC, HHS ObsessiveCompulsive Disorder Helpline Interim Place South Distress Centre Peel Distress Centre Halton Kids Help Phone Warm line (E) COAST Halton and Peel ROCK CRISIS LINE Interim Place (E) Safe Beds , CMHA Halton Safe Beds (SHIP) Our Place (Peel)

Acute Inpatient Residential

Basic Treatment (Focused Core Services)
Mental Health Clinics (THC/CVH/HHS) Mental Health Clinics (E) Child & Adolescent Mental Health Services (THC & HHS) Community Care Access Centres CAMH START program (CVH) Interim Place Child and Family Clinic Children’s Treatment Centre Reconnect Mental Health Services (E) Kinark Child & Family Services ●FACT Peel Day Program HHS Seniors' Mental Health Clinics HHS Seniors Outreach Services Reconnect (E) Addiction & Concurrent Disorders Progam (CVH & HHS) Community Support and Treatment Teams, Acton & Malton NHMHC Aberfoyle Clinic Out pt. Eating Disorder Program Region of Peel Street Outreach Team

Family Awarness & Drug Education Centre Homewood Community Alcohol & Drug Service PAARC Peel Children’s Centre Youth Substance Abuse Program (Peel) Interim Place Mental Health & Justice Prevention Program (E) Youth Net, CMHA Peel Halton Health Dept. Youth Net Halton Elizabeth Fry Society John Howard Society

Humber Regional River Hospital Inpatient Mental Health Units (CVH, HHC & THC) Inpt. Child & Adolescent Unit, HHS Centre for Addiction and Mental Health Medical Detoxification, CVH

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Mississauga/Halton LHIN MENTAL HEALTH and ADDICTIONS CONTINUUM OF CARE
Specialized Treatment Recovery Case Management
Victim Services of Peel Eden United Church Food Path The Open Door

Sustain and Support
Supportive Housing in Peel Community Living, Mississauga, Halton Supportive Housing Etobicoke/York Housing and Support in Peel Peel Living PAARC The Compass Interim Place Ontario Works CAST

Familly Awarness & Drug Education Centre FACT Peel (CAMH) ACTT Team

Associated Youth Services Community Mental Health Services (THC)

Schizophrenia Program (CVH) Rainbow Adult Day Centre PAARC Alzheimer Society of Peel George Hull Centre Peel Halton Acquired Brain Injury Services India Rainbow Community Services Concurrent Disorders Partnership

Dual Diagnosis Day Program (E) Children’s Treatment Centres Halton Children's Aid Peel Children’s Centre Psychogeriatric Resource Consultants Associated Youth Peel capacity Network,PCCN Jean Tweed Centre (E) Child and Family Clinic

CBT (cognitive behaviour therapy) CMHA Eating Disorders Program (CVH) Addiction Med. Specialists (CVH) Mental Health & Justice (CMHA Peel) START Program (CVH) ADAPT Hope Place (Halton) YSAP NHMHC (CD, DD, Psychosis) General Psychiatry Safe Beds Community Treatment Orders (CVH, THC)

Addiction & Concurrent Disorders Centre (CHV) Dixie Bloor Neighbourhood Drop-In Rehabilitation Day Program (E) TEACH ADAPT Eden Place (Consumer Survivor Support Network) CMHA Peel Schizophrenia Society of Ontario ●FACT Peel

Salvation Army Rainbow Adult Day Centre ReLinC Services (THC) Access to Recovery (CMHA) SHIP Summit Housing Reconnect (E) ADAPT CMHA Halton Court Diversion

ODSP (Peel) Salvation Army India Rainbow Community Services Ontario March of Dimes Peel Halton Acquired Brain Injury Services Victorian Order of Nurses (VON) Legal Aid (Peel) Associated Youth Services Our Place (Peel) Support and Housing Halton Grace House LAMP - Among Friends (E) FAME Schizophrenia Program (CVH) YSAP ●FACT Peel +

North Halton Mental Health Clinic CMHA Halton Release from Custody ●FACT Peel and FACT Peel+

PAR Clubhouse FAME Ontario Works (Peel) Red Cross Emergency Fund YSAP Destination Café Halton Geriatric Mental Health & Outreach PAARC HASP - OW TEACH Peer Support Summit Housing Outreach

Schizophrenia Society of Ontario STRIDE Links 2 Care Community Education CMHA Survivors of Suicide - CMHA Halton Support Housing - Halton NHMHC

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Our Recommendation: An Integrated Service Delivery Model
The DPA working group worked in four sub groups to discuss and design possible models of what the future of delivering integrated mental health and addiction services could look like. Three groups drew similar models that were characterized by a central hub and spoke and the fourth group drew a more pillar like representation. A model was then prepared based on these diagrams, coupled with conversation. On the following pages the proposed model is depicted and explained. Some key elements of the proposed model are: • It will take several years to develop and implement the model • This will be a flexible, iterative process, subject to change and redirect where appropriate, for it is impossible to address all of the facets of a model at this point in development nor finalize the components • This model is definitely not cast in stone • Co-location of services in each community as appropriate, e.g., each site may have a different array of services depending on local circumstances and needs • Virtual integration could also co-exist with the co-locations, or stand alone, in any of the LHIN communities. • It may not make sense for all agencies or services to be co- located at a satellite office or the central hub • There may be some specialized services that will be offered via itinerant specialists, e.g., eating disorders, psychiatry, OT • A client can enter the system in any geographic location, whether virtual or colocated • The central hub will be comprised of a number of administrative and management functions, again not all agencies may be represented. • This does not infer governance changes • Existing agencies will retain their governance • Existing agencies may decide to co-locate if appropriate – no governance changes would occur • In year one, co-locating natural partners where appropriate, as defined by the agencies in a position to co-locate, would initiate discovery and allow for a pilot • Virtual partners who exist today will be encouraged to continue with their integration activities • Learnings from co-location and virtual integration will continue to set the course for future model development • The model embraces the concept of outreach as required • The model depicts linkages to FHT, GP, NP, Hospitals, FHG’s – this does not represent a list of all potential service linkages, it merely illustrates the concept of linkages

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Year one work plan for a Co-location Multidisciplinary Model
Through co-location or virtually integrated services, a multidisciplinary team of skilled and diverse professionals, can offer shared service to all through any point of entry into the mental health and addictions environment. This would not be stand alone. There must be solid connections to primary health care, for example, through Family Health Teams, Family Health Groups, Community Health Centres etc. Once the DPA team presents to the Integrated Advisory Group the following activities will be initiated in the short term, either concurrently or independently: 1. Development and implementation of a “ road show” to share and disseminate the recommendation securing “buy-in” and endorsement, as well as additional advice and guidance. Target: June and July 08: To ensure key stakeholders are aware of the integrated service delivery recommendation for mental health and addictions the team will contact and present to the following bodies: • The Mississauga Halton LHIN Board of Directors • Health Care Leaders Collaborative • Health Professionals Advisory Committee • The LHIN CIO • The CEO’s of the three hospitals • Grand rounds at the three hospitals • All Mental Health and Addictions agencies in the Mississauga Halton LHIN at the executive and board level, including public health, the regions etc. • Family health teams, family health groups, primary care physicians etc. • LHIN psychiatrists, psychiatric nurses • All attendees of the 2 community engagement nights held in the month of January in Milton and Mississauga 2. Transformation of the Detailed Planning and Action team into a new planning and action committee/group Target: June 2008 • New name of the committee - System Integration Group Mental Health and Addictions (SIGMHA) • The existing Mental Health and Addictions Network will continue to meet • Team membership to be reviewed and assessed • Terms of reference to be established • Assign co-leads and their roles • Role of the current resource panel • Commitment change from volunteer to “part of the job” 124 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: • • • • • • LHIN membership on the committee Project management to be determined Development of task teams with membership from key stakeholders on a dedicated basis vs volunteers Determine leadership for each task team Develop the year one work plan and deliverables Establish evaluation processes, tracking and measurement

3. Task teams to be established to develop and implement the year one strategies and deliverables in specific areas. Target: June 2008 The suggested teams would/could be: • Co-location pilot project • Community engagement activities • Early wins • Family and client advisory • Virtual pilot project • Community engagement activities • Early wins • Family and client advisory • Education and training program X LHIN • Additional integration early wins • Measurement, tracking and evaluation 4. Initiate ongoing information and implementation sessions with the LHIN psychiatrists and consider the establishment of a LHIN wide network that would assist in the rollout. 5. Enhance links to the other DPA teams to ensure strategic synergies are explored and developed. 6. The current Mississauga Halton Mental Health and Addictions Network will continue to meet bi-annually. Many members of this Network to sit on SIGMHA as well.

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Conclusions:
We need to continue to examine new and innovative approaches to improving access and navigating the system, at the same time focusing on the needs of the client, regardless of age, culture, and their family members. This recommendation starts with the issuance of this report and the development of a year one going forward strategy and action plan, signifying the beginning of change. Everyone who works in this new integrated service delivery system should work towards being system navigators helping people navigate through the system. The logic model presented in this report illustrates the desired outcomes that will materialize over time as we put this recommendation into action. To see this recommendation realized will take time, energy, dedication and support from the whole mental health and addictions stakeholders including the mental health and addictions agencies, hospitals, primary care physicians and community leaders. The task teams will focus on the development and implementation of the year one plan and deliverables, assess and measure results, determine where changes need to occur, track successes and learn from what works and what doesn’t, set the future course and change where and when appropriate. Access to the right service, at the right time, at the right place, with the right professional is integral to the success of the recommendation. Whatever the level of mental illness or addictions, moderate to severe, there will be a place for these individuals to enter the system and receive proper care. No wrong door will be the norm and not the exception in this integrated, multidisciplinary, collaborative care system. Whether a client or their family require information, referral, assessment, counselling, case management, education, support and other services, there will be no wrong door to gain entry to the system of professionals in their home neighbourhood or anywhere in the LHIH, regardless of which service a client initially contacts. A seamless delivery of services will facilitate service linkage throughout the LHIN, whether by way of service co-location or through virtually integrated services. To the client and family, this approach to service organization results in an invisible process of inter-service or inter-professional referrals. Links to primary care are essential for a client’s needs may be complex and not reside only in a mental health or addictions domain. Shared care will address any co-morbidity needs with efficient referral within an integrated system to best meet the client’s needs for as we all know the mind and the body are connected and their synergy is crucial to recovery. The development of reciprocal relationships through linkages with primary care providers will further strengthen seamless service delivery and options of quality patient care from the most appropriate health care provider. All disciplines and allied care professionals will be connected. The ball will be carried by the integrated system 126 Mental Health and Addictions Detailed Planning and Action Team Report

Mississauga Halton Local Health Integration Network: and not one individual. No one agency or professional will be overwhelmed; instead they are all connected, sharing information and treatment. Service delivery should be client and family driven as opposed to provider driven. It is not about what the provider brings to the client, it is about understanding what the client and family needs are and then finding the right provider to bring that to the client and their family. A chain is strongest when the links are bound together with no breaks and no damage. It’s important to get the services to the client rather than the client to the services. Community based, flexible services will result when the links are joined and functioning as a whole through collaboration.

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Acknowledgments:
The DPA team and the Mississauga Halton LHIN are grateful to all of the individuals, agencies, organizations, community members, clients and families that participated in the entire process, end to end, helping us reach a recommendation that we know will “make a difference”. A huge task has been accomplished with great enthusiasm and devotion. We are thankful for this for we all know that we volunteered our time to this project without hesitation, never anticipating the demands and at the same time the rewards that would result. Working relationships have formed that were not there at the outset. Professional partnerships are evolving; connections are more solid on behalf of the entire LHIN, not just a single organization or agency. These are significant outcomes from a process that was designed to develop a model. Each and every member of the DPA team, the working group, the resource panel, the co-leads, LHIN members etc. have all contributed endless hours of their time and energy supporting the process and the development of the model. The dedication to the mandate was solid and did not waver. Without this the accomplishments to date would not have materialized in the short time that they did. Special thanks to everyone who helped organize the many meetings, providing technical and visual support, creating and implementing survey tools and analysis, assisting with the administration of the project, researching data and providing specific analysis, formatting and design, and the many reviews and assessments that were necessary to provide guidance propelling the team along their path. In particular the notables are: • Sandy Milakovic and Ian Stewart for their constant leadership and guidance • The agencies and organizations at all levels of management for supporting their employees time, effort and commitment to the process • The following MH LHIN team members: o Diane Koz, Senior Lead Health Systems Development o Marco Marchitto, Planner o Mary Lehto, LHIN Administration o Thiru Appasamy, Senior Lead Information o Dwain Dolland, Project Management Support o each of the MH LHIN Senior Leads Health System Development o Angela Jacobs, Senior Lead Performance and Integration – MH&A o the LHIN Senior Management team • The Integration Advisory Group (IAG) • The many community members who attended our engagement sessions, filled in the surveys and provided freely of their time, their comments and their desire to see change Thank You! 128 Mental Health and Addictions Detailed Planning and Action Team Report