Planning mental health services: Background and key issues

Deinstitutionalisation in Canada produced a shifr in locus of care from provincial psychiatric hospitals to general hospital psychiatric units. As a result of this approach, a number of key planning issues have emerged that must provinces are attempting to address.

Planning Mental Health Services: Background and Key Issues Donald Wasylenki, Paula Goering, Eric Macnaughton

The past thirty years have seen dramatic changes in the treatment of mental disorders in Canada. The philosophy of deinstitutionalization initially was applied to a shift in locus of care from provincial psychiatric hospitals to psychiatric units in general hospitals. In 1964 the Royal Commission on Health Services recommended that “provinces should move with all due speed to remove all patients receiving or capable of receiving active care from mental hospitals and transfer them to general hospitals” (Richman, 1983). As a result of this philosophy, between 1960 and 1976 the bed capacity of Canadian mental hospitals decreased from 47,633 to 15,Ol I , while the bed capacity of general hospital psychiatric units increased from 844 to 5,836 (hchman, 1983).

Unfortunately, the new general hospital psychiatric units did not provide care for patients suffering from major mental disorders. Rather, these units discovered a new patient population-one that was less seriously ill and that pre- viously had not received inpatient psychiatric care. In 1978 McKinsey and Company reviewed the roles of three large psychiatric hospitals in metropolitan Toronto. In comparing public psychiatric hospitals and general hospital psychiatric units, they discovered that each served a different patient population. Their observations supported the belief of health care providers, both in and outside public psychiatric hospitals, that psychiatric hospitals did indeed serve more dif- ficult patients. A two-tiered system of treatment and care had been created.

Portions of this chapter appeared in D. Wasylenki, P Goering, and E. Macnaughton, “Plan- ning Mental Health Services: I. Background and Key Issues.” Canadianlournal of Psychiatry, 1992,37 ( 3 ) , 199-206

NEW DIRECT~ONS FOR MENTAL HEALTH StRVICES. no 61. Spring 1994 OJossey-Bars Publishcrs 2 1

22 MENTAL HEALTH C A R E IN C A N A D A

As provincial psychiatric hospitals with far fewer resources struggled to care for the same severely ill patient population, readmission rates climbed from 25 to 75 percent. This is often described as the revolving door syndrome. Other indicators of system failure have been documented throughout Canada. Many patients with severe mental illnesses remain symptomatic after discharge from the hospital or while living in the community (Wasylenki and others, 1985); large numbers of such patients are unable to function in any meaning- ful social or occupational role (Barnes and Toews, 1988); 20 to 30 percent of homeless individuals have been identified as mentally ill and in need of treatment (Mercier and Fournier, 1989); and significant numbers of severely mentally ill individuals occupy detention centers and jails (Finlayson and others, 1983).

In recognition of the need to provide additional support for those disabled by severe mental illnesses, provincial governments in the 1970s began to fund community mental health programs. In Ontario, for example, the Adult Com- munity Mental Health Program of the Ministry of Health was established in 1976, and by 1990 there were more than 350 community mental health programs throughout the province, costing roughly $120 million (Ontario Min- istry of Health, 1991). This cost represents 5 to 6 percent of the total mental health budget, which is heavily weighted on the side of institutional care. Unfortunately, many of these programs have drifted away from their original mandate to serve the severely mentally ill.

Lack of coordination among the three major sectors of treatment services has emerged as a major impediment to service planning and delivery in Canada. Provincial psychiatric hospitals, psychiatric units in general hospitals, and community mental health programs operate in isolation from one another, resulting in a situation best described as three solitudes. Psychiatric hospitals remain separate from other health care facilities and programs and from the communities they serve. General hospital psychiatric units function autonomously; and, although there has been some increase in numbers of dif- ficult-to-manage patients, these hospitals continue to be selective in the patients they admit and treat. Community mental health programs tend to be relatively small and to possess little influence or presence within the health care system, and they are overburdened by demand for service. The lack of coordination among the three solitudes leads to fragmentation and lack of continuity and to the absence of accountability for the provision of comprehensive care.

Key Issues

Many of the issues raised by attempts to deal with the problems of mental health service delivery are complex. However, a prerequisite to effective planning is that they be recognized and that decisions be taken that are in keeping with current knowledge. Current provincial initiatives in Canada (see Chapter

BACKGROUND AND KEY ISSUES 23

Four) bear a striking degree of similarity to one another with regard to the key issues discussed in this section.

Severe Mental Illness. People suffering from severe mental ihesses- those who have been most disadvantaged by deinstitutionalization-make up the traditional population served by provincial psychiatric hospitals. They are the most disabled of all psychiatric patients, and yet they receive the least effective treatment and care. Increasingly, they have become the target population for mental health programs in Canada.

Severe mental illnesses are defined by diagnosis, disability, and duration (Schinnar, Rothbard, Kanter, and Jung, 1990). Diagnostically, they usually include schizophrenic disorders, major affective disorders, and severe person- ality disorders. In a subpopulation of persons suffering from these disorders, significant disability occurs to the extent that individuals are unable to function in normal social and vocational roles. And finally, a further subpopulation of those who are ill and disabled are chronically afflicted, as measured by duration of symptoms, length of disability, and hospitalization episodes. These three overlapping dimensions-diagnosis, disability, and duration-provide a framework by which to delineate the population of severely, persistently mentally ill people in any jurisdiction. Planning initiatives targeting this group should expect to engage 0.5 to 1 percent of the adult population residing in any geo- graphic area (Ontario Ministry of Health, 1990).

General Hospital Psychiatric Units. General hospital psychiatric units in Canada are ideally suited to provide intensive, short-term treatment during periods of acute relapse in people suffering from severe mental illnesses. This care should consist of rapid assessment and diagnosis, initiation of treatment, and, most important, development or acknowledgment of a comprehensive discharge plan. Studies have established that most psychiatric patients who require hospital treatment can be treated effectively in short-term settings and that the older pattern of longer-term hospitalization carries with it no added advantages (Talbott and Glick, 1986). In terms of symptomatology, rehospi- talization, and quality of life after discharge, short-term treatment in a general hospital setting is most advantageous. I t must be recognized, however, that in order to enable general hospitals to assume this role, certain requirements must be met. In some areas, more general hospital beds will be necessary, for example, and adequate facilities must be available for the emergency assessment of psychotic patients. A general hospital psychiatric unit also requires a close working relationship with both a coordinated network of community support services and a regional facility. In order to enhance their ability to deal with acutely disturbed and disturbing patients, general hospital psychiatric units also should develop intensive-care units, day hospital programs, urgent clin- ics, and adequate emergency services. In addition, each general hospital psychiatric unit should provide ambulatory psychiatric services. These services should be well connected to the network of support services in the hospital’s community. It is preferable for psychiatrists working in these ambulatory set-

24 MENTAL HEALTH CARE I N CANADA

tings to have admitting privileges to crisis, emergency, and general psychiatric beds so as to provide continuity of medical and psychiatric management.

Provincial Psychiatric Hospitals. As community- and general hospital-based services continue to evolve, the role of the provincial psychiatric hospital in Canada is increasingly seen as that of a regional, tertiary-care facility. Such hospitals should provide highly specialized treatment programs for those groups of patients within a given region who require longer-term inpatient care. Patients should reach the provincial psychiatric hospital only after careful screening in the community- or general hospital-based system of care.

Recently, empirical data have been used to attempt to delineate the tertiary-care role of the regional mental hospital within an integrated system of care. Even where a range of short-term general hospital psychiatric unit services and community support services are available, a number of patients will remain whose needs are best met by a regional facility. Gudeman and Shore (19841, in the United States, divide these patients into five groups as follows: elderly patients suffering from dementia, psychosis, and medical illnesses; mentally retarded patients with psychiatric disorders; brain-damaged patients with serious loss of impulse control; patients with schizophrenia who are chronically psychotic, assaultive, or suicidal; and chronic schizophrenic patients who exhibit behavior that makes them vulnerable to exploitation or is unacceptable even in enlightened communities. They suggest that there are at least 15 persons per 100,000 in these five categories. This figure indicates a need for fewer psychiatric hospital beds than are now available in most Cana- dian jurisdictions, but only if adequate general hospital programs and community support services are available. Using this standard, provincial psychiatric hospitals could provide more appropriate care for patients with special needs, allowing other components of the system to be used more effectively to treat patients with acute illnesses or acute exacerbations of chronic illnesses or to provide community-based rehabilitation.

Community Support Services. In the United States, i t has been esti- mated that between 50 and 75 percent of readmissions to the hospital could be avoided if comprehensive community support services were available (Bas- suk and Gerson, 1978). In any comprehensive, integrated system of care, many assessment and treatment programs and most programs that are rehabilitative and that address primarily disability should be located in the community, not in hospital-based environments.

Anthony and Blanch (1989) recently summarized the developing base of research relevant to community support systems (CSS). They noted that reviews of a variety of research studies report that persons with severe and long-term mental illnesses can be helped in the community without undergo- ing long-term hospitalization. Components of the current CSS framework in the United States include client identification and outreach, mental health treatment, health and dental services, crisis services, housing assistance, income support and entitlements, peer support, family and community sup-


port, rehabilitation services, protection and advisory services, case management, and service integration. Similar community support services are described in most provincial planning documents in Canada (see Chapter Four).

This is because universal, comprehensive health insurance removes financial bamers to such care, and thus the primary-care sector may be expected to fulfill an important function. In the Canadian context, particular attention should be paid to the role of the primary-care physician as provider of community-based medical and psychiatric services. At this time, however, little is known about the extent to which this is a major component of care or about the determinants and outcomes of care provided by this sector.

Continuity of Care. Continuity of care refers to the need to ensure the orderly, uninterrupted movement of patients among the diverse elements of the service system (Bachrach, 1981). Current Canadian strategies to reorganize services for the severely mentally ill give high priority to the creation of mechanisms to guarantee this very important qualitative aspect of service delivery All of the service structures in the world will be ineffective if patients have no access to them or if they do not meet patient needs.

Case management is viewed as the principal process, at the interface between client and services, by which to achieve continuity of care. An important aspect of the role of the case manager is that person’s acceptance of responsibility for as long as the client requires services. Case-management functions include relationship building, functional assessment, planning, linking to services, monitoring progress, and advocating on behalf of clients. Outreach and the teaching of crisis intervention functions and skills are also often included in the case-management role in relation to severely mentally ill individuals.

It is important to realize that case management not only provides coordination of services but is also a mode of therapy in itself (Harris and Bergman, 1987). The process of clinical case management can enhance a client’s capac- ities to cope and function. Whereas initially the case manager may perform various tasks on a client’s behalf, eventually the client learns to assume these activities. This is achieved through a gradual internalization of case-management functions, which allows clients to become their own continuity-of-care agents. In order to reach this objective, well-organized, well-staffed programs must be developed at the core of any service delivery system to provide front- line integration and continuity. Province-wide case-management systems have yet to be developed in Canada.

Co-Morbidity. Co-morbidity refers to the occurrence of severe mental illnesses in individuals who also suffer from other disabling conditions or who are additionally vulnerable because of life-stage processes or other issues.

In a Canadian sample, roughly 40 percent of treated patients suffering from severe mental illnesses were found also to suffer from substance abuse disorders (Toner and others, 1992). The difficulty that this combination poses is twofold. First, from the patient’s point of view, accessibility to substance

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abuse treatment programs may be denied to those with a diagnosed mental disorder, and programs for patients with mental disorders may not accept substance abusers. Second, from the service provider’s point of view, there are very few models of effective programs that can be emulated and adapted for this particular patient subpopulation.

A significant proportion of developmentally handicapped individuals also suffer from severe mental illnesses. Often they become caught up in the same catch-22 situation that faces substance abusers among the chronically mentally ill. There is increasing recognition that this group requires specialized services both at the case-management and comprehensive programming levels.

Other groups that require special attention because of the coexistence of states of vulnerability include elderly people with severe mental illnesses, tran- sitional youth, patients with coexisting physical and psychiatric illnesses or disabilities, and severely mentally ill patients who find themselves caught up in the criminal justice system. The existence of these doubly at-risk subpopu- lations requires that case-management and crisis intervention systems possess both generalized and specialized expertise and that service delivery systems provide specialized programs or possess the capacity to link individuals to appropriate programs in other jurisdictions.

Consumerism. Too often in the past, the needs and wishes of consumers have been ignored by service providers, with the result that many mental health services in Canada have been neither accepted nor effective. Research demonstrating that professionals and consumers of mental health services have very different perspectives (Goering, Paduchak, and Durbin, 1990) challenges earlier beliefs that clients are unable to define their own needs realistically. In order to develop relevant and useful services, mechanisms must be created to expand consumer involvement at all levels. This involvement should include participation in planning, operational roles in more traditional service delivery systems, and an increase in consumer-driven initiatives. These initiatives may include self-help and peer-support programs established to complement or to provide alternatives to traditional service delivery models. Innovative consumer-driven programs should be evaluated to identify strengths and weak- nesses in relation to the particular needs of their prospective clients.

The families of severely mentally ill individuals are another important emerging constituency in Canada. Although family members often bring a point of view that is somewhat different from those of consumer groups, services should not be developed without their input. Involvement of family members in various initiatives has the potential to draw in the larger community: people who have difficulty identifymg with manifestly disabled individuals may more easily provide support-personal and financial-in response to appeals from concerned family members. In general, family groups tend to advocate for the interests of the most severely disabled client groups.

The Importance of Integration. What has been lost in the move from institutional- to community-based care is overall accountability. In most Cana-


dian jurisdictions, there is no system of responsibility in place. Care has become poorly organized and inadequately coordinated-and, as a result, inef- ficient and ineffective. In order to reinstate responsibility and accountability, Canada should unify the administration of programs for the severely mentally ill at the regional level. To that end, a principal objective of current planning should be the creation of comprehensive, balanced systems of care with administrative mechanisms in place to integrate psychiatric hospital, general hospital, community mental health, and other services.

One of the principal advantages of integration is the opportunity to real- locate fiscal and human resources in order to create more balanced service delivery systems-in other words, to increase the relatively small proportion of resources available for community-based services. This may involve the development of strategies to downscale aging psychiatric hospitals over time and to flow funds to alternative services. It also may involve giving front-line hospital-based service providers latitude to recommend and implement community-based service adaptations. The challenge is to view the issue of balance and the reallocation of resources as an opportunity for improvement and col- laboration.

The most effective mechanism by which to achieve integration of services is the mental health authority. This may be a government agency or a nonprofit corporation. In either case, it oversees services through a variety of approaches, one of the most promising of which is the purchase of services from local provider agencies. This allows the authority to establish and monitor standards and at the same time respect local structures and processes and local goals and objectives in relation to the patient population. Thus, although the authority integrates services at the administrative level, it does not necessarily dictate how services are to be provided or who should provide the services. This has the potential to allow for creative and culturally specific service development at the local level.

Discussion

In Canada and elsewhere, there has been significant growth in knowledge with regard to severe mental illness without corresponding improvement in care. Unfortunately, until recently, planning mental health services has been a low priority for most provincial governments in Canada, and resource allocation has remained at a low level in relation to need. In general, in the postdeinsti- tutionalization period, reform has been resisted and change has been incre- mental, with little or no evidence of real progress. In addition, service delivery has not been an area of concentrated academic interest in Canadian depart- ments of psychiatry; very little research has been done to guide planning efforts. There is some evidence, however, that at the provincial level new interests and initiatives are beginning to emerge and that elements of a common vision are developing. In the Department of Psychiatry at the University of

28 MENTAL HEALTH CARE IN CANADA

Toronto, for example, a Mental Health Systems Research and Development Program has been established to focus academic energies on improvements in the design, delivery, and evaluation of services.

According to Anthony, Cohen, and Kennard (19901, mental health sys- t e m planning in the United States in the 1990s has been stimulated by a con- sensus about the importance of community support and rehabilitation. This “future vision” has been outlined by the National Institute of Mental Health in a technical assistance document titled Toward a Model Plan for a Compre- hensive, Community-Based Mental Health System (1987). In order to create plans that incorporate this community support and rehabilitation philosophy, Canadian planners must also develop a new, more optimistic vision of what can be accomplished with and for severely mentally ill people. It is this optimistic vision that should inform our planning initiatives. Consideration of each key issue discussed above should be undertaken in the context of an overall understanding of Canada’s vision of the provincial mental health system in relation to the target population. With regard to provincial psychiatric hospitals and general hospital psychiatric units, for example, the emphasis should not necessarily be on the elimination of beds but rather on understanding the role and functions of these facilities in the system plan, with particular attention to linkages with other components of care. Once a system vision has been developed, identification and resolution of key issues becomes much more feasible.

In Chapter Four, we describe current Canadian initiatives in planning mental health services. As will be seen, there is evidence that a common vision is in fact emerging. In addition, there is a developing recognition of important aspects of the planning process. These include involvement of key stakehold- ers and partnerships in planning structures, broad consultation, sensitive needs assessment that pays particular attention to consumer and family preferences, targeting of service delivery initiatives, and the mobilization of political will. Fortunately, there is a willingness in Canada at this time to undertake the dif- ficult tasks of planning effective services. Chapter Four describes current activities, as we have noted, and discusses both what has been learned in relation to key issues and what remains to be done.

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BACKGROUND AND KEY 1SSUES 29

Finlayson, R., Greenland, C., Dawson, F. D., Blum, H , and Pittman, G. “Chronic Psychiatric Patients in the Community ” Canadianlournal of Psychiatry, 1983,28 (8). 635-639.

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(12), 1602-1608.

DONALD WASYLENKI, M.D., is professor ofpsychiatry, University of Toronto, and head of the Continuing Care Division, Clarke Institute of Psychiatry, Toronto.

PAULA GOERING, R.N, Ph.D., is associate professor of psychiatry, University of Toronto, and director of the Health Systems Research Unit, Clarke Institute of Psy- chiatry Toronto.

ERIC MACNAUGHTON, M.A., has recently completed his master’s degree in community psychology at Wilfrid Laurier University in Waterloo, Ontario. He wasformerly research associate with the Canadian Mental Health Association, Toronto.

Documents

Planning mental health services: Background and key issues