Jill Sherman, Bob Swenson, Robert Cooke, Abraham Rudnick, Paula Ravitz, Fernande Grondin, Phyllis Montgomery, Raymond Pong,

Margaret Delmege, and Patrick Timony

September 16, 2010Thunder Bay, Ontario

DisclosureNothing to disclose

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Learning ObjectivesExplore the continuum of mental health services

in representative small northern Ontario communities

Understand unmet needs for mental health services from the perspectives of smaller communities

Identify and discuss the implications of the findings for medical education

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How do smaller, remote communities provide access to psychiatric and mental health services in Northern Ontario?

Five interrelated themes:Service delivery contextCommunity contextService delivery modelsCollaborative careInnovations

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Research MethodsStudy Area: NE / NW LHINs, excluding NURCs

Multiple Case Study ApproachTrade-off between breadth (number of cases) and

depth (level of detail possible for each case)

10 Case Study CommunitiesPurposive sampling, maximum variationStratified on OPOP services, non-OPOP servicesOther variables of interest: Language

(Anglophone/Francophone), NE/NW LHIN

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Characteristics of Communities

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LHIN

OPOP LANG POP RIO SAC # Acute Beds

C1 14 Y (but) EN <6,000

97 6 >60

C2 14 N EN <10,000

91 6 40-60

C3 14 N EN <1,000

95 5 <20

C4 14 Y EN + <6,000

79 6 40-60

C5 13 N EN <2,000

100 6 <20

C6 13 N - Other

EN <4,000

68 5 20-40

C7 13 Y EN/FR

<10,000

70 6 >60

C8 13 N - Other

FR <4,000

55 5 0 (but…)

C9 * 13 Y FR <6,000

95 6 20-40

C10 *

13 Y EN/FR

<12,000

71 3 40-60

Primary data collectionKey Informant Interviews with health and social

services providers, community representatives, and other interested (November 2009-September 2010) Mayor / Town official Hospital, FHT, CHC, other Primary Health Care Providers Designated mental health care providers (e.g. CMHA,

others) Public Health Units Social Service Providers (e.g. CCAC, Housing, CFS) Schools, Churches, other Community Services Police, EMS, Pharmacies, Legal Services Support Groups, Volunteer Groups (e.g. VCARS)

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Definitions of “mental health” Mental illness – focus on Disease / Disorder

Psychiatric / neurological disorders, SMIDevelopmental / intellectual disordersMedical problems with mental health consequences“Social disorders”

Behavioral problems, interpersonal violence, “bad parenting,” inability to care for one’s self, vulnerability

Alcohol / drugs / addictions – ambiguous status

Mental wellness – Capacity, QOL focusAbility to care for one’s self, enjoy life, participate in community life

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Definitions of “mental health services”“Counseling”“Medical mental health” – treatment focus

Hospital, ER, psychiatrists, social workers, (pharmacists)“Social mental health” – treatment/recovery focus“Holistic mental health” – wellness focus

“Everything designed to enhance individual and community wellbeing” (e.g. recreation)

Public Health, Schools, other community services – Sometimes included as preventive services

“Family Physicians” usually included when prompted associated with medications, ER treatment, referrals

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Role of family physicians?Multiple jobs -

Family PracticeER coverageOutreach - satellite clinics in surrounding

communitiesIn context of

Multiple vacanciesHigh proportion of locums

“Shared care may work in some communities, [but here] it would be a waste of my physicians’ time” (Chief of Staff)

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Overlooked as frontline providers -1Pharmacists

Serve as de facto “walk-in clinic” in small communitiesPlay key role in coordinating / managing medications,

esp. in communities relying on “Dr. of the Day” (locums)

Mediate between the clinical goal of a physician, the demands of a drug regimen, and the realities of the patient & community context

Are strongly affected by changes in demand for prescriptions (e.g. narcotics, methadone clinics), but frequently left out of policy, planning, and communication networks

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Overlooked as frontline providers -2Dentists

Also prescribe narcotics, but left out of planning, communications

Dental health reveals patient drug use, other mental health issues (particularly in children), but dentists are not able to refer patients to services that require a physician referral

EMSLack of training for mental health emergencies‘Vicarous trauma’ – lacked access to employer-

provided mental health services

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Overlooked as frontline providers -3Indian/Native Friendship Centres

Provide a variety of health, support, and advocacy/legal services

Often invited to “participate” at the table, but …

Legal ServicesOften perceive hostility rather than partnership

from health care providers (even when on the same side)

View themselves as advocates for those who cannot help themselves – incl. “system navigation”

Want more education on mental health conditions, medications

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Unmet needs - 1ALMOST ALL COMMUNITIES –

(Economic supports)Family physiciansTransportation servicesSupported living / housing servicesSenior’s services School-based counselorsServices for menDetox –

Alcohol – emphasized in NW LHIN Drugs – emphasized in NE LHIN

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Unmet Needs – 2NW LHIN –

FASD DiagnosisNE LHIN -

Parenting education / assistanceCritical incident stress debriefing

VCARS services - highly valued, where they existed

Prevention services - Difficult to define, generally deemed absent /

lackingSome notable exceptions (e.g. Public Health

Units)15

Unmet Needs - 3

Community-specific needsCounselors PsychiatristHomeless shelters, temporary housing, family-

friendly shelters (problems with gender-segregated shelters)

Services for domestic violence, sexual abuse, incest

Walk-in clinicMinority services (French, English, Native)

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Unmet needs: Information and CommunicationOverreliance on informal networks, interpersonal

networksBelief that “everyone knows everything” in small communitiesInformation shared through (closed) provider networks

Many community leaders lacked full or accurate knowledge of available mental health servicesContributed to community conflict over controversial issues

Key community members did not know where to get information on mental health services Lack of awareness of MHSIO, even among providersLack of community directories of services, or awareness of …

“There used to be…” - problem of constant changeCommunication challenges reaching low-income audiences

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Service Models = Ethical DilemmasInsufficient resources rationing – How?

Service intensity – Equity or efficacy? Extensive services – emphasis on access Intensive services – emphasis on recovery

Spatial concentration or dispersion? Most communities with visiting psychiatrists – 2 or

moreService “duplication” or service diversity?Prioritizing among acute treatment, rehab,

health promotion/prevention?

Service threshold / critical mass Effectiveness 18

Typical “Success Stories”Recruiting service providers (family physicians,

social worker/counselor, psychiatric nurse) or developing new services (FHT, CHC).

“Any time we help a client to remain in the community” – struggle to make system work for each individual

Own programOne or two programs were typically recognized by

all or most community informants as a success, e.g.Food bank, community garden, food box programs“Drop-in” centres, where they existedSenior’s programs

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Less typical success storiesCommunity fundraising initiatives, cost-

sharing, creative funding

VCARS and/or community-wide critical incident interventions

Collaboration – community-wide, between “competing” agencies, or between Native (Federal) and Provincial services

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“Success” stories?The Angry Community:

“Getting the client OUT of the community, so that they can get the help they need.”

The Depressed Community: “Can’t think of any”

Very small / remote

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Contextual factorsCommunity factors

Size / dispersionProximity to other services

Between two centresLocation in transportation networks Industry / Economy

Service Centre Transportation Centre / Resource-dependent

Stage in boom-bust cycleLeadership interest in health Unique characteristics

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Contextual Factors -2 Impact of other research –

Hill ME, Pugliese I, Park J, et al. 2008. Forestry and Health: An Exploratory Study of Health Status and Social Well-Being Changes in Northwestern Ontario Communities. Centre for Rural and Northern Health Research, Lakehead University, Thunder Bay, ON.

The Agora Group. 2010. Together: A report from the Agora Group on the development of an integrated model of addiction and mental health service delivery throughout Algoma District. North East Local Health Integration Network, Sudbury, ON. (March 2010)

Select Committee on Mental Health and Addictions, Legislative Assembly of Ontario. 2010. Navigating the Journey to Wellness: The Comprehensive Mental Health and Addictions Plan for Ontarians. (Interim Report, March 2010; Final Report, August 2010)

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For discussion…What are the implications of these findings

for medical education?

Role of family physicians in mental health?

Interprofessional education?

Distributed model of education?

Health education / capacity building?

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