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Bringing it together: Continuum of care 

From: Submission to the Select Committee on Mental Health and Addictions. Presented by Paul Garfinkel, June 3, 2009.

Ontario has learned that targeted investments improve specific areas of the system, but may increase pressures in other areas. Investments based on a whole system strategy are more likely to improve coordination and continuity of care.

In 1998 the Province released Making it Happen. This framework served as a vision for the future of the mental health system in Ontario. This vision provided the direction for investments in mental health funding over the last 10 years. One of the main elements of Making it Happen was to shift the focus of mental health services from hospital-based services to community-based services. As a result, significant investments were made between 2004 and 2008 in community mental health programs. These investments almost doubled the funding envelope of community mental health in Ontario. As part of this change, the province funded a large multisite evaluation of the impact of the new investments, the System Enhancement Evaluation Initiative (SEEI) (Moving in the Right Direction, 2009).

SEEI has taught us several important lessons on improving the continuum of care. One of the most important of these is that system change requires coordinated large-scale investments which must be driven by a comprehensive vision for the entire system. The mental health system in Ontario is, and has been, under resourced. Even a doubling of community mental health funding has not satiated demand. Rather it has resulted in increased demand in other parts of the system. In order to improve the continuum of care, the system as a whole must be examined and the impact on other parts of the system must be taken into account in individual funding decisions.

When the investments in community mental health programs were announced it was anticipated that they would have certain effects on the mental health system. It was expected that the access to services would increase and that client outcomes would improve in affected program areas. It was also expected that the use of emergency department and inpatient services would be reduced because increased community services would prevent the use of these two resource heavy services. Similarly it was assumed that the pressure on jails, courts and forensic mental health services would be reduced and that the system overall would be better integrated.

In looking at overall system performance in one region of the province it was found that there were some improvements in the match of the needs of clients to the level of care received, particularly for those clients who require intermittent services and supports (Stuart, Krupa & Koller, 2009). However, this study also found that there continued to be high levels of unmet need in the areas of social and vocational services and that a significant amount of clients who need daily intensive support (71%) are still receiving a level of care that is less than recommended (Moving in the Right Direction, 2009).

The new funds were rolled out over four years. Over the course of this time period an increase in program capacity was noted. For example, in the Early Intervention (EI) and Court Support (CS) programs studied, enrolment more than doubled; from 161 to 370 for EI and 350 to 842 for CS (Moving in the Right Direction, 2009). These programs also saw improvements in reaching and serving their specific target population. As the EI programs studied implemented the new funding they saw that the average age of their clients was getting lower and they were serving a more appropriate target group. Court Support programs were found to be serving clients with very challenging life circumstances, over and above their criminal justice involvement. Clients reported very low incomes and educational attainment, the majority of clients reported a minimum of five years of positive untreated psychotic symptoms, and more program participants had class 2 or 3 charges (Dewa, 2008).

Improvements were seen in the continuity of care for individuals in EI over the three years of the study. Indicators of continuity of care, including service match, referrals, travel time and waiting time for referred services showed improvements for this program area. It was found, however, that continuity of care for Court Support program participants was more challenging. Many clients had difficulty accessing care and referrals were less successful. This may be due to the lack of capacity in the system and the hesitancy of other providers to serve clients who have legal involvement (Dewa, 2008).

It was found through the SEEI that as more people accessed the enhanced programs and services, the demand for other services in the system also increased. Contrary to what was expected, emergency department and inpatient use did not decrease. Rather there were slight increases in volume of emergency department visits and inpatient admissions. This finding was not consistent across all user groups, however. New users of the system actually saw a decrease in use. As well, early return rates to emergency (within 30 days) also saw a decrease (Moving in the Right Direction, 2009). The system is complex and it is not well understood how one service impacts on other resources in the system. The investments targeted certain programs, but some studies in SEEI showed that the corresponding, and necessary support programs were not enhanced. There continues to be a lack of services for housing and vocational training for court support clients (Aubrey, 2009). ACT teams have had difficulty implementing the concurrent disorders model and peer support, partly because of a lack of appropriate human resources in the system (George, 2009).

The results of the SEEI study illustrate the need for a comprehensive provincial mental health and addiction strategy to provide a vision for the system and guide funding and research decisions. A vision for the whole system is critical in improving the continuum of care and the integration of services.


In Submission to the Select Committee on Mental Health and Addictions:

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