Mental Health Homecare: Reponse to the First Ministers Accord

Background

The Centre for Addiction and Mental Health is pleased that the First Ministers are taking action to implement the recommendations made by the Commission on the Future of Health Care in Canada. In our submission to the Commission, the Centre for Addiction and Mental Health recommended that:

Mental health and addiction services be included in the Canada Health Act as a key component of primary and acute care;
Health reform initiatives move beyond the funding envelopes of hospitals and physicians to include the broader supports we know make a difference to health status including: income, community supports, housing, employment and self-help advocacy;
Public coverage under the Canada Health Act be expanded to include psychiatric hospitals, home care and public funding for the costs of medications prescribed outside of institutions;
Primary care reform be accelerated and mental health and substance abuse be included so that patients with mental illness and addictions can also benefit from: a team of care providers, 24 - hour access to care, a focus on health promotion and wellness, and coordinated case management;
Health human resource planning be improved to ensure appropriate distribution of health professional resources across communities; and
Governments should forget about increased private financing - the clients we work with don't have the resources, the collection infrastructure wouldn't work, those with frequent contact with providers would be most penalized and services for people with addictions and mental health problems are vulnerable to begin with.

CAMH Response to the First Ministers Accord

The Centre for Addiction and Mental Health strongly supports the inclusion of mental health homecare in both the Romanow report and the recently signed First Ministers Accord. Governments must take the best possible advantage of this opportunity to respond to the needs of people with serious mental illness, many of whom are the most vulnerable people in our society.

The impact of mental illness on Canadians is staggering. Over 1.5 million Canadians are currently experiencing clinical depression, a disorder that affects 10-15% of Canadians at some point in their lives (CAMH, 2001). One of every eight Canadians will be hospitalized for mental illness at least once in their life (Cleghorn, 1991). People with serious mental illness not only live with the devastating burden of the disease, but are also likely to be unemployed, living in poverty, and to be at-risk of homelessness, violence, victimization and criminalization.

Despite the depth of these needs, mental health care has been called the "orphan" child of medicare because it has so often been neglected in health care funding and reform initiatives. In Ontario, community mental health programs have had no increase to their base budgets for over a decade, and have in fact lost ground due to rising operating costs.

The First Ministers commitment to providing home-and-community-based mental health services is an important step towards meeting some of these needs. It also recognizes that mental health care is no longer primarily about hospital services.

As Ontario considers how to negotiate the definitions of the Accord and develop implementation plans, the Centre offers the following advice.

Be flexible in the way that the homecare concept is applied to community mental health services.

As stated earlier, the Centre for Addiction and Mental Health is pleased to see the homecare concept - providing support to people in their home and community to prevent and reduce hospitalization - applied to services for people with mental illness.

Research demonstrates that people with mental illness can remain out of hospital when the right kinds of programs and supports are available to them in the community. This, in turn leads to better long-term outcomes for clients and a more cost-effective use of health care resources.

To this end, the Centre recommends that Ontario and the federal government consider carefully how to apply the homecare concept in the mental health care context. There is a need to be flexible and give consideration to the following issues:

In Ontario, best practice programs to prevent hospitalization of people with serious mental illness are typically delivered through community-based mental health agencies and hospitals, rather than the traditional homecare system. The term "homecare" in the new Accord must be defined broadly enough to include these programs;
The service basket for mental health homecare must be tailored to meet the needs of people with serious mental illness. This means it will need to look a little different than the traditional basket of services currently available through homecare;
The units of service funding model currently in place for homecare services is not well-suited to people with mental illness as it has limited capacity to respond to the episodic nature of these diseases;
Mental health homecare programs must take into account that treatment of and recovery from mental illness can follow different patterns than many of the illnesses for which homecare services were originally designed; and
Mental health homecare should not be confined to the transition of people from the hospital to the community, though we think it has an important role to play in supporting those transitions and in preventing and reducing hospital stays.

Don't focus on "acute" mental health needs in isolation. Ongoing, comprehensive supports in the home and community are proven to prevent and reduce acute mental health episodes.

The Centre believes that responding quickly and effectively to acute episodes of mental illness is important. Interventions delivered in the community and the home to achieve this goal should be expanded.

But we caution that responding to acute episodes of illness without adequately funding the services that prevent, reduce and shorten such episodes is counter-productive. Best practices demonstrate that the provision of ongoing, comprehensive mental health services in the home and community are essential to effectively reduce and respond to acute mental health episodes.

The community-based mental health sector plays a critical role in this area and we urge governments to enhance funding to this sector as they consider how to respond to "acute" mental health needs for people living in the community.

Build on existing community mental health treatment and care.

Although "mental health homecare" has recently achieved currency as part of the health care reform debate in Canada, providing services to people with mental illness in their home and in the community is not new. In many communities in Ontario, a range of community-based services is working to meet this need and has demonstrated their effectiveness. These programs should be the core of the "basket" of services, rather than trying to modify traditional homecare to meet the need.

The types of activities that we think you must consider as you define a mental health homecare basket include:

Mobile crisis response teams;
Early intervention services;
Mental health outreach; and
Intensive case-management services.

Ensure people with mental illness are able to access traditional homecare supports.

Although the "mental health" homecare basket will need to be different than traditional homecare services, people with mental illness also need access to personal supports, homemaking and medical care in their homes just like others in the community.

Unfortunately, homecare funding and delivery mechanisms often exclude people with mental illness. These barriers should be removed so that people with mental illness are eligible to receive these supports. We also recommend that there be strong linkages between traditional homecare services and "mental health" services and supports to ensure the best care for people with mental illness.

Take into account the episodic nature of mental illness.

Although some people may experience a single acute episode of illness followed by treatment and recovery, for many people, serious mental illness is more episodic in nature. This means that treatment and recovery may occur over a longer time frame.

In this context, treating people in their home or community means funding services and supports beyond the short-term, time-limited interventions currently available through traditional homecare programs. Services should be flexible and responsive to the differing levels of support people will require throughout different periods of their illness and recovery.

People with concurrent disorders and addictions must have access to the "mental health" homecare basket of services.

Research has demonstrated that the co-occurrence of addiction and mental health problems is high. Given this reality, we anticipate that services delivered as part of the "mental health" homecare basket will be accessed by people who have both a mental illness and an addiction.

Ensuring that people with both mental illness and addiction receive appropriate care is important because they are at greater risk of relapse and re-hospitalization, depression and suicide, incarceration, homelessness and significant family problems.

This is an area in which the Centre for Addiction and Mental Health has tremendous expertise and we would like to work with the Ministry as you think through the implications of concurrent disorders on the course, cost and outcome of services funded under the "mental health" homecare basket.

Define home broadly. For our clients a variety of settings often "substitute" for home.

As stated earlier, people with serious mental illness are likely to be unemployed, living in poverty and at-risk of homelessness. This means that for many of our clients, "home" means a shelter, a drop-in or the streets. "Home" should be defined broadly so that mental health homecare services can be delivered in these alternate settings. This will make an important contribution, not only to meeting the needs of people with serious mental illness, but also to addressing homelessness in Ontario.