September 16, 2010 Thunder Bay, Ontario

1. Mental Health Services in Smaller Northern Ontario Communities: Preliminary Findings from Community Case Studies Jill Sherman, Bob Swenson, Robert Cooke, Abraham Rudnick, Paula Ravitz, Fernande Grondin, Phyllis Montgomery, Raymond Pong, Margaret Delmege, and Patrick Timony September 16, 2010 Thunder Bay, Ontario

2. Disclosure • Nothing to disclose

3. Learning Objectives • Explore 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

4. How do smaller, remote communities provide access to psychiatric and mental health services in Northern Ontario? Five interrelated themes: • Service delivery context • Community context • Service delivery models • Collaborative care • Innovations

5. Research Methods • Study Area: NE / NW LHINs, excluding NURCs • Multiple Case Study Approach • Trade-off between breadth (number of cases) and depth (level of detail possible for each case) • 10 Case Study Communities • Purposive sampling, maximum variation • Stratified on OPOP services, non-OPOP services • Other variables of interest: Language (Anglophone/Francophone), NE/NW LHIN

6. Characteristics of Communities

7. Primary data collection • Key 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)

8. Definitions of “mental health” • Mental illness – focus on Disease / Disorder • Psychiatric / neurological disorders, SMI • Developmental / intellectual disorders • Medical 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 focus • Ability to care for one’s self, enjoy life, participate in community life

9. 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

10. Role of family physicians? • Multiple jobs - • Family Practice • ER coverage • Outreach - satellite clinics in surrounding communities • In context of • Multiple vacancies • High proportion of locums • “Shared care may work in some communities, [but here] it would be a waste of my physicians’ time” (Chief of Staff)

11. Overlooked as frontline providers -1 • Pharmacists • Serve as de facto “walk-in clinic” in small communities • Play 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

12. Overlooked as frontline providers -2 • Dentists • 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 • EMS • Lack of training for mental health emergencies • ‘Vicarous trauma’ – lacked access to employer-provided mental health services

13. Overlooked as frontline providers -3 • Indian/Native Friendship Centres • Provide a variety of health, support, and advocacy/legal services • Often invited to “participate” at the table, but … • Legal Services • Often 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

14. Unmet needs - 1 • ALMOST ALL COMMUNITIES – • (Economic supports) • Family physicians • Transportation services • Supported living / housing services • Senior’s services • School-based counselors • Services for men • Detox – • Alcohol – emphasized in NW LHIN • Drugs – emphasized in NE LHIN

15. Unmet Needs – 2 • NW LHIN – • FASD Diagnosis • NE LHIN - • Parenting education / assistance • Critical incident stress debriefing • VCARS services - highly valued, where they existed • Prevention services - • Difficult to define, generally deemed absent / lacking • Some notable exceptions (e.g. Public Health Units)

16. Unmet Needs - 3 • Community-specific needs • Counselors • Psychiatrist • Homeless shelters, temporary housing, family-friendly shelters (problems with gender-segregated shelters) • Services for domestic violence, sexual abuse, incest • Walk-in clinic • Minority services (French, English, Native)

17. Unmet needs: Information and Communication • Overreliance on informal networks, interpersonal networks • Belief that “everyone knows everything” in small communities • Information shared through (closed) provider networks • Many community leaders lacked full or accurate knowledge of available mental health services • Contributed 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 providers • Lack of community directories of services, or awareness of … • “There used to be…” - problem of constant change • Communication challenges reaching low-income audiences

18. Service Models = Ethical Dilemmas • Insufficient 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 more • Service “duplication” or service diversity? • Prioritizing among acute treatment, rehab, health promotion/prevention? • Service threshold / critical mass  Effectiveness

19. 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 program • One 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 existed • Senior’s programs

20. Less typical success stories • Community 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

21. “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

22. Contextual factors • Community factors • Size / dispersion • Proximity to other services • Between two centres • Location in transportation networks • Industry / Economy • Service Centre • Transportation Centre / Resource-dependent • Stage in boom-bust cycle • Leadership interest in health • Unique characteristics

23. 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)

24. 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?