Transcript PPT - OPOP
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
Disclosure
Nothing to disclose
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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
3
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
4
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
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Characteristics of Communities
LHIN OPOP
LANG
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
C6
13
N - Other EN
<4,000
68
5 20-40
C7
13
Y
<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
EN/FR
POP
RIO
SAC
# Acute
Beds
6 <20
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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)
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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
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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 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)
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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
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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
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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
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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
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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)
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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)
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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
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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
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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
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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
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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 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
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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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