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Using Research Evidence to Improve Community Mental Health and Addiction Services in Ontario: our best kept secret

Health system research is a vital component to ensuring effective, sustainable healthcare for Ontarians. With a deep understanding of mental health care in Ontario, and a commitment to improving its delivery and efficacy, Steve Lurie, the Executive Director of the Toronto branch of the Canadian Mental Health Association, highlights the value of investing in health system research and demonstrates where we need to go next in order to improve care for Ontarians facing mental illness and addiction.

Research supported by the Health System Research Fund has transformed care in the past, and has the promise to do so again in the future. This is just one example.

Steve Lurie, Executive Director of the Toronto branch of the Canadian Mental Health Association

By Steve Lurie, Executive Director of the Toronto branch of the Canadian Mental Health Association 

Mental health is one of the most pressing public health issues of our time. And yet, if I were to take a survey, I think most people would be hard pressed to estimate the number of people served by community mental health and addiction programs in Ontario.  In 2014/15, programs operated by hospitals and member organizations of Addictions and Mental Health Ontario and the Canadian Mental Health Association served 535,536 people at a cost of $1.85 billion. To give an idea of capacity growth, these programs served only 34,724 people in 1992 and the total spend was $5 million.

Mental health has become an increasing priority for Ontario, and the Ministry of Health and Long-Term Care has supported research and program evaluation. Provincial investment has enabled researchers and clinicians to generate the necessary evidence to identify gaps, develop solutions, and improve mental health care and services over the past 25 years. In 1992 I carried out research on 309 community mental health programs across the province. We found that 73.9% of the community programs surveyed were measuring consumer satisfaction and 82.9% reported measuring client changes or outcomes. This demonstrates that there has always been a culture of quality improvement and program evaluation in the sector.

In 1997 Dr. Paula Goering put a consortium of researchers and community mental health providers together to study program and client characteristics in the Community Mental Health Evaluation Initiative, which reported in 2004. Key findings included:

  • Community-based services and supports can increase the ability of people with serious mental illness to live in the community.
  • It is possible for people with serious mental illness to recover and lead fulfilling lives, as recent work in mental health reform has asserted.
  • Community mental health services and supports save money. For example, it can cost up to five times less to provide services to a person in the community than it would to keep that person in hospital for the same amount of time.

Between 2004 and 2006 the provincial government invested $167 million to expand community mental health and addiction programs and commissioned Dr. Goering to lead the Service Enhancement Evaluation Initiative (SEEI). Once again findings in 2009 were similar:

  • Programs substantially increased the number of clients they were able to serve. However, the newly enhanced community mental health system still does not have the capacity to serve all those in need.
  • Clients of newly-enhanced programs experienced a range of positive outcomes.
  • New funds were used to innovate and develop more efficient and effective program-level services.
  • System integration was expanded and improved when funds were targeted specifically towards integration activities.
  • Matching the level of care that client’s need with the level they receive has improved. There are, however, still many people receiving less than recommended levels of care.

Dr Goering’s collaboration with the sector on research set the stage for the world’s largest evaluation study of services to homeless people living with mental illness. At Home Chez Soi, a cross-Canadian study sponsored by the Mental Health Commission of Canada, launched in 2009 and reported its findings four years later:

  • It showed that using a Housing First approach achieved housing stability for 60-80% of clients compared to 30% for those people who received treatment as usual.
  • The study also showed that cost savings were possible, particularly for high needs clients where $2 were saved for each dollar spent.

There is a strong evidence base in community mental health and addiction programs, but we need to move beyond episodic studies to helping the sector use the data they collect for service improvement. Recently the Centre for Mental Health and Addiction (CAMH) and the Toronto branch of the Canadian Mental Health Association (CMHA) collaborated to submit a proposal to the Health System Research Fund (HSRF) competition to do just this.

The aim of our research project is to develop ways of collecting and using data effectively in three diverse initiatives in mental health and addictions care in Ontario:

  • A program for early intervention in psychosis for youth and adolescents
  • A network of community mental health agencies serving the seriously mentally ill
  • A multi-ministry strategic Framework to improve care for the priority group of individuals with dual diagnosis

These all focus on high needs populations in the area of mental health and addictions.  They are also at different developmental stages in terms of their ability to collect, use, and report data, and our team has an established track record with all three.

Steve Lurie and team, receivingan Across Boundaries Award
Steve Lurie and team, receiving an Across Boundaries Award

Embracing the Patients First priorities of the Ministry of Health and Long-Term care, our project is designed to deliver more public reports on health system performance, more innovative approaches based on evidence, and more public information for patients.

The critical ingredients needed to carry  out these Patients First priorities are high-quality data collection and use, which depends on a supporting provincial infrastructure and, equally if not more important, local stakeholder capacity to collect and use data.  Decades of past experience have shown that providing policy direction, education sessions, and even tools for data collection has not been enough to create the needed infrastructure and local capacity.  We propose that a more effective approach will be to provide three years of ongoing coaching and joint decision-making with each initiative to help enhance their data quality and ability to collect and use it for improved patient care and health system performance.

What will this work look like at the care level? Each of our three initiatives have voiced a different set of data needs that they feel are essential for improving care and services.

  • The early intervention for psychosis program needs a system to collect client feedback at each session so that practitioners could better monitor and titrate care.
  • The community mental health agency network needs organizational level indicators of unmet service needs for two particularly challenging subgroups: those with concurrent disorders, and those with repeat hospital use. The network felt that such indicators would improve their program planning, quality improvement and evaluation activities and, in particular, give them the tools to better tailor the care they are providing.
  • The multi-ministry Framework needs a strategy for evaluation. The specific focus is on developing indicators of cross-sector service coordination and support, areas which have been identified as critical gaps in the care for individuals with dual diagnosis.

It is our hope that each initiative will develop and refine a strategy to meet their data needs and will train and coach specified staff over a three-year period to implement that strategy and to sustain once HSRF funding ends. All three projects will thus improve capacity to collect data and contribute to indicator development for system monitoring and policy evaluation.

This kind of health system research, whether in the mental health and addictions sector or across the health care sector, is necessary for improving care and services for patients.  As for our project in collaboration with CAMH, it’s about helping the mental health and addictions sector find the best ways to use the data we already collect to improve our services. We are eager and ready to meet this challenge.

 

Steve Lurie, Executive Director, Adjunct Professor FISW, University of Toronto

Canadian Mental Health Association Toronto Branch

700 Lawrence Ave West # 480

Toronto ON M6A 3B4

416-789-6886

Email: slurie@cmha-toronto.net

Web: www.toronto.cmha.ca