Community-based care for people with severe mental illness in Canada

International Journal of Law and Psychiatry 28 (2005) 561 – 573

Community-based care for people with severe mental illness in Canada Eric Latimer T Douglas Hospital Research Centre, Montreal, Canada Department of Psychiatry, McGill University, Montreal, Canada

Abstract The development of mental health services for people with severe mental illness has in many ways paralleled that in other countries, particularly the United States. As reliance on inpatient psychiatric care has been sharply reduced, a wide range of community supports have been developed. Several distinct institutional and legal features have contributed to shaping the nature of these community supports, which are described herein. At present, the result is a highly fragmented system of care. Key evidence-based practices, notably assertive community treatment, supported employment, and integrated treatment for concurrent severe mental illness and substance use disorder, achieve considerable integration at the clinical level, but remain relatively unavailable in most provinces. The policy of regionalization of services risks inhibiting the development of such practices, which require more centralized technical assistance and monitoring. An evolutionary approach of gradually introducing integrated, evidence-based programs may provide the most feasible strategy for improving the system. D 2005 Elsevier Inc. All rights reserved.

1. Introduction Isabelle, who is now 51, had been living in the same one bedroom, rent-controlled apartment in Montreal for over 15 years. Unemployed most of the time, with occasional periods during which she managed to do some part-time work at a grocery store, she lived mostly from a Que´bec government disability cheque (now about $825 per month), with some additional financial assistance from her financially well-off and concerned sister, without which she could not afford her apartment. She would T Douglas Hospital Research Centre, 6875 LaSalle Blvd., Verdun, Que´bec, Canada H4H 1R3. Tel.: +1 514 761 6131 x2351; fax: +1 514 762 3049. E-mail address: [email protected]. 0160-2527/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ijlp.2005.08.001

562

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

spend her days mostly making pottery at a community organization that offers such facilities for people with severe mental illness, or playing the flute in her apartment. She had lived with a man for a few years but their relationship did not last. She keeps in occasional touch with a few friends and some relatives but is otherwise mostly alone. Although she had been hospitalized several times in her late twenties and early thirties, she had hardly been rehospitalized in the previous 10 years. Her only contact with mental health services had been a visit to her psychiatrist once every several months to renew her prescription for a conventional antipsychotic. Once a new psychiatrist tried to get her to switch to one of the atypicals, but Isabelle did not like its side-effects and insisted on keeping the previous medication. At one point her doctor suggested she contact a small community-based psychosocial program that included a supported employment component, but she was not interested. Recently her landlord decided to evict her, on the ostensible grounds that he wanted to move into Isabelle’s apartment — although the real reason was plainly that he wanted to renovate the apartment and take advantage of the now sky-high rents in the neighborhood. Between the housing crisis in the city and Isabelle’s disability, Isabelle could see no way to find alternative housing. Her sister also was unable to make any arrangements. In desperation, Isabelle set a fire in a grocery store, and was taken by the police to the nearest hospital emergency department. She was then hospitalized for several weeks, and ultimately placed in a single-room occupancy, lightly supervised residence, with periodic appointments at the hospital’s outpatient clinic. This arrangement proved inadequate. Isabelle did not take her medications and became acutely psychotic. She was again rehospitalized for several weeks. From there she was placed in a more heavily supervised residence, where her medications are given to her every day. She receives no rehabilitation services of any kind. The supervised residence she is now in keeps its residents for only one year and a transfer to another supervised residence, in a more outlying neighborhood, is being arranged. Neither Isabelle nor her sister has had any say concerning the proposed transfer. The above story, which is true except for a number of incidental details, illustrates the kind of care a person with schizophrenia can expect to get in Montreal or indeed in many other Canadian cities. Care is usually available; to an increasing extent, it is based in the community; it is typically fragmented, leaving the person with a mental illness vulnerable at many points; and only rarely does it conform to the standards of what is now considered evidence-based care. Several distinct institutional and legal features have contributed to shaping care for people with severe mental illness in Canada today. The situation, however, is in flux and several forces are at work that, at a minimum, should in time make care less fragmented. Whether evidence-based practices such as assertive community treatment or supported employment will be adopted more quickly and systematically than they have in the past, however, remains very much in doubt. 2. Important institutional features pertaining to care for people with severe mental illness in Canada 2.1. Provincial jurisdiction over health care Canada is a federal country, divided into 10 provinces and 3 (Northern) territories. This division is significant as the organization and delivery of health care in Canada (except for veterans, the military,

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

563

inmates at federal penitentiaries, specific groups of aboriginal peoples, and a few others (Standing Senate Committee on Social Affairs Science and Technology, 2004)) is viewed as a provincial or territorial responsibility, within the limited constraints of the Canada Health Act (Health Canada, 2005) and the interpretations of successive federal governments. There is no analogue in Canada to the federal Vocational Rehabilitation program in the U.S., nor do provincial governments need to obtain the equivalent of a Medicaid waiver to introduce many types of innovations into their systems. It is not surprising therefore that, at present, Canada (alone among the G8 countries (Standing Senate Committee on Social Affairs Science and Technology, 2004)) has no national mental health policy. The provinces vary widely in population. Out of a total of 32 million Canadian residents in 2005, 12.5 million (39%) live in Ontario, 7.5 million in Que´bec (23%); at the other extreme, the three territories and four Atlantic provinces combined have a population of 2.4 million, less than 8% of the country’s total. Most references to specific provincial features herein pertain to Que´bec and Ontario, and/or in some cases to British Columbia, Alberta, and Nova Scotia (the largest of the Atlantic provinces). Together these five provinces span much of the country geographically and account for over 88% of its population (Statistics Canada, 2005a,b). Despite provincial jurisdiction over health care, several factors, including federal legislation pertaining to health care, certain institutional features common across all provinces, common proximity to the U.S., a country that has had a major influence on service development in Canada (Goering, Wasylenki, et al., 2000; Rochefort & Goering, 1998), and various mechanisms of exchange of information and mutual comparison across provinces (Standing Senate Committee on Social Affairs Science and Technology, 2004), result in provincial mental health care systems bearing fairly close resemblance to each other. Furthermore, although provinces vary widely in per capita GDP (from over Can$48,000 in oil-rich Alberta, in 2003, to 42% less, or $27,978 in Prince Edward Island (Statistics Canada, 2005a,b), the federal government transfers approximately $10 billion of its tax revenues each year from the richest to the poorest provinces in order to ensure each province the financial capacity to provide a minimum level of public services to its citizens (Department of Finance Canada, 2005). This equalization process accounts in part for health care expenditures per capita being more similar across provinces than their relative wealth would lead one to expect: in 2004, health expenditures ranged from about $4275 in Alberta and Ontario, to only 14% less in Que´ bec, $3667 — the province that spends the least on health care per capita (Canadian Institute for Health Information News, 2004). 2.2. Regionalization within provinces Provinces have implemented different mechanisms for administering health care, including mental health. Starting with Que´bec in 1989, all provinces except Ontario have regionalized the administration of health care delivery, including the delivery of mental health care, in a number of different ways. (Ontario is, however, as of early 2005, in the process of setting up its own regional authorities, called Local Health Integration Networks.) General policy direction issues from the provincial level. Where regionalization has occurred, policy implementation is usually devolved to regional authorities. This is the case for example in Nova Scotia, where Mental Health Services, a branch of the Nova Scotia Department of Health, sets policy direction while nine district health authorities and the so-called IWK Health Centre (a hospital for children, youth and women) in the provincial capital, Halifax, deliver programs and services (Nova Scotia Canada, 2005). Even taking devolution into account, the number of staff dedicated to mental health within provincial ministries can be surprisingly low. In Que´bec, notably,

564

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

a mental health directorate was established only in 2004, after a hiatus of many years, and even now it includes only about a half-dozen staff. British Columbia recently set up a multi-layered structure, with a Provincial Health Services Authority that is responsible for the administration of certain provincial programs and highly specialized services, including the Riverview (psychiatric) Hospital and forensic psychiatric care. Administration of these services involves coordination with the province’s five geographically defined health authorities (British Columbia Ministry of Health Services, 2005). Alberta took a somewhat different path, carving out a relatively autonomous and well-resourced Mental Health Board (AMHB) with overall responsibility for mental health care in the province. In 2003, the AMHB devolved administration of mental health programs and facilities to the province’s nine regional authorities, keeping for itself a policy-setting role (Alberta Mental Health Board, 2005). 2.3. Extent of public insurance coverage Canada’s universal Medicare system requires that each province provide first-dollar coverage of bmedically necessaryQ hospital and physician services for all its residents, under uniform terms and conditions. As a result, there are no circumstances under which a person with severe mental illness can lose first-dollar coverage for inpatient care, hospital-based outpatient and rehabilitation services, and medical care, including psychiatric care, on the same terms as any other person in the province. (The situation is more complex with regards to medications, which are not covered under Canada’s Medicare system. Different provinces have significantly different coverage for medications, both in terms of populations covered and insurance provisions for those covered. In general though, a person classified by the welfare system as disabled, including due to mental illness, has essentially complete medication coverage. See the article by Carolyn Dewa in this issue.) In addition, provincial governments contribute significantly to the funding of non-profit community agencies that provide psychosocial, housing and other services (as detailed below), which are available at no cost to people with severe mental illness. 2.4. Three types of independent providers In Canada, three main types of independent providers are involved in delivering services to people with severe mental illness: hospitals, non-profit community agencies, and psychiatrists. There was no parallel in Canada to the U.S. Community Mental Health Centers program in the 1960s (Rochefort & Goering, 1998), with the caveat that in Que´bec, psychiatric services were sectorized, in such a way that community psychiatry teams became responsible for the provision of mental health services within their sector. 2.4.1. Hospitals With very few exceptions, hospitals in Canada – including psychiatric as well as general hospitals – are publicly funded. General hospitals typically include a psychiatry department. Hospitals receive a global budget, either directly from their provincial government or via a regional authority. In general, the budgets are historical — they are not determined by the number of case-weighted admissions, as under the Prospective Payment System in the U.S. Hospitals may, however, receive targeted amounts from the provincial Ministry of Health or from a regional authority for a particular purpose — for example, to carry out renovations, to purchase new equipment, or to develop an Assertive Community Treatment

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

565

team. In Que´bec at least, hospital administrators usually have little latitude in transferring these funds to a different purpose than that intended. In Canada as in other countries, reliance on inpatient psychiatric care has sharply diminished over the past decades. Between 1964 and 1979, the number of psychiatric hospital beds declined from 4 per 1000 people to less than 1 per 1000 population. Combining psychiatric and general hospitals, the number of days of inpatient psychiatric care per 1000 population declined by more than 38% between 1985–86 and 1998–99, from 464 to 286 (Sealy & Whitehead, 2004). At the same time, both psychiatric and general hospitals have developed a variety of outpatient and rehabilitation services, the nature and availability of which vary considerably from one hospital to the next — partly as a result of differences in budget, partly as a result of differences in provincial policy and regional implementation, partly also as a result of each hospital, and its affiliated physicians, having enjoyed considerable latitude in their programming of services. Increasingly, also, hospitals are subject to performance agreements with their regional authority or with the provincial Ministry of Health. The legal framework of these agreements varies from province to province, and practice can vary within a province across regions. For example, recently a psychiatric hospital in Que´bec received a directive from its regional authority to increase the caseload of its ACT team from 52 to 82 by the end of the fiscal year. Such a precise directive would not likely have been given in a number of other regions within that same province. The penalties for violating the performance agreements are, at present, often not specified. Indeed, there is presently considerable debate concerning the best way to structure such agreements (The Canadian Centre for the Analysis of Regionalization and Health, 2005). 2.4.2. Non-profit community agencies and CLSCs As indicated above, in addition to hospitals, provincial governments also fund (often in association with private donations, some of which may be channelled by United Way) a plethora of non-profit community-based mental health programs. The directories of the Ontario Federation of Community Mental Health and Addiction Programs list over 300 community mental health and addictions programs (Ontario Federation of Community Mental Health and Addiction Programs, 2005). In Que´bec, the Ministry of Health and Social Services lists over 400 community mental health programs, and over 120 addiction programs (Ministe`re de la Sante´ et des Services Sociaux, 2005). Most of these organizations are quite small, with annual budgets well below $1 million. They typically have a single vocation: case management; vocational rehabilitation; supervised housing; crisis intervention; support of family members; consumer self-help; artistic expression; interface between the mental health and justice systems; and so on. Relatively few are multi-service agencies; the largest in Ontario and Que´bec combined, the Toronto Branch of the Canadian Mental Health Association (CMHA Toronto), had expenditures of over $11 million in FY2004 (Canadian Mental Health Association Toronto Branch, 2005). In comparison, Thresholds, a large psychosocial rehabilitation agency in Illinois, USA, had expenses almost five times greater in FY 2003 (Thresholds Psychiatric Rehabilitation Centers, 2005). Community organizations are at this time too small, numerous and diverse to be subject to the same kinds of performance agreements as hospitals. In addition to a historical global budget from the government, as well as relatively predictable amounts from the United Way, fundraising and other private sources, they may well receive additional funds to develop specific services. They are generally not, however, subject to precise accountability mechanisms. The recent Que´bec Plan d’Action en Sante´ Mentale, in its present draft form, merely states that service agreements may be concluded between local authorities and such agencies, but in the context of free and voluntary mutual collaboration (Ministe`re de la Sante´ et des Services Sociaux, 2004, p. 30). Recent emphasis on increasing integration

566

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

of services has led to some efforts, often initiated at the regional authority level, to develop formal collaborative mechanisms across providers, although confidentiality restrictions inhibit the sharing of client-level information across organizations. The province of Que´bec has been unique for several decades in also funding Centres locaux de services communautaires (known as CLSCs), or local community (health) service centers. Historically, many have provided mental health services, although in many cases these do not target people with the most severe mental illnesses. As part of a major health care reform now underway in Que´bec, CLSCs are being merged into larger entities — usually including a general hospital and/or a public long-term care institution. These larger entities, called Centres de Sante´ et de Services Sociaux (CSSS), each have populational responsibility for a defined geographic area. In terms of mental health services, the Plan d’Action en Sante´ Mentale proposes to give them responsibility to organize or provide directly basic mental health services, in collaboration with more specialized providers. 2.4.3. Psychiatrists Psychiatrists, like almost all other physicians throughout Canada, enjoy a very large degree of clinical autonomy by virtue of the fact that their clinical income is almost always derived exclusively from billing their respective provincial health plan. They are almost all self-employed professionals. Those who care for people with severe mental illness typically do so in the context of a hospital, or occasionally, in some provinces, that of a community agency. Financial incentives for psychiatrists have gradually been becoming more favourable to services such as Assertive Community Treatment through the spread of Academic Faculty Plans, mixed remuneration (salary component plus fee-for-service component) and time-based payment, as opposed to pure fee-forservice payment. In general, though, seeing a larger number of patients for a shorter amount of time, which is not feasible for an ACT psychiatrist, remains the best way for a psychiatrist to earn a high income. Other than remuneration, relatively few means are employed to influence psychiatrists. In the hope of improving the rural/urban distribution of psychiatrists, the province of Que´bec at least limits the right of new physicians, including psychiatrists, to practice in hospitals in major urban areas. There is however no micromanagement of physicians’ clinical decisions, as now commonly occurs in some managed care plans in the U.S. Psychiatrists are essentially free to choose the patient population they wish to care for, and how. 2.5. Mechanisms for cost control Health policy makers in Canada have relied on a number of tools to control public health care expenditures, including restrictions on: medical school admissions, physician fees, public sector salaries, equipment acquisition, building projects, and even numbers of elective surgical procedures (Barer, Lomas, & Sanmartin, 1996). Such measures serve to dampen upward pressure on health expenditures, making it easier for provincial governments to limit budgetary outlays for health. In the case of mental health, cuts in the numbers of psychiatric beds have provided a convenient cost-cutting mechanism; community mental health services must then compete with many other health spending priorities for limited funds. In Que´bec at least, expenditures on mental health services as a percentage of total public health expenditures fell between 1998 and at least 2002 (to about 8.5% at that time) (Gouvernement du Que´bec, Rapport annuel de gestion du Ve´rificateur ge´ne´ral pour 2002–2003 tome II: Chapitre 2. 2003: Que´bec, Que´bec). A recent interim report by the Canadian Senate Standing Committee on Social Affairs, Science and Technology calls for bring-fencingQ of mental health expenditures, following the example of

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

567

Australia, to prevent further encroachments of this kind (Standing Senate Committee on Social Affairs Science and Technology, 2004). 2.6. Roles of mental health consumers There is considerable emphasis across Canada on the development of consumer/survivor-run services. In 1991 Ontario allocated $3.1 million to the development of consumer-run projects. Today it is estimated that there are at least 60 consumer/survivor-run projects in Ontario (Pyke et al., 2005). A recent high-profile report, however, argues for further development of such initiatives, partly on the grounds of their cost-effectiveness (Community Mental Health Evaluation Initiative, 2005). There is somewhat less emphasis on the need to develop such programs in Que´bec (Ministe`re de la Sante´ et des Services Sociaux, 2004). In Que´bec at least, however, at the provincial level and in some cases at the regional and local levels, consumers participate in planning processes, and the government’s most recent policy document calls for systematic involvement of consumers in service planning at the provincial, regional and local levels (Ministe`re de la Sante´ et des Services Sociaux, 2004). Among the province’s 400 non-profit community mental health programs, about 115 belong to the Regroupement des Ressources Alternatives en Sante´ Mentale (Association of Alternative Mental Health Agencies), which espouses a bglobal vision of the person, an dotherT way of responding to suffering and distress, and the empowerment of personsQ (Regroupement des Ressources Alternatives en Sante´ Mentale, 2005). 3. Current development of psychosocial rehabilitation programs: Case management/ACT, treatment of concurrent substance use disorder and severe mental illness and vocational rehabilitation Together, hospitals, CLSCs in Que´bec, and community agencies provide a wide array of common types of mental health and addictions programs that also exist in the U.S. — including clubhouses, case management, crisis intervention, stepwise vocational rehabilitation, supervised housing, residential programs for substance abusers, and so on. As Rochefort and Goering have written, many Canadians involved in psychosocial rehabilitation have been strongly influenced by program development and research evidence from the U.S.; a number have also received training in the U.S. (Rochefort & Goering, 1998). Even in the province of Que´bec, which looks towards Europe for intellectual and cultural inspiration to a greater extent than does the rest of Canada, a scan through back issues of the provincial Association for Psychosocial Rehabilitation’s newsletter, Le Partenaire, indicates that translations of American writings and speeches are much more common than those of Europeans or others. We will focus here on three types of programs for which evidence-based practices have been defined that contrast with more traditional services: case management/Assertive Community Treatment, treatment for people who have concurrent mental illness and substance use disorder, and vocational rehabilitation. 3.1. Case management/assertive community treatment Community organizations offering case management services, often inspired by the highly publicized Bridge program at Thresholds in Chicago (Witheridge & Dincin, 1985), have been in existence in various Canadian provinces at least since the 1980s. These programs vary in approach, some being

568

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

closely aligned with Boston University’s Psychiatric Rehabilitation Model (Rochefort & Goering, 1998), others having a variety of other philosophies and emphases. During the 1970s, one of the first hospital-based programs somewhat similar to the ACT model was developed and studied at the Montreal General Hospital (Fenton, Tessier, et al., 1979, Fenton, Tessier, et al., 1982). The psychiatrist who initiated that program, however, subsequently left Montreal for the U.S. and his program was abandoned. It was not until the early1990s that intensive case management programs, and programs more or less closely patterned after the ACT model (Allness & Knoedler, 1998; Bond, Drake, et al., 2001; Stein & Santos, 1998), began appearing in noticeable numbers in psychiatric and general hospitals. To date, Ontario is the only province that has implemented ACT on a wide scale — tying, in the mid- to late 1990s, the closure of several psychiatric facilities to the development of ACT programs. By 2002–2003, Ontario had 61 ACT teams, receiving $57 million in funding from the Ministry of Health and Long-Term Care (Ontario Ministry of Health and Long-Term Care, 2003). Ontario established a central technical support service which operated until 2003. In spite of this, there remain concerns about model fidelity. For example, fewer than half of a sample of 33 teams reported providing 75% or more of contacts out of the office; and the 33 teams had an average staff : client ratio of 1 : 5, considerably less than the standard of about 1:10 (George & Durbin, 2004). Other provinces also have some ACT programs, but these programs are far fewer in number (Nova Scotia Department of Health, 2004). The Que´bec government has to date maintained an ambiguous stance with respect to the ACT model, on the one hand advocating the development of ACT-like programs, that provide intensive support in the community to people who do not benefit from less intensive care, but on the other hand refraining from any clear endorsement of the ACT model per se (Ministe`re de la Sante´ et des Services Sociaux, 2004). The Que´bec Hospital Association, in contrast, has issued practice guidelines in French (Association des hoˆpitaux du Que´bec, 2000; Association des Hoˆpitaux du Que´bec, 2004) and organized provincial conferences explicitly advocating for fidelity to the ACT model. Partly as a result of these activities, some health regions have allocated funds for the startup of a few teams. In early 2005 there exists in Que´bec a loose association of 18 hospital-based programs, of which about a half-dozen are consciously patterned after the ACT model. As in Ontario, the issue of how best to adapt the model to remote rural areas where the population is highly scattered looms large. The provincial government’s sensitivity to the need for considerable, and somewhat improvised, adaptation in rural remote areas, together with concerns about the perceived coerciveness of the model that a number of providers have expressed, are two important reasons why the Ministry of Health and Social Services has been reluctant to endorse the ACT model. 3.2. Programs for the treatment of concurrent substance use disorder and severe mental illness As in other countries, people with severe mental illness and substance use disorder in Canada most often encounter separate services that often do not communicate with each other (Mueser, Noordsy, Drake, & Fox, 2003). Increasing recognition of the importance of integrating the two forms of treatment has, to date, mostly led, in Canada, to efforts to improve communication across programs — with some exceptions, such as the Cormier–Lafontaine clinic in Montreal. ACT teams, which are supposed to include substance use specialists and to provide integrated treatment, are the most likely place to find integrated treatment for mental illness and substance abuse in Canada. (There have existed for some time programs that provide integrated treatment, for people with non-psychotic illnesses, for example at the Montreal General Hospital). In Que´bec, initial experimentation with integration on one ACT team

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

569

(Latimer, Mercier, & Crocker, 2001) has convinced many other provincial ACT team leaders of the importance of including at least one substance use specialist on the team. 3.3. Vocational rehabilitation Vocational rehabilitation programs in Canada span a wide spectrum, from hospital-based occupational therapy to sheltered workshops, clubhouse-type transitional employment, consumer-run businesses and now supported employment. While there is broad consensus that most people with mental illnesses need work to provide meaning and structure to their daily activities, and recognition that competitive workplaces are typically inimical to people with severe mental illness, there are considerable disagreements as to the best approach to ameliorate the situation. At least four types of programs are present in the field of vocational rehabilitation in Canada, as in a number of other countries: (1) programs that emphasize sheltered settings, where there is no expectation that the consumer will move on to competitive employment; (2) programs that aim, often through transitional work experiences, to prepare clients for competitive employment; (3) consumer-run businesses and social firms, which see employment within themselves as a valid long-term goal for people with severe mental illness; and (4) supported employment, which seeks to help people with severe mental illness find individually matched competitive jobs with minimal pre-vocational preparatory phases (Becker & Drake, 2003; Bond, 1992). Supported employment programs, however, particularly those that follow the Individual Placement and Support (IPS) model (Bond, 1998), which specifies that employment specialists should be placed within clinical teams, are only beginning to emerge. The premise of IPS that competitive employment is most desired by consumers and most conducive to their recovery is not widely shared. Consumer-run businesses are particularly visible in Ontario. The Ontario Council of Alternative Businesses (OCAB) represents 11 consumer-run businesses, which together (according to OCAB’s web site) employ over 600 psychiatric survivors. The recent interim report on mental health, mental illness and addictions of the Standing Senate Committee on Social Affairs Science and Technology calls for the development of more such businesses. Some other English-speaking provinces have been seeking to emulate this model (Canadian Mental Health Association Vancouver Burnaby Branch, 2005). Que´bec in contrast has many social firms (entreprises sociales), which are government-subsidized and provide employment for many people who have difficulty integrating the regular labour force. These firms however are not normally consumer-run. The province of Que´bec has adopted in some respects a more pro-active approach to facilitating the integration of people with disabilities into the workplace than other provinces. Workplace integration contracts (Contrats d’Inte´gration au Travail, or CITs) may be arranged between an employer and the government, via a regional agency, which cover a declining percentage of the worker’s wages. This percentage often starts at 80% for the first several months. The contracts are supposed to make the employer financially indifferent between hiring a less productive disabled worker (who is still paid at the normal rate for the position) and a non-disabled worker. Advocates for people with mental illness in Que´bec have decried the fact that they are structured to decline progressively, as the productivity of people with mental illness is more likely to wax and wane than to increase steadily; thus people with mental illness often keep their job only as long as it is sufficiently subsidized. The expansion and adaptation of CITs is an important element in the vocational rehabilitation component of the Que´bec government’s proposed action plan for mental health for 2005–2008 (Ministe`re de la Sante´ et des Services Sociaux, 2004). This plan makes no mention of supported employment

570

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

patterned after the IPS model; indeed, at present, there is only one such supported employment program in the province, located at the Douglas hospital in Montreal. The development of supported employment in other provinces is also quite limited, although there do exist a half-dozen programs in British Columbia (Corbie`re, Bond, et al., 2005) as well as others in Toronto. 4. Current trends and prospects for adoption of evidence-based practices At least two significant trends are currently influencing the development of services for people with severe mental illness in Canada. First, as alluded to earlier, the governance of health care services in general, including mental health services, is moving toward the establishment of more precise accountability mechanisms. Second, there is increasing recognition of the need for more integration of care. With the singular exception to date of Ontario’s aggressive ACT policy, however, attempts to achieve this integration mostly involve the development of a variety of inter-organization communication protocols. As one might expect, there is some evidence that enhanced inter-provider communication can yield direct benefits for clients (Rosenheck, Resnick, & Morrissey, 2003). There is also, however, rather stronger evidence that, in general, attempts at integrating care that fall short of placing mental health, substance abuse and vocational specialists within a single clinical team are, in general, somewhat less effective in terms of client outcomes (Goldman, Morrissey, et al., 1994; Rosenheck et al., 2002). The inclusion of relevant specialists within a single clinical team, clearly the most direct mechanism for facilitating communication across types of treatment and rehabilitation providers, is a hallmark of three practices now considered evidence-based: Assertive Community Treatment, integrated treatment for mental illness and substance abuse, and the Individual Placement and Support model of supported employment. The establishment of such programs is difficult in a system characterized by the presence of so many small, highly specialized community agencies. There are however some hopeful signs. The Canadian Health Services Research Foundation has been promoting for several years now the importance of strengthening linkages between researchers and decision-makers — to the point of offering grants specifically designed to encourage such linkages (Lomas, 2000). In all of Canada’s largest provinces at least, such linkage mechanisms between mental health services and policy researchers and decision-makers are already either well-established or in the process of being established (Goldner, Beause´jour, & Adair, 2004; Jacobson, Butterill, & Goering, 2003; Ministe`re de la Sante´ et des Services Sociaux, 2004). While decision-makers have many objectives and face many constraints precluding an exclusive focus on implementing evidence-based practices, greater awareness of such practices can only be helpful. As happened most visibly, but not only, with Ontario’s ACT policy, opportunities to use new monies to fund the development of evidence-based programs can be a politically practicable means to gradually increase access to evidence-based practices. At the same time, the parallel development of more precise accountability mechanisms gives governments and regional authorities the opportunity to monitor fidelity to program standards. There is a potential contradiction, however, between the exigencies of evidence-based practices, and the policy of regionalization. In provinces that have devolved administrative responsibility for health care delivery to regional authorities, quality control of individual programs would naturally be seen as a regional responsibility. Yet, experience shows that the expertise needed to successfully assist programs in acquiring a high degree of fidelity to a program model such as ACT or supported employment is rare even within an entire province. It is unrealistic to expect to find it within each regional authority. Mechanisms therefore need to be instituted that allow regional authorities to work collaboratively with a

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

571

provincial-level technical assistance and support service. Indeed, given that expertise with different evidence-based practices typically lies with different individuals and programs, one would anticipate the formation of different technical assistance and support services for different evidence-based practices — following a pattern similar to that in the state of Ohio, for example, where nine Coordinating Centers of Excellence, each focused on a different evidence-based practice, have been established (Ohio Department of Mental Health, 2005). These could, alternatively, be integrated within a single entity, analogously to the National Institute for Mental Health in England (NIMHE) (National Institute for Mental Health in England (NIMHE), 2005) — with the difference that in the Canadian context, such an entity is more likely to be organized at the provincial level. 5. Conclusions The development of mental health services for people with severe mental illness in Canada has in many ways paralleled that in other countries, particularly the United States. As reliance on inpatient psychiatric care has been sharply reduced, a wide range of community supports have been developed, reflecting the variety of program models and philosophies found in many other countries, as well as some unique emphases. In its interim report, released in November 2004, the Standing Senate Committee on Social Affairs, Science and Technology highlighted the fragmentation of care that people with severe mental illness typically receive in Canada (Standing Senate Committee on Social Affairs Science and Technology, 2004). The present challenge is to achieve greater service integration, in a way that benefits the people being served. Here the plethora of small community agencies in Canada, together with the trend toward regionalization of administration of provincial care, pose special challenges. Key evidence-based practices such as ACT, supported employment and integrated treatment for dual disorders involve integration of people who presently work in different organizations within the same clinical team. Furthermore, they require considerable, specialized support to be implemented successfully. An evolutionary approach of gradually introducing integrated, evidence-based programs, supported by centralized technical assistance and support services, may provide the most feasible strategy for improving the system.

Acknowledgements The author thanks Janet Durbin, Paula Goering, Alain Lesage and an anonymous referee for many helpful comments and suggestions. Any remaining errors are the author’s. The author also gratefully acknowledges salary support from the Fonds de la Recherche en Sante´ du Que´bec (Que´bec Health Research Fund).

References Alberta Mental Health Board. (2005). Alberta mental health board website: http://www.amhb.ab.ca/ Allness, D., & Knoedler, W. (1998). The PACT model of community-based treatment for persons with severe and persistent mental illnesses: A manual for PACT start-up. Arlington, VA7 The National Alliance for the Mentally Ill. Association des hoˆpitaux du Que´bec. (2000). Cadre de re´fe´rence: Le suivi intensif en e´quipe pour personnes atteintes de troubles mentaux graves. Montre´al: 29. Association des Hoˆpitaux du Que´bec. (2004). Guide de pratique pour les e´quipes de suivi intensif dans la communaute´, Vol. i45. Montre´ al, Que´bec7 Association des Hoˆpitaux du Que´bec.

572

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

Barer, M., Lomas, J., & Sanmartin, C. (1996). Re-minding our Ps and Qs: Medical cost controls in Canada. Health Affairs, 15(2), 216 – 234. Becker, D. R., & Drake, R. E. (2003). A working life for people with severe mental illness. New York, NY7 Oxford University Press. Bond, G. (1992). Vocational rehabilitation: Handbook of psychiatric rehabilitation. In R. P. Liberman (Ed.), Toronto, Ontario7 Macmillan Publishing Company. Bond, G. (1998). Principles of the individual placement and support model: Empirical support. Psychiatric Rehabilitation Journal, 22(2), 11 – 23. Bond, G. R., Drake, R. E., et al. (2001). Assertive community treatment for people with severe mental illness — Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9(3), 141 – 159. British Columbia Ministry of Health Services. (2005). Mental health and addictions British Columbia Ministry of Health Services website: http://www.healthservices.gov.bc.ca/mhd/ Canadian Institute for Health Information News. (2004). Canadian Institute for Health Information News website: http:// secure.cihi.ca/cihiweb/dispPage.jsp?cw _ page=media _ 08dec2004 _ e#capita Canadian Mental Health Association Toronto Branch. (2005). 2004 Annual Report, Statement of Revenue and Expenses: http:// www.toronto.cmha.ca/PDFs/cmhato _ annual _ report _ 2004.pdf Canadian Mental Health Association Vancouver Burnaby Branch. (2005). CRB — Introduction: http://modena.intergate.ca/ cmha-vb/test/Pages/index.htm?crbbprog.htm Community Mental Health Evaluation Initiative. (2005). Making a difference: Ontario’s community mental health evaluation initiative. Toronto, Ontario7 Centre for Addiction and Mental Health. Corbie`re, M., Bond, G. R., et al. (2005). The fidelity of supported employment implementation in Canada and the USA. Vancouver, B.C. Department of Finance Canada. (2005). Transfer payments to provinces: http://www.fin.gc.ca/FEDPROV/eqpe.html Fenton, F., Tessier, R. L., et al. (1979). A comparative trial of home and hospital psychiatric care: One year follow-up. Archives of General Psychiatry, 36, 1073 – 1079. Fenton, F. R., Tessier, L., et al. (1982). A comparative trial of home and hospital psychiatric treatment: Financial costs. Canadian Journal of Psychiatry, 27(3), 177 – 187. George, L., & Durbin, J. (2004). Presentation to technical advisory panel for ACT Ontario. Goering, P., Wasylenki, D., et al. (2000). Canada’s mental health system. International Journal of Law and Psychiatry, 23(3–4), 345 – 359. Goldman, H. H., Morrissey, J. P., et al. (1994). Evaluating the Robert Wood Johnson Foundation program on chronic mental illness. Milbank Quarterly, 72(1), 37 – 47. Goldner, E., Beause´jour, P., & Adair, C. (2004). Personal communication, March 2004. Health Canada. (2005). Canada Health Act: http://www.hc-sc.gc.ca/medicare/home.htm Jacobson, N., Butterill, D., & Goering, P. (2003). Development of a framework for knowledge translation: Understanding user context. Journal of Health Services Research & Policy, 8(2), 94 – 99. Latimer, E., Mercier, C., & Crocker, A. (2001). Prestation de soins inte´gre´s pour les personnes atteintes de troubles mentaux graves et persistants dans leur milieu de vie. Montre´al, Quebec7 Centre de recherche de l’Hoˆpital Douglas. Lomas, J. (2000). Using dlinkage and exchangeT to move research into policy at a Canadian foundation. Health Affairs, 19(3), 236 – 240. Ministe`re de la Sante´ et des Services Sociaux. (2004). Plan d’Action en Sante´ Mentale 2005–2008: Document de consultation (pp. 1 – 57). Ministe`re de la Sante´ et des Services Sociaux. (2005). Re´seau: Organismes communautaires. Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2005). Integrated treatment for dual disorders: A guide to effective practice. New York, NY7 The Guilford Press. National Institute for Mental Health in England (NIMHE). (2005). Website: http://www.nimhe.org.uk/ Nova Scotia Canada. (2005). Programs and Services: http://www.gov.ns.ca/health/programs.htm Nova Scotia Department of Health. (2004). Mental Health Act Introduced: http://www.gov.ns.ca/health/release. asp?id=20040929002 Ohio Department of Mental Health. (2005). Ohio’s Coordinating Centers of Excellence (CCOE) Initiatives: A Resource for Evidence-Based Practices: http://www.mh.state.oh.us/initiatives/soqic/f.pdf Ontario Federation of Community Mental Health and Addiction Programs. (2005). Provincial agency directory: http:// www.ofcmhap.on.ca/

E. Latimer / International Journal of Law and Psychiatry 28 (2005) 561–573

573

Ontario Ministry of Health and Long-Term Care. (2002/2003). 2002/03 Ontario ACT Data Outcome Monitoring Report. Pyke, J., Darcy, P., Densmore, D., & Durbin, J. (2005). Operational review of the Ontario peer development initiative (Research Proposal). Toronto, Ontario. Regroupement des Ressources Alternatives en Sante´ Mentale. (2005). http://www.rrasmq.com/presentation.html Rochefort, D. A., & Goering, P. (1998). bMore a link than a division:Q How Canada has learned from U.S. mental health policy. Health Affairs, 17(5), 110 – 127. Rosenheck, R., Lam, J., Morrissey, J. P., Calloway, M. O., Stolar, M., & the ACCESS National Evaluation Team. (2002). Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Psychiatric Services, 53(8), 958 – 966. Rosenheck, R. A., Resnick, S. G., & Morrissey, J. P. (2003). Closing service system gaps for homeless clients with a dual diagnosis: Integrated teams and interagency cooperation. Journal of Mental Health Policy and Economics, 6(2), 77 – 87. Sealy, P., & Whitehead, P. C. (2004). Forty years of deinstitutionalization of psychiatric services in Canada: An empirical assessment. Canadian Journal of Psychiatry, 49(4), 249 – 257. Standing Senate Committee on Social Affairs Science and Technology. (2004). Interim report on mental health, mental illness and addiction. Ottawa, Ontario: 1st session of the 38th parliament. Available on the Parliamentary website at:. www.parl.gc.ca Statistics Canada. (2005a). Gross domestic product, expenditure-based, by provinces and territories: http://www.statcan.ca/ english/Pgdb/econ15.htm Statistics Canada. (2005b). Population by year, by provinces and territories: http://www.statcan.ca/english/Pgdb/demo02.htm Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe mental illness. New York, NY7 W.W. Norton. The Canadian Centre for the Analysis of Regionalization and Health. (2005). Vancouver 2004: Effective health region size and design: How should health regions be designed for effective performance? Available at the following website:. http:// www.regionalization.org/Conferences/Conf _ 05/Conf _ 05 _ Announce.html# Thresholds Psychiatric Rehabilitation Centers. (2005). Financial Information: http://www.thresholds.org/financial.asp Witheridge, T. F., & Dincin, J. (1985). The bridge: An assertive outreach program in an urban setting chapter. In L. I. Stein & M. A. Test. (Eds.) The training in community living model: A decade of experience, vol. 26 (pp. 65 – 76). San Francisco, CA7 JosseyBass.