What will be different

 

Individuals with a psychiatric disability live in integrated housing that they have selected in their community; work in jobs and/or participate in meaningful activities that they have chosen; have positive relationships with their families; and have friends who rely on them for support and on whom they can rely.

 

Individuals have services and supports available that they have had a central role in developing, selecting among, and evaluating. These services and supports are focused on supporting people in their recovery processes in their local communities, and are delivered as close to home as and in the least intrusive way possible.

 

Individuals have access to a comprehensive, well-integrated and balanced range of community, ambulatory and inpatient services and supports, offered by both professionals and peers.

 

Services and supports are offered in the context of and are responsive to people’s economic, cultural and social situations, are based on the latest relevant knowledge and are oriented toward successful coping, empowerment, self-direction and recovery.

 

Efforts to change negative public attitudes and their resulting behaviours, such as discrimination, are in place in local communities and are working. Local community resources and the responsibility to include all citizens in community life are seen as an integral part of the community framework for support.

 

Users of services have the resources and authority to hold service providers and funders accountable for the quality of mental health treatment, services and supports they receive.

 

Individuals with a psychiatric disability are not defined by their disability or illness, are recognized for their strengths and are empowered and have the resources to define and live the lives they want to lead to the absolute best of their ability.

 

Source:  Government of Ontario. (December 2002) The time is now: Themes and recommendations for mental health reform in Ontario. Final report of the Provincial Forum of Mental Health Implementation Task Force Chairs.

 

The key types of services that are required to make such a system a reality are presented in graphic form in the diagram “The Continuum of Care.” This diagram is drawn from one of the Ontario Mental Health Implementation Task Force reports (Toronto-Peel Implementation Task Force Report).[166]

This framework does not present a definitive listing and categorization of services and supports; those listed are not exhaustive but are illustrative of the services and supports that are needed. Thus the model should be regarded as one useful way of depicting the range and types of services and supports that are required in a transformed mental health system.

One advantage to this framework is that it is able to encompass the full range of services and supports, listed under three “levels of need” (first-line, intensive and specialized), with a fourth category that cuts across the three levels. This terminology moves away from commonly used terms that some associate with an overtly medical approach, i.e., primary, secondary and tertiary care. As discussed in Chapter 3, the Committee believes strongly that mental health issues should be approached from a variety of perspectives, only one of which is the “medical” model.

 

Each level of need is associated with a particular array of services and supports. People will usually receive most of their services from within a particular level, but they are not limited only to the services within that level.

 

a)         First-line

First-line refers to prevention, assessment and treatment provided by frontline providers, including family physician, primary care clinics, and the providers of mental health services, social services, and hospital emergency services. For most people with mental health problems, the first-line level will be their first contact with mental health services, usually through their family physicians or primary health care teams. When someone’s illness is not too serious or of short duration, the provision of first-line services will usually be enough to meet the person’s needs.

 

First-line services and supports therefore must be easily accessible to people no matter what their specific needs. Providers at this level must to be able to respond to a very wide range of needs, and be extremely sensitive to the confusion, fear, and concern of those experiencing symptoms of mental illness, perhaps for the first time. They need also to be culturally sensitive so that they can respond appropriately to the needs of people from a diversity of backgrounds.

First-line services and supports must be well connected not only to each other, but also to more intensive and “cross-level” mental health services and supports that can be called upon as needed. Individuals who are diagnosed with serious and ongoing mental illness will usually be referred by first-line service providers to intensive or specialized services for further assistance.

 

b)         Intensive

Intensive refers to mental health assessment, treatment and support services that are provided in community or hospital settings for people with serious mental illness. People living with serious mental illness will often require ongoing, long-term support from service providers, but not necessarily daily contact. Intensive services and supports are designed to provide continuous contact and support for people who, without them, would be at risk for repeated or prolonged institutionalization in health care or correctional facilities. The needs of most people living with a serious mental illness should be met by community-based intensive services and supports. People who suffer from acute, severe impairment in personal functioning and are at significant risk, such as someone with a severe post-partum depression, could also require these kinds of intensive services.

 

Services at this level address the serious and complex mental disorders most common among the general population (including concurrent disorders, eating disorders, first episode schizophrenia, and personality disorders). Service integration can be facilitated through intensive case management. Intensive services and supports must be well connected to first-line and “cross-level” services and supports and must be able to access, and be backed up by, specialized services and supports so that together they can address people’s unique and/or particularly complex needs effectively.

 

c) Specialized

Specialized refers to highly specialized mental health programs provided in community or hospital settings that focus on serving people whose serious mental illness is characterized by complex and unstable mental disorders. Only those very few people with serious mental illness who require ongoing, daily contact with service providers will need to access such specialized services and supports. As these services are the most specialized, least available and most expensive resources in the mental health system, they must be reserved for those who truly need them and used only when intensive and cross-level services and supports have failed to work for a given individual.

The following are among those whose problems require that they be addressed at this level:

§         elderly people suffering from dementia, psychosis and medical illness,

§         people who are developmentally disabled with psychiatric disorders and who often display aggressive behaviours,

§         people living with schizophrenia who are chronically psychotic, aggressive or suicidal,

§         people with complex, treatment-resistant mood disorders.

Specialized services are not synonymous with long-term, institutionalized care. Rather, treatment, rehabilitation and support services can be provided by multi-disciplinary teams that work in ways to enable many people living with these illnesses to continue to live in the community.

Individuals who use specialized services and supports will not always need this level of care. The need of individuals for the whole range of services and supports must be monitored and reassessed continuously as they progress through the recovery processes and as their needs change.

d) Cross-level

Cross-level services and supports is a term used by the Toronto-Peel Implementation Task Force to refer to those services and supports that may be needed regardless of whether someone is being served at the first-line, intensive or specialized level of the mental health system. They include housing and housing supports, educational and vocational services and supports, drop-ins and other social/recreational supports, as well as consumer and family peer/self-help supports. Cross-level services and supports are typically — and most effectively and efficiently — delivered in the community, and are amongst those services and supports most often identified by people living with mental illness and their families as being fundamental to the recovery processes.

 

5.3.1     The Continuum is Local and Complex

The preceding section described the types of services and supports that must be in place for people living with mental illness to live meaningful and productive lives in the community. In the real world, however, what is available will depend on many factors that are unique to the history and circumstances of each community; each will have its own particular mix of services and supports. These will vary not only from province to province, but from region to region and municipality to municipality.

This inescapable regional variation was noted in the mental health plan issued recently by the Quebec government:

The situation in each particular region, as well as available expertise and experience, may mean that the continuum of mental health services differs from region to region. Services must be tailored to suit local needs. At the same time, it is necessary to ensure that a continuum of basic services (what we have called “required services”) is in place.[167]

During its cross-country hearings, the Committee was impressed by testimony that described the integrated provision of community-based services and supports in Brandon, Manitoba. Further investigation by Committee researchers, who visited Brandon during the summer of 2005, confirmed the Committee’s initial impression that Brandon stands out as an example of how hard work and careful planning can yield effective results. But, as noted in Chapter 3, the Brandon experience also illustrates also how efforts to provide an integrated continuum of care are both complex and fundamentally local in nature.

The Committee does not believe it wise to attempt to dictate a uniform model that could be implemented somehow across the country. It is not even possible (or desirable) to do this on a province-wide basis because the effectiveness and efficiency with which services are delivered depend critically on a number of local particularities, including the history of local institutions and the number and characteristics of the people who live in each community. The Brandon experience illustrates this critical point. While it cannot serve as a template or uniform model, many valuable lessons can be learned from Brandon’s success in integrating mental health services, lessons that can be creatively applied throughout the country.

Southwest Manitoba is largely rural farming country, with Brandon, a city of 45,000, as its major urban centre.  Health care in Manitoba is managed through Regional Health Authorities (RHAs).  The Brandon RHA serves the city and, in addition, provides referral and other services to the surrounding Assiniboine RHA (112,000 square miles, population 80,000) and to four other RHAs in rural areas to the north and east of Brandon. 

For most of the 20^th century, mental health services for Brandon and the western portion of Manitoba were delivered from the Brandon Mental Health Centre (BMHC), a large psychiatric institution dating from the early 1900s.  Mental health leaders in Brandon started planning in the 1980s to transfer the centralized services in the BMHC to the community.  The number of beds in the aging BMHC buildings started to decrease in the 1980s, and the BMHC was closed in stages between 1994 and 1999.

Albert Hajes, Regional Coordinator, Mental Health Program, Brandon Regional Health Authority, described to the Committee how key aspects of this transition were managed.[168] In the first place, attitudes had to change:

A very important point is that with the closure of BMHC we had to go through a process of shifting the beliefs of patients and staff to one that supported the principle that people could live with mental illness disability in the community and have good quality of life including a greater participation and full citizenship. It required a shift in thinking away from the traditional institutional model not just in terms of the staff and the patients, but also in the general community.

As well, Mr. Hajes spoke of the need for advance planning:

A transition of this magnitude was not possible without the development of strong community-based services within the general community to support clients. Considerable work was done prior to the implementation of mental health reform and the transition of services to strengthen the capacity of the service structure and the community to sustain clients.

Mr. Hajes then described some of the measures that were taken:

Key principles included recruitment and training of proctor paraprofessional staff to provide close and frequent contact with clients to assist with their independent living. We worked for the establishment of skill development and capacity building for clients to acquire the abilities to function with relative autonomy. We helped our clients to gain access to resources and have greater participation within the community. We established the full spectrum of services that are needed to support clients in a normalized community setting.

Brent White, Program Manager, Residential and Support Services in Brandon, elaborated on the proctor program:

In Brandon, we have developed something we call a “proctor service,” which has been likened to home care service, if you will, for mental health clients.  Those individuals provide support services to individuals supporting long-term goals.  It involves the client in terms of an empowerment process, engaging them in working towards their goals, which might be living goals, educational goals, vocational, or social goals.  We have paid a lot of attention to the provision of supportive social programming as well for people.[169]

The proctor program has since been adopted by other regions of Manitoba. In Brandon, the proctors, who are mostly employed part-time, each help approximately 150 clients.  Proctors are drawn in approximately equal proportions from health professional or psychology students, from people trying to enter the job market, and from retired people looking for part time work; approximately one-third of proctors are themselves former or current clients of mental health services.

Mr. Hajes also stressed the importance of broader community involvement:

Additionally, there was the need for formation of strong partnerships with other health and social service agencies, hospital services, physicians as well as police, school divisions, property owners and housing authorities and others. …   If we were asking community partners to share in responsibility for service to mental health clients, we also needed to provide a backup service to them.

Finally, Mr. Hajes explained how the lack of doctors in Brandon served as a catalyst for innovation:

We have a large generic workforce of community mental health workers that have credentials of psychiatric nursing, psychology and social work. The Brandon Mental Health Centre employed a similar staff that did not include many psychiatrists and physicians.

In fact, truth be told, we went through a period of very lean years. At one point in time, we actually had one psychiatrist who came from Winnipeg two or three days a week to sign the documents, and we had a couple of physicians with some mental health experience. That developed the capability and the capacity of the non-medical workforce to be able to respond to the needs. The competencies of our workforce are significantly better, I believe, than what you would see in most other mental health regions.

Currently, the various programs in Brandon are coordinated by a management team that meets every two weeks.  Mental health programs receive approximately 10% of the total funds of the Brandon Regional Health Authority, which has preserved the mental health budget allocation even in years when deficits loomed.

 

 

First contact with the system can be through a readily accessible and visible “store front” location centrally located in downtown Brandon, close to public transportation and other services on which mental health clients depend. This community-based centre also has close working relationships with several allied services and agencies. One of these is the Brandon Friendship Centre, an Aboriginal peoples’ organization to which people can be referred for traditional culturally appropriate treatments, with funding provided through a services contract with the mental health program.

Intensive Case Managers serve people who are living in the community but need continuing support to manage their daily lives. The Psychosocial Rehab-Residential Services helps them find accommodation in the rental market, where they have access to the proctor service described above. The Westman Crisis Services is a nurse-run, 24/7 telephone response centre that operates a mobile crisis intervention service as well as a crisis stabilization unit that can accommodate up to eight people for approximately five days. Those who need acute in-patient psychiatric care can be referred to the Centre for Adult Psychiatry, a 25-bed acute care psychiatric hospital facility connected to the Brandon Regional Health Centre.

There are also programs for people at both ends of the age spectrum. Mental Health Services for the Elderly serves seniors in their homes, while those elderly clients who need acute in-patient care can be referred to the Centre for Geriatric Psychiatry. The Centre operates a 22-bed acute care psychiatric unit connected to the Brandon Regional Health Centre and manages to return 70% of people who are admitted from their home environments to their homes after discharge. The Brandon Mental Health Program’s Child and Adolescent Treatment Centre (CATC) is located in its own building next to a high school; it also focuses on enabling each young person affected by a mental illness to return to his or her school, family and community.

 

5.4       COMPLETING THE TRANSITION TO COMMUNITY-BASED SERVICES

Although community-based services are being developed in many regions of the country, such as Brandon, the Committee believes that there is still much to be done to allow people living with mental illness to have access to the services and supports they require to live productively in a community setting. Of those who responded to the Committee’s second e-consultation, 80% indicated that the services required by people living with mental illness were not available in their communities.[170]

The consequences of not having access to services and supports in the community are that people living with mental illness must rely on institutional services that are generally much more expensive, and often not as beneficial. Nancy Beck, Director, Connections Clubhouse in Halifax, recounted the case of a 72-year-old veteran with schizophrenia: 

[Clyde] requires a couple of hours a week of personal care and a couple of hours to help prepare meals.  As a mental health client, he is not able to access home care and against his wishes, the recommendation is that he receives long-term care.  We estimate it would cost $400 a month to honour Clyde’s wish and help him remain in an apartment that he has lived in for 15 years.[171]

Other witnesses stressed the importance of accessible and appropriate housing not only as the necessary foundation for people living with mental illness to remain in the community, but as a cornerstone of reform of the entire mental health system. In the words of Stephen Ayr, Director of Research, Capital District Health Authority in Halifax:

The next issue is housing. I need not say anything more than if the issue of housing is not addressed, then it is unlikely that any provincial mental health reform will have an impact on the problem.[172]

Witnesses told the Committee that the money that had been spent previously on providing institutional care was not always transferred to the community. Jocelyn Greene, Executive Director, Stella Burry Community Services in St. John’s, spoke of the impact of funding cuts to health care during the 1990s:

In particular, in 1995, the cutbacks from the federal government funding resulted in cutbacks in this province in health care and, in particular, the closure of 97 out of the 127 long-term beds at the Waterford Hospital, which is our provincial psychiatric facility.  It is not too strong to say that none of those savings realized from the closure of those beds went back to the community.  Wherever they went, they certainly did not come to those of us who work in the community.[173]

Further evidence of the difficulties confronted by community-based mental health services can be found in a survey of its members conducted by the Ontario Federation of Community Mental Health and Addiction Programs in 2002. It concluded that:

§         Since 1992, most of the Federation’s 212 member organizations have experienced a net decrease of 20% in provincial funding for core programs, taking into account the increased cost of operations since then.

§         Eighty percent of respondents have had to close programs temporarily to cope with fiscal pressures. Twenty-five percent of them have closed programs permanently.

§         Almost half of the people who need the services of the Federation’s member organizations must wait for 8 weeks or more to access them.

§         For a significant number of programs (18%), the waiting time can be a year or longer.[174]

The Committee was told that the Ontario government is currently making significant investments in mental health services in the community, as are most other provinces. Over the past two years in Ontario, core budgets for community mental health programs have been increased for the first time in 12 years. Despite these efforts, it is clear that there is still a long way to go. For example, Carrie Hayward, Director, Mental Health and Addictions Branch, Ontario Ministry of Health and Long-Term Care, told the Committee that:

Ontario has 6,750 supportive housing units for people with mental illness or addictions, but the Provincial Forum of Mental Health Implementation Task Forces called for 10,000 more across the province, so continued federal support for affordable and supportive housing is welcomed.[175]

More generally, the pattern of use of hospital resources by mental health patients, as revealed by a recent Canadian Institute for Health Information (CIHI) report, suggests that there is still considerable scope for shifting treatment to the community. The report’s analysis of inpatient hospitalizations indicates that mental health patients are more likely to be hospitalized for extended periods than any other patient group. According to the report:

While the Mental Health patient group made up the smallest percent of all hospitalizations, at just over 3%, it had the third highest contribution to total number of days (7.4%), and had the highest average length of stay of all patient groups, at 14.0 days, more than double the national average length of stay.[176]  

And:

In contrast to all patient groups, only 50% of patients in the Mental Health group stayed in hospital for seven days or less. Nearly one-quarter of Mental Health patients stayed in hospital for 19 days or more; almost three times higher than all patient groups combined (7%).[177] 

According to the Organisation for Economic Co-operation and Development (OECD), acute care inpatients are defined as those patients with an average length of stay in hospital of 18 days or less; those required to stay in hospital for longer than 18 days are classified by the OECD as long-term patients. The nearly one-quarter of mental health patients in acute care hospitals who are there for 19 days or longer are, in fact, long-term care patients who are occupying beds in acute care hospitals. While part of the explanation for longer stays in hospital by mental health patients may relate to the nature of their illnesses, it is nonetheless reasonable to assume that many are being kept in expensive acute care hospital beds because there are no alternatives available in the community.

In fact, witnesses told the Committee as much. Roy Muise recounted his experience:

 

I remember the time when I was ready to leave hospital and I had nowhere to go because I had no income and I had no money.  I spent 13 days in hospital only because I had nowhere to go.  It is very difficult, given the gaps in our employment history, first, to get a place to live and, second, to come up with the damage deposit and things like that while we are trying to turn our lives around.  So, yes, there needs to be something done in housing, that is for sure.[178]

The use of acute care hospital beds to accommodate mental health patients for an extended period for reasons similar to those that kept Roy Muise — completely unnecessarily — in hospital, represents a serious misallocation of scarce and valuable resources; in all probability, the patients’ recovery will likely have been substantially delayed to boot! The Committee believes, unfortunately, that this is precisely what is happening right across the country now.

 

5.5       THE NEED FOR A MENTAL HEALTH TRANSITION FUND

As noted earlier, the evidence suggests that, while the transition to community-based services should not be looked on as a cost-saving measure, it will not cost government any more to fund a predominantly community-based system than it does to run one heavily dependent on the institutional sector. The question then arises as to why governments have not been able to complete the transition to a community-based system, given that it offers so many advantages to people living with mental illness and yet costs no more once the transition is complete. There are a number of reasons to explain the uneven progress that has been made across the country in moving towards an integrated continuum of mental health care based predominantly in the community.

The most important of these relates to the dynamics of transferring existing financing from the institutional to the community-based sector. A recent article on the restructuring of mental health policy in Ontario noted that:

 

Closing psychiatric hospitals, however, takes political will and seed money to develop an infrastructure of community services on which such closures rely. A circular argument lies at its core: while the funds needed to develop community services are tied up in hospitals, hospitals cannot close in the absence of community programs. Transitional funds must thus be allocated to develop a community infrastructure.[179]

There are three points to bear in mind in this regard. First, the savings that will eventually accrue from downsizing the institutional sector do not materialize all at once; they accumulate gradually as institutional services are phased out. The practical problem, therefore, is that there are no immediate savings available from within the mental health system to finance the creation of new community-based services. Second, because the phasing out of the old system and the introduction of the new one both take time, the two systems must operate in parallel over a considerable period of time; this too costs money. Third, there is never a guarantee that, over the period of time necessary, the money saved by closing a big institution, for example, will find its way back into the mental health sector.

For these three reasons, the Committee believes that a Mental Health Transition Fund (MHTF) must be established. Such a fund would allow the Government of Canada to make money available to the provinces and territories for investment in services and supports that contribute to the transition toward a community-based, integrated continuum of care for Canadians living with a mental illness. This Fund would be a time-limited investment to cover the costs of the transition and to accelerate the process of developing the community-based system.

Once a new “steady state” has been achieved — when the community-based services and supports, integrated along the full continuum of care, are fully in place — the provinces and territories will be able to sustain the new community-based system with the same level of government spending as was devoted to the old system with its heavy reliance on institutional delivery. Thus, any federal funding directed at helping the provinces and territories move in this direction would be a genuine transition fund; it would not constitute an ongoing obligation for the federal government, nor generate increased costs for the provincial and territorial governments.

 

The Mental Health Transition Fund is unlike many other federal initiatives called “transition funds,” including those such as the Primary Care Transition Fund. Too often, such federal initiatives have resulted in the creation of new programs that must either be supported by new provincial money or disbanded once the federal programs that sparked their creation come to an end. Such initiatives are not truly transitional in that once they are started they place ongoing obligations on provincial and territorial governments to fund them with “new money” on a continuing basis.

 

The Committee has been very careful in crafting its recommendations to ensure that this does not happen in the case of the Mental Health Transition Fund. It is a genuine transition fund in that it is designed solely to cover the costs associated with the shift from one way of organizing mental health services to another that will cost the same once the transition is complete and the transformed system is up and running.

 

The Transition Fund approach is the most appropriate way for the federal government to invest in what is a provincial responsibility - the delivery of mental health services. Because the federal government is not responsible for the delivery of mental health services in the provinces and territories, it cannot determine which specific services and supports are most appropriately funded with federal money. That requires a detailed understanding of what is needed, which can come only from doing the job day in and day out. Therefore, the provinces and territories must decide how to allocate the money to be transferred.

This, of course, is nothing new. It is in line with many recently negotiated health-related agreements between the federal and provincial/territorial governments. In fact, since the creation of the Canada Health and Social Transfer in 1995 the provinces have been masters of how they spend federal transfer payments related to health and social affairs.

The need for flexibility in relation to federal funding to assist with the diverse local needs of mental health service providers was highlighted by Bonnie Arnold from the Canadian Mental Health Association of Prince Edward Island, who used the example of home care:

However, home care has a very different interpretation from province to province.  We believe that it is critical that the federally transferred funds must be sufficiently flexible that they can be used in the most creative and effective ways to best deliver mental health services to P.E.I. and not be tied to one type of service.[180]

It is legitimate, however, for the federal government to expect some form of accountability for its funding, in keeping with its responsibilities to Canadians to properly manage public funds. In this case, the federal government, and Canadians generally, should be assured that the money is: (a) spent on mental health projects; and (b) used to increase the total amount each jurisdiction spends to enhance mental health and treat mental illness.

Moreover, the Committee intends that these funds must not only be incremental to the existing level of provincial or territorial spending. The amount allocated must also take into account the increases in mental health funding that would occur with the overall growth of health care spending in each province and territory. In other words, the new funding must be over and above provincial mental health spending, which should increase at the same rate as the rest of health care spending in the province concerned.

It is important to clarify two points with respect to the Committee’s insistence on the need for new federal money to be used to supplement provincial or territorial spending. First, the Committee does not specify the new or expanded services in which the provinces and territories should invest. It will be up to each province or territory to allocate the new funding to those particular services it needs most, whether to expand or enhance existing services or to create new ones. Second, if individual provinces and territories are able to save money by enhancing productivity, it is entirely up to them to decide how these productivity savings are best spent.

Many believe that to be sure new federal money will be used for its intended purposes, it must be “ring-fenced” in some fashion. As Christine Davis, President, Canadian Federation of Mental Health Nurses, told the Committee:

When money is given to ministries of health and then to health authorities, health authorities do what is most pressing, and that is to reduce wait lists for hip surgery, knee replacement, cardiac surgery and that kind of thing.  If it is not earmarked for mental health, it is not put into mental illness and addictions.  Mental illness and addictions are at the bottom of the hierarchy of health care, and people with those problems are seen as less deserving than others.  It almost needs to be earmarked for mental health from the get-go.[181] 

Some witnesses were concerned that ring-fencing funding for mental health could set restrictive limits on the total amount of funding that was available. But even these witnesses agreed that, given the pressing needs to accelerate change in the mental health sector, ring-fencing was a good idea.

This is how Dr. John Service, Chair, Canadian Alliance on Mental Illness and Mental Health, expressed it:

You put it best yesterday, Mr. Chairman, when you said you are between a rock and a hard place with these ringed funds.  On the one hand, it can be cherry-picked in tough times.  We know that has happened across the country.  I have been in the game for 30 years and it has happened many times in my experience.  Ringed funds are very vulnerable.  They also are in a ghetto by themselves; they accentuate separation.  One of the things that ringed funds and targeted funding can do is kick-start change.  It can buy change.  If it is done right and it is tied into the longer term and structural change that is needed, it can be helpful.[182]

The Committee noted in its report on “Mental Health Policies and Programs in Selected Countries” that this type of ring-fencing was used in the initial phase of implementing the National Mental Health Policy in Australia.[183] All levels of government in that country made a commitment to some form of budget protection so that new injections of federal funds would not be negated by a concurrent reduction in state and territory funding. Specifically, the agreement between governments to protect mental health resources had two components:

§         a commitment to maintaining the level of expenditure on mental health services; and

§         a commitment to reinvest any resources released from closure or rationalization of services back into mental health programs.

The Committee was told by Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, for the Department of Health and Ageing, Government of Australia, that efforts to protect mental health spending had been successful, to the point that they were no longer needed. He said that:

 

 

In fact, one of fears of the federal government 10 years ago was that if we were to give money for mental health, then the states and territories would simply take it and spend it somewhere else. We had an agreement with them that they would maintain their level of funding if the federal government added to the pie. We actually tracked the dollars and the states and territories had to report to a system of monitoring expenditure. We do not need that system now, 10 years later, because governments, realizing how important this is at a jurisdictional level, would not use the money for something else because it has become such a political issue in the communities.[184]

Despite these arguments in favour, it does not appear to the Committee that it is possible to develop at this time a system of ring-fencing that would allow for robust accountability down to the local level. In fact, the Committee commissioned research on the viability of ring-fencing funding for mental health at the level of the Regional Health Authority. The study concluded that not only is there a “lack of coordination of mental health information provincially and nationally, there is limited population needs assessment, service profiling or links between health, social services, justice and education along the journey of care.”[185] In short, the health information system available to track spending on health care, including mental health, is inadequate for the purpose.

The Committee believes, nonetheless, that it is possible to establish a set of procedures, overseen by the Canadian Mental Health Commission, that would ensure that Transition Fund money was spent as intended. Disbursement of the fund should be managed by the Canadian Mental Health Commission, the establishment of which was agreed to by all the Ministers of Health (with the exception of Quebec) and officially announced by the federal Minister of Health on 24 November 2005.[186] The Commission’s expertise on mental health policies and best practices and its arm’s-length relationship to government make it better placed than Health Canada to oversee the administration of the Transition Fund.

The Committee believes that priority should be given to initiatives directed at improving the lives of people living with serious mental illnesses, children and adults alike. Those living with these conditions will benefit most from the delivery of a fully integrated continuum of care. But at the same time, this continuum will make a range of services available in the community that will also assist those living with mild to moderate mental illness.

For example, accessible first-line services are needed as the first point of contact both for those with serious illnesses who will need referrals to intensive and specialized services, and for those who can be cared at the first-line level. Similarly, the development of cross-level services will benefit everyone living with a mental illness, although priority access to such services as supportive housing should clearly be given to people coping with serious illnesses.

The Committee is also particularly concerned that the mental health needs of children be a consistent and strong focus in the development of community-based mental health services and supports. As reviewed in greater detail in the next chapter, the needs of children and youth are too often an afterthought, left to the end even in discussions of how to improve the overall mental health system. The Committee believes strongly that this must be rectified.

The Committee recommends:

9

That the Government of Canada create a Mental Health Transition Fund to accelerate the transition to a system in which the delivery of mental health services and supports is based predominantly in the community. That this Fund be made available to the provinces and territories on a per capita basis, and that the Fund be administered by the Canadian Mental Health Commission that has been agreed to by all Ministers of Health (with the exception of Quebec). That the provinces and territories be eligible to receive funding from the Mental Health Transition Fund for projects that:

·      Would not otherwise have been funded; that is, projects that represent an increase in provincial or territorial spending on mental health services over and above existing spending on services and supports, plus an increment equal to the percentage annual increase in overall spending on health; and that ·         Contribute to the transition toward a system in which the delivery of mental health services and supports is based predominantly in the community. That in allocating the resources from the Mental Health Transition Fund priority should be given to people living with serious and persistent mental illness and that a strong focus should be maintained on meeting the mental health needs of children and youth.

 

5.6       THE COMPONENTS OF THE MENTAL HEALTH TRANSITION FUND

This section discusses some of the key services and supports that would be eligible for funding under the Mental Health Transition Fund (MHTF). The total funding required for these initiatives will be discussed in Chapter 16.

To repeat the Committee’s opinion, the MHTF should have two main components: a Mental Health Housing Initiative (MHHI) that will provide federal funds for the development of new affordable and appropriate housing units as well as for rent supplements to allow people living with a mental illness, who could not otherwise afford to do so, to rent accommodation at market rates; and a Basket of Community Services (BCS) that will assist provinces in providing to people living with mental illness a range of services and supports in the community.

 

5.6.1     The Mental Health Housing Initiative (MHHI)

It would be hard to overestimate the importance of adequate housing for people living with mental illness, in particular those whose illnesses are serious. The scale of the problem is indicated by studies showing that somewhere between 30% and 40% of homeless people have mental health problems, and that 20-25% are living with concurrent disorders, that is, with both mental health problems and addictions.

The Committee heard a consistent story everywhere. Christine Davis, President, Canadian Federation of Mental Health Nurses, put it this way:

Housing is protection from illness.  Housing is protection from the vagaries of mental illness, from the voices, from the fears.  The federal government must address the lack of affordable housing.[187]

Finding suitable housing is an ongoing challenge. Carol Solberg, Executive Director, Schizophrenia Society of Saskatchewan, explained to the Committee that: 

Most people on social assistance live in very small homes, which are not always in safe parts of town; they may be dingy and do not promote good mental health.  I believe that if a person with good mental health had to live in some of those situations they probably would become ill or, if nothing else, depressed.[188]

Jan House told the Committee of her experience trying to find adequate housing for her daughter in Halifax:

Physical environment is especially important for those with mental illness; however, because they often have little or no income, they are often forced to live in the worst possible neighbourhoods filled with high crime, drugs and violence.  In order to ensure she is living in a safe and positive environment, my daughter has been forced to move three times in one year.[189]

Witnesses noted the impact that reduced federal funding has had on the availability of affordable housing. According to the CMHA, between 1980 and 2000, the number of affordable housing units created by the Government of Canada dropped from 24,000 to 940.[190] Linda Chamberlain, of The Dream Team in Toronto, spoke of the shortage of available housing:

That is the whole problem. We do not have enough housing. Most times there is a waiting list of 10 years. Sometimes, some of us have taken five years to get in. That is why [we] need more housing. There is just not enough built.[191]

Bonnie Arnold, of the CMHA in Prince Edward Island, recounted the challenges that confront agencies in the wake of reduced government housing subsidies, as they continue to strive to assist people living with mental illness to secure adequate housing and the services they need. 

While I am speaking about housing, another concern that has come up at the working group level is the fact that subsidized housing programs that were once supported by the federal government no longer exist.  It is true that new money has been made available to assist in building housing, but it is impossible for agencies to be able to make the rents affordable to the tenants, who are often single with low income…[192]

The Committee was also presented with evidence that programs designed to provide support to people living with mental illness do in fact accomplish this goal. Darrell Burnham, Executive Director, Coast Foundation Society/Coast Mental Health Foundation, told the Committee:

We serve well over 2,000 people.  I want to highlight two categories of services.  One is that we provide an array of supported housing.  Indeed, we pioneered supported housing for people with mental illness in 1974 and now serve over 544 people in many different forms of housing throughout the Lower Mainland in decent neighbourhoods in the community.  We have found that it is not only a cost-effective means, in that it keeps people healthy and out of hospital, but also they blend well into the communities.  They are not places that stand out and cause any concern in the neighbourhoods, so supported housing works.[193] 

Suzanne Crawford, Program Manager, LOFT Community Services in Toronto, elaborated on the strengths of the supportive housing model:

 

Why does supportive housing work? We think it works because we promote recovery and independence.  We have heard this over and over. We focus on safety.  We focus on the physical space.  We focus on the 24-hour hands-on support.

As I said, we need our psychiatrists.  We need our clinicians, but you know what? They come into the home.  They are there for an hour and they leave.  Who is there for the 24 hours a day?  It is the supportive housing, and it is the supportive housing in a very psychosocial model.  It offers security.  It offers peace of mind.  It offers flexibility.[194]

Phillip Dusfresne of The Dream Team spoke to the Committee from personal experience:

I used to live on the street and now I am a member of The Dream Team which is a project that was created by the boards for Mental Health Services and Housing Services back in 1999. …

We demonstrate the life-altering benefits of supportive housing by telling our stories to politicians at the various levels of government, social service agencies, service clubs, high school and university students, consumer groups and other institutions. …

People who live in supportive housing live independently. Each of us is assigned a support worker that we could go to whenever we need help. The support workers could help us get on social assistance. They could help us with résumés if we want to go looking for a job. They could help us with doctor and dentist appointments or day-to-day activities if we are not feeling well, but for the most part, we live independently. We do our own cooking, cleaning, grocery shopping and that. Most of us do not have 24-hour support.[195]

The Committee was also told about a variety of innovative projects that are under way across the country, both in the governmental and the non-governmental sectors. Audrey Bean, Co-President of L’Abri en Ville in Montréal, told the Committee:

 

 

 

We work with the psychiatric institutions to identify people who would benefit from our particular kind of living arrangement. We deal with two things that are essential to stability for someone with a mental illness. One is permanent housing, a home, a place where they can invite people to, a place that reinforces a sense of identity, and a place from which they can then re-relate to their families. 

Then, what we provide is social support, so that we have dinners, people go to one another’s houses and we provide that bridge back to the community for a person who has suffered the isolation that those with a mental illness so often suffer.

It is a model that is simple and can be done by any community. We are about … 100 people, with 30 residents, about 60 or 70 volunteers, and a working board of 20 people. We now have a grant. We had one from Human Resources Development Canada, and now one from the McConnell Foundation, to replicate our model in other communities in Canada.[196]

And David Nelson, Executive Director, CMHA, Saskatchewan Division, told the Committee of

…a positive new initiative in this province that is, I believe, groundbreaking.  It is the Saskatche­wan Rental Housing Supplement. … It will assist persons with all types of disability to improve their housing situation, and extends well beyond the stereotypical ramp and washroom modifications generally needed by the physically disabled.  It will provide resources to those with mental health problems on a continuing basis to assist with renovations such as larger windows, enhanced security, noise control and housing closer to services. ...

The supplement is strictly for people who are in the rental market and it will not go to the landlords. It will follow persons when they change homes.[197] 

The Committee was convinced by the testimony it heard that there is need for a major federal investment in housing. Moreover, the testimony points to three interconnected dimensions to be taken into account with respect to this investment: more housing units are required; more assistance is needed so that people can afford to rent existing apartments at market rates; and more supportive services are needed so that people can live in the community. All three dimensions must be addressed.

The investment required in new supportive housing and supportive services for people living with mental illness cuts across areas both of federal and provincial/territorial responsibility. The provision of the necessary supportive services is a provincial responsibility. Thus, the Committee believes that federal support for these services and supports should be channelled through the Transition Fund to be administered by the Canadian Mental Health Commission. The Committee recommends:

10	That services and supports directed at enabling people living with mental illness to be housed in community settings be eligible for funding as part of the Basket of Community Services component of the Mental Health Transition Fund and administered by the Mental Health Commission

 

The Committee believes that the first two interconnected dimensions described above (to build new units and to provide rent supplements) should also be channelled through the Transition Fund. However, in managing the housing portion of that Fund, the Canadian Mental Health Commission should make use of existing structures and bodies at the federal level that are already responsible for affordable housing initiatives, such as the Canada Mortgage and Housing Corporation.

The Committee notes that, in March 2005, the federal Minister of Labour and Housing announced that rent supplement programs would henceforth be eligible for funding under the existing Affordable Housing Initiative launched to fund the construction of new affordable housing units. The Committee believes that a similar approach should be used with respect to federal financing of housing initiatives for people living with mental illnesses.

The Committee therefore recommends:

11

That, as part of the Mental Health Transition Fund, the Government of Canada create a Mental Health Housing Initiative that will provide funds both for the development of new affordable housing units and for rent supplement programs that subsidize people living with mental illness who would otherwise not be able to rent vacant apartments at current market rates. ·         That in managing the housing portion of the Mental Health Transition Fund, the Canadian Mental Health Commission should work closely with the Canada Mortgage and Housing Corporation.

 

The recommended size of the Mental Health Housing Initiative is discussed in detail in Chapter 16, along with a financial accounting of other recommendations in this report.

 

5.6.2    The Basket of Community Services

In addition to housing, many services and supports are needed in order to enable people living with serious mental illness to live safely in their communities. Those described below have all been demonstrated to improve the lives of people living with mental illness by making it possible for them to live productively in the community. They are within the Basket of Community Services that are widely recognized by governments as being at the core of a community-based mental health system:

§         Assertive Community Treatment (ACT) teams that provide continuous and comprehensive treatment, rehabilitation and support services to people with serious mental illness who have multiple and complex needs that cannot be met with less intensive levels of support.

 

 

§         Crisis Intervention units that provide accessible and mobile crisis response services and supports, 24 hours a day and 7 days a week, to clients of all ages.

§         Intensive Case Management that enables people to meet their treatment, support and recovery objectives, maintain positive change, and live as independently as possible in the community.

The Committee is aware that these three by no means constitute all the services that should be eligible for funding under the Mental Health Transition Fund. Many others, such as early psychosis services, services for people with mental illness involved with the justice system, consumer drop-ins, peer support, employment support programs, concurrent disorder programs, services aimed at the mental health needs of refugees and immigrants, could be funded through the Basket of Community Services. But, as we have already noted, it is the particular circumstances of each community that should determine the content of the basket of services that will be most effective. Therefore, the recommendation below is not intended to be prescriptive; it recognizes explicitly the need for local flexibility, subject only to the condition that the services be community-based.

The Committee recommends:

12

That a Basket of Community Services that have demonstrated their value in enabling people living with mental illness, in particular those living with serious and persistent illnesses, to live meaningful and productive lives in the community be eligible for funding through the Mental Health Transition Fund. That this Basket of Community Services include, but not be limited to, such things as Assertive Community Treatment (ACT) Teams, Crisis Intervention Units and Intensive Case Management programs, and that the only condition for establishing the eligibility of a particular service for funding through the Mental Health Transition Fund be that it be based in the community.

 

The recommended size of the Basket of Community Services is discussed in detail in Chapter 16.

 

5.6.3    Promoting Collaborative Care

Most people who seek professional help for a mental health problem will likely see a physician first, rather than a psychologist, social worker, or other provider. This is due primarily to the relatively larger proportion of physicians practising in the community and the manner in which the health insurance systems operate in the provinces and territories — in general, only the cost of seeing a physician is paid for by public funds, while the services of other mental health professionals, such as psychologists, often require private out-of-pocket payment.

 

The Committee believes it important to encourage implementation of collaborative care initiatives in the development of an integrated, community-based continuum of care. Collaborative care is the most promising strategy to improve both access to, and the quality of, treatment and services at the first-line level. A recent American study of “Evidence-Based Mental Health Treatments and Services” reported on the success of collaborative care projects:

For example, the evaluation of one model of collaborative care using non-physician mental health specialists shows that patients with depression treated with the collaborative care model in primary care settings experienced a significantly greater reduction in symptoms over a one-year period than did patients treated with usual primary care.[198]

The idea of collaborative care builds on “shared care” initiatives that were developed to promote greater cooperation between psychiatrists and family physicians. Collaborative care, in the sense intended by the Canadian Collaborative Mental Health Initiative (CCMHI) seeks to widen “the collaboration to include a wide variety of mental health providers, consumers and family members in the partnerships.”[199]

Dr. Nick Kates, Chair of CCMHI, explained to the Committee that

…there are a number of benefits to this kind of integration. The first is that it can increase access to mental health services for a large number of individuals who otherwise would not reach services. We know that 72 per cent of individuals with a mental health problem receive no mental health care over the course of a year, but 80 per cent of these individuals visit their family physicians.[200]

Dr. Kates went on to describe the range of services that could be provided in a primary care setting, including:

…early detection, health promotion and prevention, consultation, treatment, monitoring, and even some rehabilitation services, but we would stress the need to see mental health and primary care systems as complementary. One will not replace the other.[201]

Dr. Kates also told the Committee:

We also see the benefits of pharmacists, dieticians, care navigators, peer support programs, as well as the greater involvement of consumers and family members. We believe in a model of client-centred care. We think that primary care is in a unique position to be able to do this. Our concept of client-centred care includes the development of collaborative care plans, seeing the consumer as an active partner in treatment, the development of peer support mechanisms, and involving consumers in all aspects of planning, delivering and evaluating mental health services in primary care.[202]

In its published material, the CCMHI further notes that:

Providing mental health services in primary health care settings can be accomplished through various means, for example: providing direct mental health care in primary health care settings, or providing indirect mental health support to primary health care providers in primary health care settings. In the first instance, mental health care is provided by a mental health specialist; in the second, mental health care is delivered by a primary health care provider who is supported by or consults with a mental health specialist.[203]

It further notes that:

Collaborative mental health care takes place in a range of settings including community health centres, the offices of health care providers, an individual’s home, schools, correctional facilities, or community locations such as shelters. Settings vary according to the needs and preferences of the individual, and the knowledge, training and skills of the providers. Collaboration may involve joint assessment or care delivery with several providers present with the consumer, families and caregivers, when appropriate, or it may take place through telephone or written communication. In other words, effective collaboration does not require that the health care providers be situated in the same physical location.[204]

Funding for the CCMHI project expires in March 2006. The Committee believes that the work begun by the CCMHI should be pursued in two ways, and therefore recommends:

13	That collaborative care initiatives be eligible for funding through the Mental Health Transition Fund. That the Knowledge Exchange Centre to be established as part of the Canadian Mental Health Commission (see Chapter 16) actively pursue the promotion of best practices in the development and implementation of collaborative care initiatives.

 

5.6.3.1   Human Resource Issues

In its final report on the acute care, or hospital and doctor, system,[205] the Committee highlighted overall shortages in human resources in the health care system. Anecdotal evidence suggests that these same shortages affect the mental health sector. Throughout the health care system, an aging workforce, along with long lead times for educating and training new providers, mean that existing shortages are likely to get worse over the coming years.

The human resource issues raised during the Committee’s hearings intersect with the need to foster collaborative care models in mental health. Although there are few hard statistics on human resources in the mental health field, it is abundantly clear that the kinds of human resource shortages that pervade the health care sector generally also affect the mental health sector. Encouraging the development of collaborative care practices that make more efficient and effective use of existing human resources in mental health is one way of addressing this shortage.

Unfortunately, most recent human resource studies do not provide a detailed breakdown of the human resource shortages in the mental health sector. A CIHI report on health care providers has noted, however, that psychologists have the highest mean age of the regulated health professions.[206]

Another example is provided by the National Symposium on Gaps in Mental Health Services for Seniors in Long-Term Care (April 2002), in which shortages of professional and non-professional participants were described as one of the most important problems in the provision of mental health services in long-term care.[207]

The absence of national human resource planning affects the mental health sector as much as the rest of the health care system. In its final report in October 2002, the Committee made several recommendations aimed at increasing the number of health care providers across the complete spectrum of health care professions and occupations. Should these recommendations be implemented, the numbers of mental health providers would increase as well.

The Committee wishes to stress that it is particularly important to increase the numbers of all mental health providers because so many services and supports that are critical to improving the lives of people living with mental illness are provided outside the health care system as such. As elsewhere in the health care system, shortages of health care providers is one of the main factors that contribute to unacceptably long wait times for access to mental health services. The Committee notes that the Canadian Psychiatric Association recently issued benchmark wait times for care for a number of psychiatric illnesses, and believes that this represents a further step towards ensuring that people have timely access to the mental health care they require.[208]

Several other human resource issues specific to the mental health field are given prominence by the need to move toward greater use of collaborative care models. The potential for widespread implementation of collaborative mental health initiatives depends to a considerable extent on the broader health care landscape - the creation of multi-disciplinary primary care teams in particular. The slow pace of primary care reform across the country is cause for particular concern.

In practical terms, the difficulties associated with reforming primary care mean that, for many years to come, many solo-practice general practitioners will continue to provide the bulk of the mental health care that their patients receive. It is well known that the fee-for-service model of physician remuneration discourages physicians from spending the extended periods of time that their patients require to help them with their mental health issues. Dr. Richard Goldbloom, Professor of Pediatrics, Dalhousie University, put it this way in his testimony to the Committee:

I happen to function currently as a consultant.  Most of the children I see are referrals from primary care physicians.

It did not take me long to learn that the number one reason for referral is that the primary care physician realizes this will take more than 10 minutes.

Sir William Osler once said that when doctors speak of matters of principle, they invariably mean money.  There is a practical problem in mental health.  That is, that people are paid by the number of patients they see.  As long as that is the case, you will not see much mental health care in primary care.[209]

One measure that could help family practitioners who continue to be remunerated by fee-for-service arrangements, but who wish to enhance their capacity to assist patients with mental health issues, was described to the Committee by Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, for the Department of Health and Ageing, Government of Australia. Mr. Casey told the Committee that three years ago the Australian government had introduced a program designed to facilitate the delivery of care to people living with mental illness; it rewards primary care physicians financially for spending more time with people with mental health problems.  He explained how this program came about and its main features:

We have been told that if you are a GP and someone comes into your consulting room and you think they have a mental health problem, you keep quiet, because if you open the dialogue, you will still be there 20 or 30 minutes later, and of course, fee for service is the treatment model. We have encouraged them by saying that if it will take 20 minutes, we will pay them extra for taking the time. Currently, about 15 per cent of our GP workforce has enrolled in this program. We have about 3,500 GPs who are now enrolled in this program and recognize themselves as people who can offer slightly more and better mental health care. That is a new program.[210]

The Committee believes similar initiatives should be encouraged in Canada. Provincial and territorial governments should work closely with the medical associations in their jurisdictions to adjust the fee schedules to reward primary care physicians who increase the time they spend with patients who have mental health problems. Some provinces have already taken measures in this direction. For example, in New Brunswick, fee-for-service physicians can bill for psychotherapy, patient counselling, and family counselling up to 4 hours per day per patient. They can also be reimbursed for time spent case conferencing with allied mental health service providers.

A study of human resource issues by the Canadian Collaborative Mental Health Initiative pointed to another issue the Committee believes must be addressed. The CCMHI report notes that “differences in compensation are especially apparent for providers who shift between institutional and community care practice environments”;[211] those practising in the community setting are paid less. The Committee believes that such inequities are simply wrong and are likely to inhibit the full development of community-based services. The Committee strongly encourages provincial and territorial governments to pursue initiatives designed to remove this financial barrier and facilitate the easy flow of mental health service providers between institutional and community settings.

5.7       OTHER INITIATIVES

5.7.1     Support for Family Caregivers

Family members play an essential, at times lifesaving, role in caring for persons living with mental illness.  Almost 60% of families of people living with serious mental illness are estimated to be serving in the capacity of primary caregivers, usually with little guidance, support, relief or respite.[212] These family members often must also contend with the difficulties of navigating through a fragmented mental health system on behalf of their loved ones.

Recognizing their importance and the value of the care they provide, family caregivers were sought out and invited by the Committee to appear at public hearings in every province and territory.  We have given “voice” to their concerns in Chapter 2 and have sought to respond to their input. This report addresses two key matters here:  income support and respite care services.

5.7.1.1  Income Support

The Committee was told that family caregivers are being financially affected in a number of ways.  For example, they often have to take time off from their jobs to care for a family member living with mental illness.  In this regard, Dr. Kellie LeDrew, Clinical Director of the Newfoundland and Labrador Early Psychosis Program, noted that:

I think many times we underestimate the burdens that are placed on families. If you want to look at the cost of mental illness, oftentimes we underestimate the indirect cost of mental illness. Many of these mothers — and oftentimes it is the mother — have had to take time off work. I have had to give numerous notes for mothers who had to take time off work to stay home so that the son does not have to go into the hospital. They do not want to leave him because they are afraid something will happen.[213]

The Committee believes that caregivers should receive some form of financial assistance from government when they have to leave work temporarily to care for a family member who is mentally ill.  A number of compelling reasons lead us to this belief:

§         Persons living with mental illness benefit by receiving long-term help from a familiar source, outside an institutional setting.  With this help they may also be spared contact with the criminal justice system or homelessness.

§         Caregivers benefit by maintaining stable employment over time.  They are also better able to maintain a supportive relationship with the affected family member.

§         Employers benefit from being able to retain valued staff and avoid costs associated with other forms of leave (e.g., sick leave) that may be relied on when leave to care for a family member is unavailable or available only for brief periods of time.

§         Governments benefit by keeping caregivers in the workforce and persons living with mental illness out of hospitals, long-term care facilities, prisons, and off the streets, all of which will result in cost savings to the public purse.

The Committee is aware that Compassionate Care Benefits are currently available to eligible Canadians through Employment Insurance (EI).  However, these benefits are restricted to persons who have to be absent from work to provide care or support to a gravely ill family member at risk of dying within six months.[214]  Recent reports suggest that this program has been seriously under-utilized by its target constituency, in part at least because of the restrictive eligibility criteria that are currently in place.

Given the enormous surplus in the EI account[215] and the recent decision of the Supreme Court of Canada[216] affirming Parliament’s constitutional authority to adapt the EI plan to the new realities of the workplace, the Committee believes that it is appropriate to make Compassionate Care Benefits more widely available.  Therefore, the Committee recommends:

14

That compassionate care benefits be payable up to a maximum of 6 weeks within a two-year period to a person who has to be absent from work to provide care or support to a family member living with mental illness who is considered to be at risk of hospitalization, placement in a long-term care facility, imprisonment, or homelessness, within 6 months. That eligibility for compassionate care benefits be determined on the advice of mental health professionals and that recipients of compassionate care benefits be exempt from the two-week waiting period before EI benefits begin.

 

5.7.1.2               Respite Care Services

The responsibility of providing care and support to a family member living with mental illness can place caregivers at risk of burnout.  Brenda McPherson, Provincial Coordinator of Psychiatric Patient Advocate Services for New Brunswick, testified that:

…many of our caregivers or parents of these [psychiatric] patients are literally burnt[out].  They have been caring for these individuals since the age of 12, 13 or 14. The caregivers have gone through the justice system, they have gone through foster home systems, and so on. By the time their children are 25 and 30…the caregivers are … burnt[out], and they have access to little or no resources. That is why I think it is important that the federal government play a role, and partner with the provincial government to enhance the services and the resources that the province has.[217]

To avoid caregiver burnout, the Committee believes that respite care services available to families must be significantly improved.  A variety of models were suggested, including: 

§         having a public health nurse make home visits to the families of persons recently diagnosed with mental illness to offer information and support;[218]

§         providing in-home respite care that frees caregivers to go to their own medical or other appointments, attend support groups, or shop for groceries;[219]

§         establishing adult daycare services;[220]

§         improving institutional respite care by making it available more often and for longer periods.[221]

Given the diverse needs of family caregivers, and recognizing that these needs may shift over time, it seems logical to make a variety of respite care services available.  Therefore, the Committee recommends:

15	That initiatives designed to make respite care services more widely available to family caregivers, and better adapted to the needs of individual clients as they change over time, be eligible for funding through the Mental Health Transition Fund.

 

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