1999 Annual Report,
Provincial Auditor: Chapter 4(3.09), mental health program,
community-based services activity
Ministry of Health and Long-Term Care
Mr John King, assistant deputy minister, health care programs
division
Mr Dennis Helm, director, mental health, health care programs
division
Ms Gail Czukar, manager, mental health legislative policy
unit
Mr Tom Peirce, consultant, health reform implementation
team
Ms Diana Schell, counsel, legal services branch
STANDING COMMITTEE ON
PUBLIC ACCOUNTS
Chair /
Président
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Vice-Chair / Vice-Président
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Mr John Hastings (Etobicoke North / -Nord PC)
Ms Shelley Martel (Nickel Belt ND)
Mr Bart Maves (Niagara Falls PC)
Mrs Julia Munro (York North / -Nord PC)
Ms Marilyn Mushinski (Scarborough Centre / -Centre PC)
Mr Richard Patten (Ottawa Centre / -Centre L)
Substitutions / Membres remplaçants
Mr Dan Newman (Scarborough Southwest / -Sud-Ouest
PC)
Also taking part / Autres participants et
participantes
Mrs Claudette Boyer (Ottawa-Vanier L)
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Mr Steve Peters (Elgin-Middlesex-London L)
Clerk pro tem / Greffier par intérim
Mr Douglas Arnott
Staff / Personnel
Mr Ray McLellan, research officer, Research and Information
Services
The committee met at
1039 in committee room 1, following a closed session.
1999 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE
Consideration of chapter
4(3.09), mental health program, community-based services
activity.
The Chair (Mr John
Gerretsen): I'd like to call this meeting to order,
which is a continuation of the hearings held by the standing
committee on public accounts dealing with chapter 4 of the 1999
Annual Report of the Provincial Auditor, and specifically dealing
with the mental health program, community-based services
activity.
I'd like to welcome you,
Assistant Deputy Minister, and your delegation. You'll have about
15 to 20 minutes to make your presentation, and afterwards we'll
throw it open to the members who are here.
Mr John
King: Good morning, Mr Chairman. I'm sorry we're a
little late. We were waiting for someone to come and get us
rather than be here, so I apologize.
The Chair:
That's all right. We were almost going to hold the parliamentary
assistant hostage until you got here.
Mr King: I'm
not going to comment on that.
I'm John King. I'm the
assistant deputy minister for health care programs at the
Ministry of Health and Long-Term Care. I am joined this morning
by Dennis Helm, who is the director of mental health for the
health care programs, and also Gail Czukar, who is the manager
for mental health legislative policy. On behalf of the ministry,
we are pleased to meet with the public accounts committee
today.
Let me begin by saying that
the ministry is committed to ensuring all Ontarians can rely on
quality health care.
A strong Ontario economy has
made it possible for the provincial government to increase health
care spending by $1.5 billion since its 1995 commitment of $17.4
billion. In fact, we expect to increase funding by another 20%
over the next five years to meet future needs.
In 1998-99, the ministry's
actual operating expenditures totalled $18.9 billion. This year,
the budget is expected to be $20.9 billion. That's over one third
of the entire government budget.
Of our total health budget,
the ministry spends over $2.4 billion on mental health programs
and services. Programs supported by this funding include
community-based services, homes for special care, provincial and
specialty psych hospitals and general hospital psychiatric
units.
The ministry directs $406
million toward community-based mental health services in Ontario.
This year, this $406 million was an increase of almost 90% over
1994-95. This includes 335 community-based mental health
agencies, 152 homes for special care, and 84 supportive housing
providers, together with $1.3 billion in other mental health
services such as OHIP, drug programs and long-term care, $5.4
million in program administration, and $869 million toward
hospital-based services. We arrive, then, at the total commitment
of $2.4 billion per year in mental health services.
With respect to the
Provincial Auditor's report, in 1997 the Provincial Auditor
assessed the ministry's performance on community-based services
activity. The goal of the community-based services activity is to
develop a system that will support people with mental illness
living fulfilling lives in the community. The activity funds
community mental health programs, including community-based
mental health services, children's mental health programs,
residential homes for special care, and the community psychiatric
payment program.
I am pleased to say that the
ministry has made substantial progress in the areas outlined by
the Provincial Auditor.
Under mental health reform,
the auditor recommended that the ministry should periodically
evaluate its progress in meeting the mental health reform
targets. Our response is that the ministry has begun benchmarking
progress and outcome through the multi-year community mental
health evaluation initiative. This initiative involves outcome
evaluation projects, focusing on case management, crisis response
and consumer-survivor and family initiatives. The project team
includes the Ontario Mental Health Foundation, the Centre for
Addiction and Mental Health, and the Canadian Mental Health
Association, Ontario division. The initiative also allows us to
closely monitor bed ratio shifts within the mental health
system.
The research projects funded
through the multi-year community mental health evaluation
initiative are in the early stages of implementation. These
projects will provide the ministry with vital information
regarding cost-benefits and
outcomes related to core community mental health functions. Once
the data become available, the ministry will be in a position to
revisit and refine the mental health reform targets.
As well, the auditor
recommended that we should develop and compare the costs and
outcomes of community-based care with those for institutional
care for various levels of service or care. The mental health
minimum data set is intended to enable ministry staff to analyze
and compare the cost of community care and institutional care.
The following mental health minimum data set activities are
underway.
Since 1997-98, community
mental health year-end reporting includes newly developed
reinvestment fund indicators.
A psychosocial rehabilitation
tool kit has been developed and is being implemented and will
provide rehabilitation outcomes, such as change in
hospitalization rates and change in housing, employment,
education and financial circumstances. The PSR tool kit will
collect and report most of the minimum data set client
information.
A minimum data set client
data snapshot survey has been completed. For those community
agencies and hospitals that participate in the snapshot, we are
now able to answer questions regarding service availability,
clients and utilization patterns.
The results of the minimum
data set client data snapshot and the technology survey have been
distributed to all mental health provider organizations. Work is
underway to develop the minimum data set across the province.
The ministry's IT priority
review board deferred the development and implementation of the
mental health minimum data set project due to other priorities in
the Y2K compliance. We are now reviewing IT priority projects
with the completion of the Y2K project.
With respect to operating
plans, the auditor recommended that the ministry ensure that all
information submitted is in accordance with ministry
requirements. The ministry has streamlined and simplified
reporting requirements by refining the operating plan guidelines
and process requirements it distributes to mental health provider
organizations. We have utilized the streamlined operating plan
package containing all information required by the ministry since
1997-98.
As well, the auditor
recommended that the ministry require operating plans to be
submitted, reviewed and approved on a more timely basis. The time
frame for the operating plan process depends on the government's
estimates-budget process. This has had an impact on the timing of
the issuance of the operating plan guidelines and process
requirements. In spite of this organizational challenge, the
Provincial Auditor has acknowledged our progress. We have
consistently sent out packages before the commencement of the
fiscal year in each of the past three years. The health care
programs division, through the regional office structure, will
coordinate all hospital and community operating plan processes as
much as possible.
With respect to performance
monitoring, the Provincial Auditor recommended that the ministry
define acceptable levels of care and establish performance
benchmarks and outcome measures and monitor programs against
them. We have defined levels of care and systems outcomes in the
ministry's recent document entitled Making It Happen:
Implementation Plan for the Reformed Mental Health System and
Operational Framework for the Delivery of Mental Health Services
Reports. Released in August of last year, Making It Happen
enables regional and local planning processes to align and
rationalize community mental health services.
We are ensuring we implement
the objectives of Making It Happen in a timely manner by
establishing mental health implementation task forces. These task
forces will operate in all health regions across the province.
The northeastern task force has already been established, and
additional task forces will be announced shortly. The task forces
will provide advice to the ministry on the allocation and
reallocation of community investments to support policy
directions. We will base performance benchmarks, targets and
outcomes on the multi-year baseline data captured by the mental
health minimum data set that I mentioned earlier, as well as on
data captured by the district health councils and the mental
health implementation task forces.
1050
With respect to management
information systems, the Provincial Auditor recommended the
ministry should accelerate the development and implementation of
an appropriate management information system. The ministry, in
response, completed a technology survey in 1998 which has enabled
the ministry to assess and evaluate direct electronic transfer
alternatives. Community mental health programs' budget systems,
financial logs and sessional fees systems have all been
implemented. These are being further refined following the
completion of the year 2000 projects.
With respect to the community
psychiatric payment program, allocation of funds, the auditor
recommended that the ministry ensure that sessional funding is
allocated on a reasonable and equitable basis rather than on a
historical basis. Through the implementation of the commission
recommendations and directives, the ministry now ensures that new
or reconfigured priority services are receiving appropriate
sessional fee allocations. This allows us to make sure that
medical and specialist support is available.
With respect to monitoring,
the auditor further recommended the implementation of a procedure
such that timely information is received on the use of sessional
funding, and sessional funding is spent in accordance with
ministry guidelines. The ministry has implemented a computerized
community sessional fee logging system that enables timely
follow-up. Also, the reporting compliance is improving through
ongoing verbal and written reminders to government agencies. By
the 1997-98 year-end, sessional fee reports had a compliance rate
of almost 100%.
With respect to homes for special care quality of
care, the auditor recommended that the ministry mandate
compliance with the minimum standards of care as a condition of
licence renewal. The ministry is developing a comprehensive
supportive housing policy for people with serious mental illness
that will set out standards and monitoring mechanisms for all
supportive housing, including the homes-for-special-care program.
These standards and monitoring mechanisms will help to ensure a
consistent approach to the programs being funded by the ministry.
The policy might have legislative implications for the Homes for
Special Care Act.
With respect to processing of
payment and recoveries, the Provincial Auditor recommended that
we improve our procedures to help ensure we recover the payments
made on behalf of the residents of homes for special care that we
are entitled to. The ministry has implemented a computerized
homes-for-special-care information system. The modifications to
the system include the capability to produce aging reports.
Therefore, we would be able to facilitate a more efficient
recovery process.
Under respite care grants,
the auditor requested that the ministry should assess whether it
should continue to provide respite care grants for staff relief.
On August 12, 1998, the government approved a rate change within
the Homes for Special Care Act to increase the per diem payment
level from $27.63 to $34.50, which is consistent with other
residential housing programs providing similar types of services.
Respite care grants will cease on April 1, 2000. This will not
affect client care adversely because of the increased payment
rate which came into effect on September 1, 1998. The increase
will ensure that appropriate levels of resident care and services
continue to be provided by homes for special care while a
comprehensive housing policy for people with serious mental
illness is being developed.
In conclusion, I believe the
ministry has demonstrated significant movement forward on the
recommendations of the Provincial Auditor. The ministry has shown
a commitment to Ontario to create an integrated and comprehensive
mental health system that emphasizes prevention and access to
services and improves public safety, and I believe we are
delivering on that commitment. Beyond even the scope of the
auditor's report, since June 1998 we have announced significant
investment to mental health community-based services.
In December 1999, we
announced $19.1 million to expand community-based mental health
services to a total of 51 assertive community treatment teams and
to enhance court diversion, psychogeriatric outreach, case
management and crisis support services.
In March 1999, this
government announced its provincial housing strategy, which
included $45 million in each of the next three years to provide
housing and housing supports for people with serious mental
illness. Of this $45 million, $20 million was identified for
initial release to provide permanent housing and supports to
approximately 1,000 people with serious mental illness who are
intensive users of emergency hostels. This strategy is in
addition to the $2.5-million homelessness initiative in 1997-98
that enhanced services to Ottawa, Hamilton and Toronto.
In 1998, we announced $60
million in funding to support enhancements to community-based
mental health services, additional forensic beds and court
diversion, and long-term-care services for the mentally ill.
Finally, I'm proud to report
that all of the service enhancements resulting from the
$23.5-million community investment fund in 1997-98 are
operational. The community investment fund increased community
services and supports for people with severe mental illness. The
service enhancements included case management, crisis response,
family initiatives and consumer-survivor initiatives. These
initiatives will ensure that all Ontarians have timely access to
services they need.
We are strengthening the
continuum of care for people in need and we will continue to do
what is necessary to improve and enhance access to these
important services.
That is all I have to say, Mr
Chairman, for the formal portion of this program and we're happy
to answer any questions that the committee may have, with the
support of my colleagues.
The Chair:
Thank you very much for your presentation. The third party will
not be represented here today as Ms Martel apparently is ill.
What I propose we do is limit each question-and-answer period to
15 minutes so that there will be two go-arounds before lunch
today. We start with the government side.
Mrs Julia Munro (York
North): I appreciate the opportunity that you have
provided us in being here today.
There are a number of issues
obviously in the course of the morning that we'll have an
opportunity to speak to and get some response from you. One of
the overall issues that I think would be appropriate to start off
with this morning is the whole issue of integration and the fact
that while there are so many very important pieces in health care
in general in the province, and it's certainly something our
government has taken some leadership on, the question of
integration is one that people find particularly important, being
able to access service. I wondered if you could give us an update
on the way that integration between mental health services and
health care in general is taking place, particularly at the
regional level, because obviously that's where the individual
Ontarian is looking for some kind of access point.
Mr King: As
I mentioned, the Ministry of Health and Long-Term Care budget is
almost $21 billion, and of that portion, the health care programs
division, which I am responsible for, is a total of about $14
billion. This includes all of the health care programs other than
physician services, labs and diagnostic imaging.
1100
Recently, the ministry
identified the need to look at regionalization of their health
care programs division. We are in the process now of setting up
seven regional offices. These regional offices will be scattered
throughout the province and they will include hospitals, mental
health and long-term care. Although we have not moved to a regional structure in the
other parts of the system, it is very important that the ministry
move in this direction and provide services locally, have local
access and a single point of entry for our stakeholders.
If you can picture this, you
can see that we would have the hospital personnel, program
personnel, long-term-care and mental health personnel all working
side by side. This is in our hope to provide an integrated
service delivery mechanism for clients, patients and residents in
Ontario. By this, I think it really strengthens the continuity of
care that we're trying to promote. So we're integrating at the
regional level. That is very important to the ministry, but it
also will promote for our stakeholders who enter the system that
concept of integration in their communities.
I might emphasize that now we
have ministry people outside of Toronto at the local level who
will also monitor our activities out there and the accountability
that everyone is expecting for the dollars that are spent on
health care.
I hope that shares our
integration strategy with the ministry. There are other things
that we can elaborate on as far as the integration with mental
health services is concerned, which I'm sure will come up
later.
Ms Marilyn Mushinski
(Scarborough Centre): When we're talking about moving
from institutionalized care to a more community-based care, I
understand that you have set up some ACT teams, or assertive
community treatment teams, and I'm very interested in how you
arrived at this particular model. I'm going to probably be asking
you a supplementary question on the regionalization aspects of
that, because I have some particular concerns as it pertains to
my own riding of Scarborough Centre, and how it responds also to
Mr Newman's report, 2000 and Beyond. Could you tell us a little
bit about the program and then I'll ask a few more questions.
Mr King: I
did want to comment on the move from the institution to the
community. A number of years ago the balance between the
institutional and community care was about 75% institutional, 25%
community. Our goal, of course, is to bring everything closer to
home. That's not only in mental health but other services in
health care. We are now at an average of about 60% institutional,
40% community, so it's very important that we build up the
community supports as we are deinstitutionalizing clients and
patients.
We were very fortunate to do
some benchmarking on ACT teams in the States, and we have created
a model here in Ontario. I'm going to have Dennis Helm elaborate
a little more on the ACT teams, because I believe very strongly
that this is a real success story for Ontario, to develop this
team approach that really delivers that support in the community
that the patient would have otherwise received in an institution.
We are now able to deliver that in a community setting.
Mr Dennis
Helm: When we started the reform activity in looking at
our goals of restructuring the system from an institution-based
to a community-based system and looking at the restructuring of
the psychiatric hospitals, we wanted to look at a best-practice
model that really linked directly with our goals in that area. As
John mentioned, through a review of activities in other
jurisdictions, we developed a commitment to the assertive
community treatment concept, which is basically involving many
disciplines in terms of providing supports and services to
clients. They are basically a self-contained clinical team that
provides intensive treatment and rehab to about 100 clients per
team. So it's very intensive. These supports are provided on a
24-hour-a-day basis, 365 days a year.
When we established the best
practice of assertive community treatment teams, we wanted them
to have a very direct relationship to the restructuring in our
psychiatric hospitals. As you know, the commitment had been made
to ensure that community supports are in place before we consider
any bed downsizing within our psych hospitals, and the treatment
teams were identified as a key program to make that link. So when
we established these treatment teams, and we're now up to 51 full
or partial teams-they're in various stages of implementation-for
the majority of these 51 teams we have developed a sort of
contract with the providers that they must have a direct link
with the psychiatric hospitals so that if there are patients in
the hospitals who are ready for discharge into the community,
there is a direct link to these treatment teams. We felt that
this intensive interaction would be a perfect discharge mechanism
from the psychiatric hospitals into the community with these
kinds of supports, which in turn link with other service
providers, including housing.
So as a best practice, we are
in various stages of implementing these and we have established
an evaluation mechanism whereby this best practice, or this
instrument, will be evaluated along with other reform priority
investment tools. They will be evaluated and reported back to the
ministry in terms of whether any adjustments should be made and
to look at the cost-benefit analysis and especially the
quality-of-life point of view.
Ms
Mushinski: I wonder if you can just tell me, as you
implement this particular aspect and other mental health reforms,
how you can ensure that the specific needs of various communities
within Ontario are being met. For example, the needs of a very
diverse community in Scarborough Centre probably are quite
different from those in a far-reaching and remote community in
the north. I'm wondering how the mental health reforms address
those specific divergent needs of the province.
Mr Helm:
When we identified the community treatment teams, as an example,
as a priority 4 investment, ministry staff led a community-based
activity working with service providers, and I'll use Toronto as
an example. We worked with existing community service providers
here. We looked at the work that had been done by the district
health councils in terms of identifying the service
priorities.
We were keen on the assertive
community treatment team concept but we wanted to make sure that
any investments really
reflected the regional needs that have been identified. So, for
example, working with the Toronto service group and the district
health council, we looked at the priority target populations that
they have identified; it could be a specific ethno-racial
community, a forensic group. Developmentally disabled groups
specifically had been identified, with a developmental problem
plus a mental health problem. So through our implementation
process we have the flexibility to work toward different target
populations, and we did address the needs of specific
communities; for example, in Toronto, having a treatment team
established that specializes in services for the developmentally
handicapped population with a mental health issue as well.
As another example, and even
elsewhere in the province, treatment teams and all of our
community investments are expected to have a forensic component
as opposed to a parallel forensic system in the community. So
treatment teams are expected to have a forensic capability.
Within Toronto, because of the population and the demand, we did
provide some specific funding to one team to truly develop a
forensic capability so they in turn could work with other
treatment teams in the city to help spread that expertise around
forensic clients and the services they require. So we do try to
address the specific population needs as much as we can.
1110
Ms
Mushinski: I have one question about housing. Can you
tell me what the ministry is doing to address this? I'm
particularly interested in this. I was on a Canadian Mental
Health Association task force 25 years ago looking at supportive
housing models in the community. I just have a serious concern
that we may be abandoning some of those earlier policies for
supportive housing. Could you tell me what the status of the
ministry's supportive housing strategy is for the mentally ill,
please?
Mr King: I
think you're touching on two areas. One is the operations, with
things such as the homelessness strategy, and also we have some
policy and strategy development in housing.
I'm going to ask Dennis to
refer to the operations. I'm sure Gail will have some comments on
the housing strategy that's being developed now.
Mr Helm: The
housing service really has been identified for quite a long time
within the mental health reform strategy, that adequate housing
is critical for our target population in terms of moving out of
an institution into the community, and with the homelessness
issues that have been identified across the province.
In 1997-98 was really the
beginning of our homeless strategy, and that was when $2.5
million was identified for reinvestment in three areas of the
province: Ottawa, Hamilton and Toronto. It was identified
specifically that we needed support services to address the
mental health issues of people living in hostels and shelters.
That was the beginning of our initiative into this area, really a
result as well out of the homelessness studies that were
undertaken in various cities in Ontario, including Toronto, and
in the provincial review of homelessness and housing. So we
started that process.
Then in 1999 there was a
significant step, in our view, for our target population, when it
was announced that there would be a three-year, $45-million
commitment for each of those three years to look at again housing
and homelessness for the mentally ill. In phase 1, which took
place in 1999, a total of just over $20 million was
allocated-about $14 million of that was provincially
allocated-again first targeting the cities that were identified
with the lowest vacancy rates and perhaps the highest homeless
population, and those were Ottawa, Hamilton and Toronto.
We have been working very
closely with the communities in terms of moving this along and
working towards the establishment of 1,000 units. That could be a
combination of rent supplements, which are specifically geared to
an individual in a rental situation, plus then capital, perhaps
acquisition of units, and renovations.
We are proceeding to
implement those and we are very pleased with the achievement we
are making, considering that in previous years very little had
been done in terms of our target population for housing. So the
achievement of having 1,000 units that we're working towards was
very welcome.
The Chair:
Is that 1,000 in the province?
Mr Helm: A
thousand in these three cities right now. That's phase 1. We are
implementing that now, and progress has been made. There will be
a phase 2 and a phase 3, which we will combine. Just to remind
you of what I said, there was a three-year commitment, $45
million per year. I just talked about the first-year first
phase.
For phases 2 and 3 we are
looking at very shortly going out for a request of interest from
parties across the province. We are allocating the remainder. At
the end of the day the full $45 million will be annualized in
community supports.
We are allocating the
remainder of the funding to all regions of the province, based on
population, and with a specific addition, in terms of a funding
ratio, for those areas where we expect there will be some
in-patient restructuring in the psychiatric hospitals, to make
sure that we are in every community in the province, but to a
greater extent in those communities that will be experiencing a
restructuring of in-patient services. Our commitment is to have
the community supports in place before the downsizing takes
place. So we are in the midst now of this phase 2, where we will
be going out and requesting expressions of interest so we can be
working with the communities and identifying where the remainder
of that funding will go.
Ms Gail
Czukar: As Dennis mentioned, there has been activity in
this area for some time. The ministry has been working with two
other ministries to develop a comprehensive housing strategy and
housing program; so municipal affairs and housing and MCSS have
been involved in this as well. The ministry developed a committee
to advise it on the housing policy. That committee included
members of the service providing community, consumers and consumer groups as well as homes
for special care providers to give them advice about what the
housing policy should encompass. That policy is under
development, is being approved as we speak, and should be ready
for release soon, but the intention is to have a consolidated
provincial program that will look at a number of these different
programs and put them together-the domiciliary hostel program,
homes for special care, the supportive housing and so on-so that
there will be a consistent approach, with consistent standards,
in supportive housing. So that work is underway and should be
released soon.
The Chair:
We went over the time a little bit. We'll make it up in the next
round. I'll turn to the official opposition.
Mrs Lyn McLeod
(Thunder Bay-Atikokan): As you can see by the number of
us who are here, we have a number of questions and concerns in
the area of mental health and we too appreciate the opportunity
to talk with you about mental health. I think too often it
doesn't get the focus that it needs, so this is really a welcome
opportunity.
We'll start by following up
on Marilyn Mushinski's questions about the whole area of
supportive housing. I'm glad to hear the details of the
three-phase program to provide supportive housing in
communities.
My concern is the adequacy of
the support that is provided in non-hospital settings. I'd like
to preface my questions by asking whether or not you have any
statistics yet on the number of people who are currently in
psychogeriatric beds in hospitals that are scheduled to close and
how many psychogeriatric beds will remain for that population of
people. In other words, we know the proposed loss of overall
beds, but I wonder if you have something on the loss of
psychogeriatric beds specifically.
Mr King: Mr
Chairman, is it okay if we continue to direct questions over to
the experts here, perhaps, when we get into some of the
details?
The Chair:
We want to hear from the people who have got the answers.
Mr King:
That's why I brought this entourage today, so we'd make that we
have the right answers for people. I apologize that I don't have
all the answers.
Mr Helm: In
terms of the psychiatric numbers-I'll talk specifically about the
provincial psychiatric hospitals-I don't have statistics with me,
but in terms of the psychiatric hospital system across the
province, as you know, it is going through a divestment transfer
process. A key element of that is to do a patient survey of every
client in the hospital, and psychogeriatric clients are included
in that. We are finding that there are a number of
psychogeriatric clients in the provincial psychiatric hospital
system who could be perhaps better housed in the long-term care
system or in the community with supports. That information is
being used to formulate a discharge plan that would then be
looked at and co-ordinated with our community activities, such as
a community treatment team, that might be appropriate for
psychogeriatric clients perhaps who are able to live in the
community if they have the supports in place. A key requirement
is that those persons must have the supports assigned to them
before they go out into their own apartment or shared
accommodation, either through a treatment team or through an
existing case management program, for example, that we have in
the community.
1120
That is being done in all
psychiatric hospitals across the province. We have this baseline
data that would help us, with the funding we have now and as new
funding is announced through mental health task forces which we
might get into. That would be information they would use as well
to determine where the resources should be allocated, what kind
of service providers should be funded for different types of
services, which could vary from region to region.
Mr King: I
was just going to add to that, if I might. This is why we feel
it's so important that the ministry regional offices are set up
so that the link with mental health and long-term care, in this
example, is a strong link so that we can ensure there's a smooth
transition with these patients.
Mrs McLeod:
Is it possible to get statistics on the change specifically in
psychogeriatric beds? Is that information you'd be able to
provide?
Mr Helm: In
terms of what is planned?
Mrs McLeod:
What's proposed, yes.
Mr Helm: We
could probably gather very high level data, not patient-specific
obviously, but just the general findings of what they would need,
how many might be appropriate for a long-term-care facility or,
if they go to the community, the types of supports. We could put
together that broad, high-level information if that would be
helpful.
Mrs McLeod:
It would be very helpful. I'll be very upfront about my concern
and the reason I'm focusing at this point in our discussion
specifically on psychogeriatrics. I notice that there's an
adjective that has come into this-Mr King used it again this
morning-and that's that as you look toward community supports in
the deinstitutionalization process, you're looking at those who
have a serious or severe mental illness.
One of my concerns is, all
right, where do the seniors with Alzheimer's or with dementia fit
into that picture? Can I assume that a senior who has Alzheimer's
or a dementia of some sort at a fairly advanced stage is
considered to be somebody with a serious or severe mental
illness? My concern in asking about the psychogeriatric beds,
because I understand that there's a significant reduction in the
proposed psychogeriatric beds in a hospital setting, is, where
are these people going to go?
If we look at support in a
community setting and a supportive housing setting, an
Alzheimer's patient typically needs a secure setting. They
typically need 24-hour supervision. I'm aware that there are
Alzheimer's patients now who are in wings of long-term-care
facilities. You've mentioned that's one of the alternative
placements for people who might now be in a psychogeriatric bed in a hospital
setting. There's obviously a huge difference in funding that's
available to that individual for support if they are in a
psychiatric hospital or if they were to go into a chronic-care
bed, which I think is the setting for most of the psychogeriatric
beds with the deinstitutionalization, compared to them being in a
long-term-care facility at $70 a day with a copayment or being in
supportive housing, a special care home, where I think you just
said the rate was $34 a day. Of course, the other alternative
support is a home situation where it becomes tremendously costly
to provide one-on-one 24-hour supervision.
I'm really concerned about
where this population, people who are currently in
psychogeriatric beds, is going to go, and following that, with an
aging population, where the expanding population of people with
Alzheimer's is going to go.
Mr King:
This is also a good example of where this has gone beyond the
mental health program. We just recently announced an Alzheimer's
strategy for the province. We have initiatives underway right now
for Alzheimer's patients. They are gathering that information on
the local level. Again, coming back to your point, we are also
very concerned about how the Alzheimer's patients are being cared
for and treated, not only in institutions but also in the
community setting, to have supports in place. There's a whole
other strategy in place for the Alzheimer's patient that has been
recently announced.
Mr Helm: I
think it's important to stress and we want to be clear that
within our mental health reform strategy we are maintaining a
range or a continuum of services. There will be psychogeriatric
beds in our system even post-transfer to a public hospital. We
will have community supports for those, where appropriate, who
can live in the community, and if people are more appropriately
relocated to a long-term-care facility. The mental health side of
the ministry and long-term care have been working together for
the last couple of years on how to ensure the best quality of
service for a mentally ill client in a long-term-care
facility.
You may be aware of one of
the previous announcements. Out of the $60-million announcement
in June 1998 was a training initiative for mental health workers
to be assigned to long-term-care facilities to provide not only
behavioural support but also programming support to try to get at
some of the issues you were referring to.
Mrs
McLeod: I appreciate the broad view. I'm going to leave
my questions at this point because I want to give my colleagues
an opportunity.
My concern is I know there
are psychogeriatric patients now in-let me rephrase it, because I
think language may be a part of our problem here. People with
advanced Alzheimer's and dementia are in long-term-care
facilities now. I don't believe that $70 a day is enough to
provide support at the level which that patient needs. What is
the ministry doing to really identify the care needs of those
individuals and ensure that the dollars match the care needs? I'm
not seeing the specifics to give me comfort that as more and more
people develop severe Alzheimer's or are discharged from
hospitals, we're going to have the dollars in place to meet their
level of care needs.
Mr King:
Under another initiative that's happening in the long-term-care
side, they are doing a levels-of-care study right now, addressing
some of these issues, and also looking at the funding system in
long-term care to address not only complex continuing care but
then the chronic care, long-term-care funding system for this
type of patient. So it is being addressed. We were focusing a
little more on mental health here, but there are other branches
of the ministry addressing some of those dollars.
That $70 a day is not the
long-term-care rate; it's not the chronic care rate right now.
I'm not sure where the number you're quoting is coming from, but
the long-term-care patient rate is around $100 and the chronic
care rate is closer to $300 a day. Many of these patients are
presently housed in that setting. We are looking at that funding
system right now for the future.
Mrs
McLeod: I cross my fingers and pass it on to my
colleagues.
Mr Steve Peters
(Elgin-Middlesex-London): I have two questions. The
first is in the area of the supportive housing policy that's
being developed. As we're seeing this move from institutions to
communities and the policies being developed-and you said that
consultations are taking place-I would like to know who all is
being consulted. In particular, I'd like to know whether
municipalities are being consulted on this move towards the
development of supportive housing. The municipal councils are
going to be hearing from the neighbourhoods that may be proposed,
and I would like the assurances to know that as these policies
are being developed, everybody who is potentially going to be
impacted or affected by the move from the deinstitutionalization
is going to know what is going on and what is being proposed.
Mr King:
First of all, with the project that has just recently been
announced with the 1,000 units that were referred to in those
three communities, it has been an area of difficulty going into
local communities and their saying, "Not in my backyard," that
type of experience. That was our first phase. We've learned a lot
from this process that will certainly be incorporated into the
phase 2 and phase 3 that we're dealing with. Dennis will probably
want to comment specifically on your issue with respect to
notification and education in this area.
Mr Helm:
From an operational point of view I can address a few things and
then maybe Gail will in terms of the broader consultation. In
phase 1 of the housing that I mentioned, for example, and our
planned phase 2, once it is started we spend a lot of time in the
community with service providers, who are already in housing
perhaps, but really anyone within the health-MCSS system will be
brought to the table and be made aware of what opportunities we
have. Through that consultation process we will be talking with
providers, the city, consumer groups and family groups
specifically for that community about the dollars we have
available, how we might best allocate them to meet the reform agenda, the bed-pressure
issues and the support services. So on the implementation side we
try to be as inclusive as possible with all members of the
community before we make a recommendation within the ministry as
to where the dollars will be going, and for what services.
On the policy side there
was another opportunity for input.
Ms Czukar:
As I said, the committee that was struck to give the ministry
advice about the development of the housing policy included
people who are out there and who have had a lot of experience in
trying to set up programs and have run into exactly the kinds of
issues you are talking about, so that experience was brought to
bear. But I think what you're talking about is really an
implementation issue and will come up when the policy is being
implemented.
1130
The Ministry of Municipal
Affairs and Housing was involved in that and will be giving us
further advice on how to roll that out in a way that is going to
be compatible with the municipalities' agendas as well.
Mr Peters:
The Health Services Restructuring Commission, when it issued its
report for the London and St Thomas psychiatric hospitals, talked
about the construction of a new 65-bed forensics unit at the St
Thomas site. At some point-and hopefully I can get this
answered-that directive from the restructuring commission changed
from 65 beds, and it is my understanding it may be down to about
49 beds. From what I understand-and I'd like some
clarification-that may be as a result of some of the new beds
that are going to be created in the Hamilton area, but there are
some questions that I've had from within my own constituency.
We're at 65 beds; we're talking 49 beds now. At what level, at
what point, is it going to be said, "We can't justify
constructing a new forensics facility," that 49 beds isn't the
right number? I'd just like to know where things are going with
forensics.
I'm concerned with
forensics, having lived in a community that's had a forensics
unit for a number of years. The auditor talked a bit about a
needs analysis of the forensics beds. I'd just like assurances
that we're not going to be seeing any changes in the standards,
what the level of a forensics patient is now-it may change. For
people who currently may be in a forensics bed, something may
change so that it can be said that they may be suitable to be out
in the community. It's a concern. If I can't get it today, can I
get some further information about where things are going as far
as forensics is concerned?
Mr King:
We certainly do have a direction on forensics. You started out
with the analysis of the commission. The commission really did
provide advice on specialty beds, tertiary beds, long-term-care
beds, but not with respect to forensic. They left that with the
ministry to develop a strategy. We have developed a strategy for
forensic beds, but due to a number of changes that are occurring
with the court system etc, we're also re-looking at that number
right now. We're reviewing beds for forensics in the
province.
Specifically for the
London-St Thomas area, the divestment of the PPH is going to St
Joe's in London in the first tier and then it will move
throughout the community of southwestern Ontario after that. We
can be more specific if you like on some of the forensics there.
We have one of our consultants here with us today if you would
like more information on that.
Mr Peters:
I can leave you my card.
Mr King:
OK, that's great. This is something that is dear to Dennis's
heart, as far as forensic beds. I think it's an area that we all
want to make sure we monitor very carefully, the numbers in the
province and where they are located. So Dennis has some comments
with respect to that.
Mr Helm:
The forensic strategy for health has been developed through a
committee that I chaired with other ministries, with MCSS, with
the Attorney General and the Solicitor General. Through that
interministerial committee we developed a provincial strategy for
forensic across all of those ministries, and then within the
Ministry of Health we also produced a strategy, and specifically
a bed strategy, because as John King mentioned, the commission
left the siting and sizing of forensic beds up to the ministry.
We did our review, we looked at what best practices existed
across the province and came up with a general ratio for secure
beds of 3.8 beds per 100,000 population. That has been, and is,
leading our plan in terms of bed numbers and location.
Through the reform agenda
and using that bed ratio, we are looking at establishing 144 new
forensic secure beds in various locations across the province. We
feel that once they're up and running with all the other
community supports in place, that should go a long way to helping
with the pressure we are currently facing. As time goes on, as
with any reform, you always re-evaluate and reconsider the
direction, and that's the review that John mentioned. We are
proceeding on this basis for bed implementation. What we will be
looking at is, is that ratio appropriate or is it not?
In terms of your specific
question about reinvestments or about recent announcements, I
know there had been some discussion on London-St Thomas bed
forensics and Hamilton. When the Hamilton announcement was made
for 52 medium-secure beds, that did not take beds away from
anyone. I know, and maybe that's what you're getting at, that in
London-St Thomas there was a plan to maintain the beds they have
there and at the same time, over a period of time, enhance
services in London-St Thomas. So when we announced 52 beds for
Hamilton, that was to set up a secure system they never had
before for the Hamilton catchment area. We announced Toronto and
Whitby as well. The beds that will be coming for London-I think
it was nine in addition to what you have now-will be the regional
secure system there.
Our goal is to have a
regional secure system in every region of the province, maintain
a maximum-secure setting
in Penetang-the expertise is there; the numbers warrant that.
We're looking at non-bedded
issues as well, because forensic services aren't only related to
beds. Through community treatment teams-as I mentioned earlier,
we've established a forensic specialty-we've supported the
forensic court here in Toronto, which has been very important in
terms of moving things along, and we have established a number of
forensic court workers across the province as well. So there is
that bed component that we're looking at, and announcing beds,
plus the community side.
Mr King:
Mr Peters, we also identified a number of other questions that
you had in your remarks. Gail has a comment she'd like to
make.
Ms Czukar:
You mentioned that you didn't want to see patients being put out
in the community perhaps because of a lack of beds or not enough
beds in the system. I just wanted to make it clear that that's
not really the prerogative of the ministry. Decisions about
whether people are to be kept in custody in a hospital or given
custodial discharges lie with the Ontario Review Board. That's
the body that makes decisions about what kinds of conditions to
put on people if they are going to go to the community.
Currently, of course, the hospitals that are designated under the
Criminal Code-because this is a Criminal Code matter-are the
psychiatric hospitals that Dennis has been talking about, the
Centre for Addiction and Mental Health and the Royal Ottawa
hospital. Under the Criminal Code, patients can only be attached
to those hospitals, as it were, by the Ontario Review Board, and
those decisions are made by a panel of five experts.
I just wanted to address
that point, that it's not up to the hospital to say, "We're out
of beds today so this one is going to be out in the
community."
The Chair:
We have four minutes left for each caucus at this stage.
Ms
Mushinski: I still have a couple of questions and I'd
like to follow up on that just a little, if I may. I think this
whole area of mental health, mental illness, protection of
individuals is very complex and certainly leads to a lot of
confusion in the general public's mind about the rights of
individuals over the rights of the community. Can you tell me
what role the ministry has in terms of public education to make
sure that government policy is disseminated into the community
while at the same time protecting the rights of individuals?
1140
Ms Czukar:
In 1998 the minister announced the mental health reform
implementation as well as a mental health law education project
and review of legislation. The mental health law education
project has been ongoing since that time. It's headed by Michael
Bay, who is the chair of the Consent and Capacity Board for the
province. He knows this area of the law intimately, and he has
done many, many sessions around the province for mental health
service providers, police officers, emergency workers and the
general public. Families and consumers have attended these
sessions. I'm told that they're extremely well attended and very
well liked. He's done a number of those and has provided
information on people's rights but also on the powers of
hospitals and police officers and physicians to ensure that
people who are not able to look after themselves because of a
mental disorder or who may be a danger to themselves or others
are appropriately brought to hospital for assessment and
commitment.
He has recently been
focusing on issues with respect to cold emergencies or emergency
treatment of various sorts. He distributed a poster on mental
health emergencies to all the emergency rooms in the province
shortly before Christmas to ensure that people who work in
hospital emergency rooms know when they have the authority to
hold people for assessment and for commitment.
Those are some of the steps
the ministry has been taking to inform people.
Cold emergencies: I guess
various municipalities have their own systems in place, but
certainly here in Toronto the municipal officials have their
criteria when they decide that a cold emergency is to be
declared, when the temperature's going to drop to a certain
point, and then certain special measures can be taken. These
powers, however, in the Mental Health Act are not related to cold
emergencies; those powers are always there. It's simply a
question of a more objective standard about when someone might be
showing a lack of capacity to care for themselves due to a mental
disorder if they're choosing to sleep on the street at minus 40
degrees or something.
Ms
Mushinski: My other question has to do with
accountability. As we're moving services from institutionalized
care to more community-based care, how do we monitor
accountability of the service providers or the community
deliverers of mental health service?
Mr King:
In general, I think "accountability" is the strongest word that
we would like to use in the ministry right now-accountability for
all the dollars that are moving out into the province. We have
established a number of accountability frameworks for reporting
from the field-indicators, outcomes and how the money is being
spent. I'll have Dennis directly respond to your question on what
we're doing as far as the move from institutional to
community-based is concerned, but I did want to leave with the
committee that accountability is one of the biggest areas where
we're moving in the ministry, to ensure that all areas where
we're delivering health care are where we would like to ensure
that those dollars are being spent in the right place at the
right time, and also that the outcomes are effective.
Mr Helm:
Many of our recent investment initiatives have been very focused
on a certain model-for example, community treatment teams,
intensive case management-building upon our existing
accountability frameworks, which include the annual operating
plan process where they identify what they have done the year
before and what they plan to do in the coming year. As John said
in his opening remarks, we're co-ordinating that with the submissions out to the
public hospitals and specialty hospitals so that everything comes
together.
In addition to that normal
reporting, there is a requirement up front that they report
specifically, at least for the initial period of time, on the
achievements made specific to the investment that they have just
received, whether it's a community treatment team or some other
function. We're very clear: With these investments and best
practices, we develop standards within the ministry and share
them with all the service providers so that when we enter into a
contractual arrangement, they know exactly what is expected of
them. They monitor and report specifically on the community
investment fund initiative or community treatment team initiative
to us as part of our ongoing activity in terms of operating plans
and reviews.
In addition to that, we
have been, as we mentioned, identifying some very specific legal
agreements. Again, through the community treatment teams there's
a legal agreement that we will have with the provider in terms of
what is required from the psychiatrist who will be on staff on
the treatment team: the roles, responsibilities, and the
reporting back. We want them to be very focused on their 100
clients, we want a very strong link between that model and the
restructuring in our inpatient psychiatric hospitals, so we want
to make sure there is a clear link between those two, meaning
hopefully some clients from our psych hospitals who are able to
be discharged go into a treatment team and are linked with
housing in that way. So we spell all this out in terms of
expectations and it's a formal agreement and part of the
operating plan process that we have put in place.
Mr King: I
might also add, if I could, with the accountability of moving
from the provincial psych hospitals to the divestments, that we
will also have an accountability framework in place to ensure
that movement is consistent with provincial standards. So there
will be service agreements at the new sites that will house these
beds, as well as the tier 3 when they actually move out to other
sites throughout the province, to ensure that we maintain the
same standards that are presently there in the provincial
system.
The Chair:
That's the time period. To the opposition, 10 minutes.
Mrs Claudette Boyer
(Ottawa-Vanier): I'm mostly interested in the homes for
special care. You mentioned that in your phases 2 and 3 you would
support the different outgoing programs. I do have in my riding a
hostel program, which is in a house of special care. You've
mentioned-I think we were talking about care grants-that first it
was $27.
Mr King:
Yes. It was increased.
Mrs Boyer:
So when was it $27 a day, as a per diem?
Mr Helm:
It was increased in September 1998.
Mrs Boyer:
It was increased to $34?
Mr King:
Correct.
Mrs Boyer:
Now, all your outgoing consultation and everything would be a
different program. Is there a possibility to increase this
allotment?
Mr Helm:
It's difficult to know what the outcome will be, but clearly
through the consultation process of the housing strategy, I would
think, and Gail could comment on this, that items would be put
forward for discussion in terms of structure, relationship, and I
would assume per diem rates will be raised in that forum.
Ms Czukar:
I can't say whether they will be raised or not. We have to get
advice on that. But as I said, the idea is to make the different
programs consistent and to ensure that service providers are
getting consistent funding for meeting the same kinds of needs.
That's what has to be evaluated in the final analysis in deciding
what the right level of funding is for all of the programs.
Mr King:
Our understanding is that the increase in the per diem has
assisted greatly. We have not had a great deal of feedback, a
great number of individuals coming back and saying that's
inadequate at this time.
Mrs Boyer:
Why I'm asking this question is because I know that for this
resident I'm talking about, absolutely it's not enough. They've
met with the Ministry of Community and Social Services to see
what the regional municipality could do about it, and I was just
wondering if you had heard about it. Why I'm very concerned about
this is that I was told that if they don't get more per diem,
these people-and there are about 175 in this house-will be put on
the street because the money is not there to take care of it and
they will become homeless.
1150
Mr King: I
think what's happening here is we're probably talking about-
Mrs Boyer:
The hostel program.
Mr King:
-the hostel program, which is under the Ministry of Community and
Social Services. It's in municipalities, so it's really outside
of our jurisdiction on this. I'm not sure I really want to
comment on those areas.
Ms Czukar:
It's still the same issue, because the effort of the domicile
housing strategy is to make the hostel program, supportive
housing and homes for special care consistent and to make the
funding consistent for meeting the same levels of standard.
Mrs Boyer:
So they would still get the $34 and they should have another
financial implement by another ministry? Is that what you're
trying to say?
Ms Czukar:
No, it'll be made consistent across all of the ministries. So if
there's going to be an increase and the people in that kind of
housing have the same kinds of needs and the same needs for
programming and so on as people in homes for special care and
those rates are raised, then the others should be raised too.
That's the effort of the housing strategy.
Mrs Boyer:
When I asked different ministries I was told they couldn't do it
for just one; they had to do it to the province. I was answered
back that it was about a $25-million increase. I think it's a
mental health issue, because most of those 175 people are mental
health patients and there should be an interchange between
different ministries. It's going to be another problem at
the end of April if we
put these people on the street. They're going to be another
burden to another program.
Ms Czukar:
As I said, we are working closely with MCSS and the Ministry of
Municipal Affairs and Housing to ensure that doesn't happen. I
don't think anybody is going to be put on the street.
Mrs Boyer:
So that could be an initiative that could be taken towards the
commitment that you have to provide supportive housing.
Ms Czukar:
Yes.
Mr King:
We'll take those comments back.
Mrs Boyer:
Thank you. That's what I wanted.
Mrs
McLeod: There are lots of questions. Maybe in the few
minutes left I'll ask you about another targeted population that
we've had concerns about, and that's the number of people who are
incarcerated in Ontario who actually should have been admitted to
a psychiatric hospital but there was no bed, or perhaps part of
your answer will be "or could have been supported in a community
setting with treatment if the community supports had been
there."
I don't know if you have
numbers on the number of people who have been incarcerated, who
have been recognized as having mental illness and needing some
form of treatment.
Mr Helm: I
don't have any statistics with me, but I can say that we have
been doing a number of things to try and minimize the backlog
there. For example, we're working very closely with our
psychiatric hospitals so that when someone in the jail system is
identified for an assessment, depending on the severity of the
case, we're trying very hard to do the assessments, if
appropriate, in the jail setting. It's faster, it can be done
quickly, at least an initial determination. That's something
we're trying to do, so it doesn't necessarily have to be a
transfer to a bed that might or might not be available.
We've put in a number of
forensic court case workers across the province to be there even
before an issue goes to court, to try and have it diverted. We've
been very successful in a number of cases to get people diverted
for very minor cases out to the community as long as they're
linked with supports and services.
Those two things have been
helping a lot. There are some cases where a client might be in
jail who really does need a bed setting, and we try very hard to
transfer the person into the closest psychiatric hospital. If we
have to go farther afield, we do that.
The bed strategy that I
mentioned isn't fully operational yet, but we have announced a
number of beds. Hopefully once those are in place they will
address some of the pressures. As we continue with community
programs such as treatment teams with a forensic component, for
example, and continue to enhance court diversion workers, once
these beds are in place we will hopefully address some of it.
Mrs
McLeod: Do you mean the supportive housing beds you were
speaking about earlier? I'm just not sure which beds you were
referring to.
Mr Helm:
Sorry. If they have to go into a psychiatric hospital bed-
Mrs
McLeod: Are you talking about going into a forensic
bed?
Mr Helm:
Yes. Is that what you were talking-
Mrs
McLeod: Actually, I think it's not.
Mr Helm:
OK. Sorry.
Mrs
McLeod: I really think the forensic issue is quite
different from the issue that I'm raising, which is people with
mental illness who haven't been able to access treatment or who
may be in a crisis stage and actually do need hospitalization at
that moment in time, but there is no psychiatric bed to take
them, and so the police have no alternative but to take them to
jail. You know that I come from northwestern Ontario. That has
been a huge concern in our region, and it has been a concern for
police officers, who say, "We have no place to take them except
to jail because they are a danger to themselves or to
others."
We're also in a community
where we're about to have a 50% reduction in the numbers of beds
that are currently available as psychiatric beds in a different
setting, and I think it's going to be a real dilemma for the
police officers to know: "Where do we take people now? Do we take
them to one of 17 beds in the acute care hospital that are
designated for psychiatric?" If it's a supportive housing
situation, which is the alternative, I suspect those beds will
all be full. So we still have a crisis component: Are we going to
have enough beds for crisis situations to deal with a population
which is now being incarcerated totally inappropriately?
Mr Helm:
According to our current plan-and to be honest, we don't know
100% whether it will be sufficient; that's why we want to do a
review-we have on the books to create 144 new forensic secure
beds across the province, and we've started that implementation
in terms of announcing certain cities to get the construction
going. That should help.
Mrs
McLeod: I think the forensic is a separate issue,
because they are people who are dealing with the court system.
I'm talking about mentally ill patients who have no contact with
the court system, who don't belong in front of the courts, who
belong in a mental illness treatment program.
Mr Helm:
Schedule 1 beds in public hospitals are also part of the reform
strategy. We are enhancing schedule 1 or acute beds across the
province, in addition to what I mentioned, the 144 forensic
beds.
Mrs
McLeod: That's in lieu of beds that are now in
psychiatric facilities.
Mr Helm:
It's in addition to the beds in psychiatric facilities. In
psychiatric facilities, in psychiatric hospitals, the beds that
we've identified for possible closure down the road are very
specialized beds that we feel we might not require once the
community supports are in place. So we're putting in forensic
secure beds in those settings, but at the same time we are
putting in acute beds, like schedule 1 mental health beds and
children's beds, in the general hospital sector.
Mrs McLeod: But there is,
certainly in my region, a very significant reduction in the net
number of acute psychiatric beds.
Mr Helm:
At Thunder Bay Regional?
Mrs
McLeod: Yes.
The Chair:
Could I just ask some clarification on that. In the health care
restructuring commission report that came out just about a year
ago at this time, it's my understanding that the number of
psychiatric beds in the province were actually going to be
reduced from something like-I don't know-
Mrs
McLeod: It was 50%.
The Chair:
-2,900 to something like 1,760 beds by the year 2003. Is that not
a reduction, then? I'm reading right from the ministry's own
health restructuring commission report. It says that the 2,900
mental health beds there were in 1995-96 are going to be reduced
to 1,767 by the year 2003. Is that the issue you're raising, Mrs
McLeod?
Mrs
McLeod: Very much so. The bottom line is, we have people
in jails now who presumably need to be in a crisis bed, and those
crisis beds currently-there are some schedule 1 beds, obviously,
but the majority of them are in psychiatric hospitals. The system
currently isn't offering enough flexibility to prevent those
people from being incarcerated. My concern is, with a 50%
reduction in the overall number of beds-if we don't have
flexibility now, how are we going to deal with those people in
crisis in the future? Are we going to have more people in
jail?
Mr Helm: I
think that through the bed strategy for the entire system-when
the commission talks about beds that should close, within our
ministry we look at bed closures only at the point when it makes
sense, where we have the community supports in place. The plan is
to go in a certain direction. The actual implementation could
have flexibility as we get there. If we feel community supports
are in place and some bed restructuring is warranted, we would
pursue that on a case-by-case basis.
To come back to some bed
numbers-I know you were talking specifically about forensic, but
there are other ones.
Mrs
McLeod: No, I'm actually talking about acute crisis
beds.
Mr Helm:
Children's beds, for example-
Mrs
McLeod: No, I'm talking about acute adult
psychiatry.
Mr Helm:
Acute forensic only. OK.
The Chair:
Not forensic; just acute beds.
Ms Czukar:
I think there's some confusion here. The reason that Dennis keeps
coming back to forensic is that the police can't pick people up
and take them to jail without charging them with something. When
they charge them with something, in our system they're a forensic
client. At that point, there are the diversion options and there
are other options in the system. When they're being held in jail
because there's no other bed, we identify that person as a
potential forensic patient.
Mrs
McLeod: I understand. Look, I know we need forensic beds
for people who need a forensic, secure setting, but these are
people who are being charged and become labelled as forensic
patients because they couldn't access a system that was not in
jail.
Mr Helm:
In terms of acute beds, period, we have 195 acute beds that are
planned to be put into the system across the province.
Mrs
McLeod: So, 195 versus the closure numbers of acute
beds; a net increase of 195 acute beds?
Mr Helm:
It's 195 new acute beds. The closures tend to take place on the
side of specialty and tertiary beds. According to the commission,
we're over-bedded on the PPH side, to be honest, on the specialty
side. So we're downsizing on the specialty side after we have
community supports in place. The acute side is under-bedded now,
so we have to raise the number of acute beds and forensic
beds.
Mrs
McLeod: It is possible, Mr Chair, to get some data
tabled with the committee?
The Chair:
We'll get back to that this afternoon. It's 12 o'clock now. We'll
recess, and we'll resume again at 1:30.
The committee recessed
from 1202 to 1334.
The Chair:
I'll call the hearings back into session, and I believe we're
over on the government side now. Any questions at all by
anyone?
Ms
Mushinski: I'd like to continue my line of questioning
with respect to outcome evaluation. I think one of the auditor's
outstanding concerns was that there needs to somehow be a
comparative evaluation done of the cost of home-based or
community-based care versus the cost of institutionalized care
for the mentally ill. I'm assuming that some of these cost
evaluations have been conducted with respect to moving from
institutionalized care to community-based care. Could you comment
on that?
Mr Helm:
When we do our financial planning for mental health reform, we do
some costing forecasts on, for example, the cost of bed services.
As you know, part of the plan for restructuring is to close beds
down the road and reinvest that money into community support. So
we do have costing on that side.
Ms
Mushinski: Yes. Could you repeat that? I think it's
important that we understand that.
Mr Helm:
When we start with our mental health reform agenda, which
includes community investments plus inpatient downsizing, we do
costing exercises of putting a cost per bed, for example, in a
psychiatric hospital so that when the time comes when we feel
community supports are in place that then warrant a review of
possibly closing some inpatient services, we have a cost value on
those beds. So when those beds are closed, we have an actual
dollar value, pot of money, available to us to then reallocate to
various areas of the province, based on our planning.
When we evaluate and
reallocate money elsewhere in the province, as I mentioned
earlier, it's really focused in on best practices and to address
the needs of that community.
A while back, when we started reinvesting into the
various areas and into best practices, we set up an evaluation
process to evaluate reform overall, including our bed ratios, our
shifts and the effectiveness of best practices. As John mentioned
in his opening remarks, we have an evaluation exercise that's
just starting with the Mental Health Foundation, the Centre for
Addiction and Mental Health and the Canadian Mental Health
Association-Ontario. They will be doing an evaluation process to
report back to us primarily, from our point of view, on the
quality-of-life indicators that come out of this. Clearly, our
reform agenda is to improve services, have them closer to their
home community etc, and the best practice model. So we want some
feedback: Have we been successful in that regard of quality of
service, changing the circumstances in their lives, and also how
effective has it been from an economic point of view, but perhaps
more importantly, from a social service quality point of
view?
Ms
Mushinski: So the in-patient downsizing exercises aren't
as a result of being wedded to any particular economic exercise
but are more from the perspective that our government believes
that community-based care provides better quality of service as
well as quantity of service for the patient.
Mr Helm:
That's correct, yes. As we go through the reform exercise, it is
not a cost saving exercise. We have been clear that any savings
in terms of bed closures, for example, come back to us
corporately in the ministry to reallocate all of that funding out
to the community. Equally, on the psychiatric hospital divestment
process, it is not a cost saving activity at all; it's a
commitment to transfer the resources, and in some cases
additional resources, to ensure that the mix of services is
maintained and improved. We're not faced with a cost constraint
exercise here at all.
Mr King:
This is consistent with the strategy also in the hospital system,
that we're moving from a dependency on the in-patient side to the
community. I just wanted to follow up on the question earlier
because I felt like we'd left that bed situation up in the
air.
Mrs
McLeod: I don't mind; if we don't have time for that, we
can do that later.
Mr King:
That's fine; I'll do that later.
Mrs
McLeod: I'd be happy to have it now, but we will come
back to it.
The Chair:
We'll wait until we finish this.
Ms
Mushinski: You don't mind him cutting into my time,
then?
Mrs
McLeod: No, I offered it back. I thought that was really
a non-partisan thing to do.
Ms
Mushinski: You can have it.
I think Bart had a
question.
The Chair:
You have about 15 minutes.
1340
Mr Bart Maves
(Niagara Falls): I just wanted to say that the report
we're here about today is actually the follow-up report. The
auditor came back after the 1997 report to do a follow-up report
in 1999. We often get ministries in here, and the members of the
committee give them a good grilling on things occurring in their
ministries and pick on some of the things the auditor has pointed
out. I do want to remark, though, at the outset of my comments
that the opening line of the auditor's 1999 report is,
"Recommendations relating to the following areas of our 1997
report have been substantially implemented ...." There are
several areas. I'm not going to read them; anyone can do that on
their own. They include, though, the definition of acceptable
levels of care, homes for special care respite grants, and a
variety of other things. I want to congratulate the ministry for
implementing those recommendations over the past two years, since
the auditor did his initial report.
One thing in this 1999
report concerns me. The Provincial Auditor talked about four
areas: mental health reform, performance monitoring, management
information systems and homes for special care quality of care.
There are five or six things that he points out: progress in
meeting mental health reform targets, comparing the costs and
outcomes of community-based care with those for institutional
care, outcome measures and monitoring programs against them, and
a few other things.
In the ministry's response,
they all are dependent upon the completion of the mental health
minimum data set. I note that the ministry's response to the
auditor is that this has been deferred because of the year 2000
and the effort there. In your remarks, Mr King, you referred to
the mental health minimum data set, but there doesn't appear to
be any timeline as to the completion of that. In order to fulfill
some of these remaining recommendations, which are actually
stemming from the 1997 report, that data set has to be completed.
So I'm a little bit concerned that we may still be looking at a
few more years down the road and it could end up four or five
years after the auditor's initial 1997 report before you are able
to implement some of these things. Can you give me any comfort on
the completion of the data set and the timelines?
Mr King:
I'm not sure I can give you any comfort; I will certainly respond
to the issue that we have right now in the ministry. The year
2000 project took a lot of time and energy from all of us in the
system and we did have to put a number of projects on hold. We
had to prioritize to ensure patient safety in the system, and
that's why the Y2K had the attention it did.
We have prioritized a
number of projects right now at the ministry. As you may or may
not understand, we also are doing the same with the CCHCs in the
system. We have information systems that we're trying to deal
with in the community health centres. The hospitals are still
looking at a new funding formula. So there are a number of
priorities in the system.
We have identified that
this is a priority for us in the mental health system and we will
continue to put that priority forward, but it has to be taken
into consideration in context with all the priorities in the
system. But I'd like to assure you that we believe it is very
important to have this information from the field so that we can
do comparisons as well as benchmarking and to ensure the accountability. Those will be
our priorities for all of the areas. We hope that will be
addressed in the next two years.
Mr Helm:
If I could add, there are a number of other accountability
mechanisms that we are following through on. Hopefully the
minimum data set will be approved and we can go forward, but in
the interim we are proceeding in a number of other significant
areas.
In the mental health area,
we have refined the annual operating plan process, which is
fairly standard in many program areas, meaning simplified it,
and, as I mentioned earlier, we built in a very specific
accountability component for new initiatives. If new money is
given for a community treatment team, they report specifically on
that in terms of the clients, the issues. So we are collecting
some of the information that has been identified by the auditor
and through the minimum data set.
Also, on the hospital side,
to ensure that we get the appropriate data once our psychiatric
hospital services are divested to public hospitals, we have gone
through an exercise of altering the chart of accounts, which is
the standard reporting requirement for our hospitals. So when a
public hospital does assume responsibility for our psychiatric
hospital services, they are able to report in enough detail on
the mental health side so that we have the baseline data about
the clients, their medical diagnosis, their requirements for
discharge. One other thing we have is the psychosocial
rehabilitation tool that is used in the community that we have
supported, and that's another mechanism for client data,
assessment data. Together that helps meets some of our
information needs, but hopefully the minimum data set would bring
a lot of that together.
Mr Maves:
By definition, then, is it going to take a certain number of
years of experience in compilation of data before you're going to
be able to derive any conclusions from that data?
Mr Helm: I
think it would take probably one full year to get things up and
running. If through the ministry we can confirm the minimum data
set is a go that we've always been planning on, then we have to
go into a full piloting. We had a limited pilot to see if the
tool works. We have to apply it more across the board, look at
the technology survey that we've completed, and see what upgrades
are required in our programs for them to deliver that data. I
think that would take about a year, which would take us to the
end of the next fiscal year, and then hopefully full reporting
could start at that point. In the interim, we would rely on the
other data mechanisms that I've outlined. That's all tentative
time frames, but my best guess.
Mr Maves:
Similarly, the auditor's fourth recommendation under homes for
special care was that you should "mandate compliance with the
minimum standards of care as a condition of licence renewal." I
have two questions in this regard. The first is, does the
ministry agree with that principle?
Mr King:
Absolutely.
Mr Maves:
Secondly, this also is dependent upon the ministry developing a
comprehensive housing policy that will set out standards and
monitoring mechanisms for all supportive housing. This is
separate, apart and distinct from the mental health data set. So
where are we on the development of that comprehensive housing
policy?
Ms Czukar:
As I was mentioning this morning, that comprehensive housing
policy is in the approval process and it should be, we hope,
approved shortly and be available for the next stage of
implementation. As I mentioned also, the notion of standards of
care has to be applied not just to homes for special care, but to
the other forms of housing that are going to be covered by the
policy, ie, supportive housing and domiciliary hostels. These
programs now have different funding mechanisms. They are not
licensed programs like HSC. HSC has legislation; dom hostels
operate in quite a different way. The need for consistency is
there. That's what the policy and strategy are aimed at. There
will be consultation on implementing that policy so that there is
a link between the standards of care, the levels of funding and
the licensing.
1350
Mr Maves:
Do you think we'll able to have that up and running for the 2001
fiscal year?
Ms Czukar:
That's certainly the hope.
Mr Maves:
OK.
The Chair:
That's 20 minutes right there.
Mrs
McLeod: I know my colleagues have questions for this
session, but just let Mr King respond, if he wishes to, on the
bed issue.
Mr King:
Yes. I wanted to get back to this because I felt we left it
somewhat confusing at the end. I think we were talking about
different levels of care. The commission has basically directed
us on the divestment of the PPH hospitals, and that will involve
PPH closures. The numbers are clearly documented. I can get the
numbers for you.
At the same time, the
commission has also directed, based on certain bed numbers and
formulas throughout the province, the opening of additional beds.
Until the year 2003, we will consistently open beds in the whole
area of children's mental health and acute mental health beds,
which are the majority. We will also have some tertiary and
certainly forensic beds. It's really a timing issue. In the next
four to five years we're going to have more beds than are
required in the system, and then as the community supports are
built, we will begin to downsize on the specialty side.
As far as the acute numbers
are concerned-and you were actually giving us some numbers of
going from 2,900 to 1,700-there is a decrease in the number of
specialized beds, but at the same time we're also increasing on
the other side. There are certain communities right now that have
more beds than they will in the future.
You had also asked about
Thunder Bay. There will be a decrease in beds in Thunder Bay, but
these beds are also moving out to other communities, like
London-St Thomas,
Windsor and other areas in southwestern Ontario.
So it's really somewhat of
a timing issue. If you want specific numbers, we could always
come back to that at some point. But I did want to clarify that
because I felt we left that very confusing. I try to explain
things in the simplest terms. If I didn't explain that well, then
we'll have somebody else try.
Mrs
McLeod: I think probably one of the difficulties is the
HSRC does not actually refer to acute beds, and maybe that's
because acute beds are considered to be schedule 1s in acute care
hospitals, and the HSRC recommendations don't distinguish when
they look at the beds in the psychiatric hospitals. They just
have a lump-
Mr King:
Number.
Mrs
McLeod: They call them all chronic beds, except for the
forensic, which are separate. If I take the Thunder Bay example,
we have already 24 schedule 1 beds in an acute care hospital.
Those are to go to 30.
Mr King:
Correct.
Mrs
McLeod: They were supposed to go down to 17 and,
revised, they're going to 30. So that, I understand, is an acute
care bed. But at the same time, we have 118 beds in the
psychiatric hospitals that will go down to 51. This is not
counting any forensic beds. So 61 beds net is the loss. I don't
know, because the HSRC report doesn't distinguish it, what
portion of those are psychogeriatrics, and where my concern
should be with psychogeriatric beds and where my concern would be
with what I called acute, but I probably need a different term.
It's people in crisis.
Mr King:
Right.
Mrs
McLeod: As I said, police right now have an alternative
potentially to take them to a schedule 1 bed, although that would
be highly unusual. Most often they would take them to a psych
hospital and there would be a crisis admission. It's those beds
that I was trying to get at. Certainly there's a significant loss
of beds from the psych hospitals, which is the figure my
colleague was using.
Mr King:
The other part that I think we're missing in that equation is the
community supports, though, because that's what we're trying to
build up in the system as we downsize those beds, and also have
the ACT teams in place.
Mrs
McLeod: I appreciate that. I also, by the way,
appreciate the fact that there has been a hold put on the closure
beds until community supports are in place. I acknowledge that
and I'm appreciative. I guess what I'm looking at in terms of the
planning is to make sure that we retain a flexibility so that we
can respond to people in crisis. I think there is a real concern
about whether or not the number of beds remaining in the system
is going to be adequate to provide that flexibility.
Mr King:
Again, I feel that we are dealing with a direction that has been
given, and we will continually monitor this also. We continually
monitor all the resources in the system.
Mrs
McLeod: Rather than pick up on the reference, I'm going
to turn it over to my colleague, who has a number of
questions.
Mr Richard Patten
(Ottawa Centre): Thanks for being with us today. I have
two categories of questioning. One is related to some services in
my own area, which I probably know better than the general field.
I'm relating it, though, to the area of mental health reform.
You may be familiar with
the Royal Ottawa Hospital, which is an ancient facility, 85 years
of age. It was originally designed for patients who had
tuberculosis and therefore it was a good place for people to walk
around. The place was designed very well. It's now an old
facility with patients who stay there sometimes three to a room,
divided by curtains. It's completely inappropriate for long-term
stays. With the decommissioning of Brockville, I know not all of
the beds-there are about 300 beds, something in that
neighbourhood-but roughly 180 will be redistributed and some of
those will be going to Ottawa because a lot of the patients who
are in the long-term arrangement are from Ottawa.
They have a dilemma. I know
it's not easy for you folks, because you've got the auditor and
you have the restructuring commission and you have your own
government and your own ministry and everybody looking at what
you're doing, but the hospital is faced with dealing with the
recommendations of the restructuring, or at least the ministry
is. They like very much your document Making It Happen. They
think that is extremely well done, and they have put together a
vision of what they believe fits within that framework. But they
can't respond to both. I hope there's no one here from the
restructuring commission. They like this approach because they
think the other one is quite limited and is a patchwork, sort of
"We'll catch up and just make a little bit of an addition to this
place." How do you deal with a situation like that?
Mr King:
If that's a general question, we have been working with all of
the communities that have commission directions and we are
proceeding on the commission directions because they were, by
law, the way we were moving. If there were some concerns with
certain communities on what the directions did say, they were
asked to refer that back to the commission.
John Oliver, my colleague,
is the assistant deputy minister for restructuring. John and I
would meet on a regular basis with the commission to see if we
could assist those organizations. They then would go back to the
minister with advice if there were to be changes. So we did have
a process in place to try and work on that. Failing that, we
would follow the commission directions, and that is really the
way we're moving now.
I mentioned earlier that I
do have someone here from the hospital restructuring
implementation team. If you would like to direct a question
specifically about the Royal Ottawa Hospital, we can maybe
address that as far as the divestment from Brockville is
concerned.
Mr Patten: No, I won't take the
time of the committee to do that, but I would like to chat, if I
might, with one of your officials later or whatever, if that's
OK.
Mr King:
That's fine.
Mr Patten:
I'm just saying that the document-and I had a chance to read it.
By the way, that's not for general distribution, is it, Making It
Happen?
Mr King:
Yes, it is.
Mr Patten:
I think we could only get it through the library.
Mr King:
It is available.
Ms Czukar:
We have many.
Mr Patten:
You have extra copies? OK.
Mr King:
We should have brought some copies today. I'm sorry about
that.
Mr Patten:
That's both the operational framework and the implementation
document?
Mr King:
Yes, that's correct. We can make sure you receive copies of
that.
Mr Patten:
The document on best practices I thought was quite helpful as
well.
However, having said that,
the restructuring commission says the fact that-and this is from
its most recent report, I gather, which was in February. So
that's a year ago. I wonder if this is still true. They're
saying, "Little has happened over the last two and a half years
to move the PPH changes forward"-provincial psych hospitals-"has
not only stalled the progress of mental health reform in all
regions of the province, but it has contributed greatly to the
increased scepticism about mental health reform in general."
They go on to say, "In
particular, there's a lack of confidence among providers,
individuals with mental illness disorders and their families that
a ministry-led process will be able to respond expeditiously to
local circumstances."
Is that an outdated
judgment, do you think? What has happened in the interim, because
that's a year ago that that was made?
1400
Mr King:
I'm not sure I really want to comment on the commission. They
basically have made their comments based on their observation. We
are working as best we can with those communities that are
affected. I think if we see that there are major issues and it's
not in the right direction, then we will try and improve that
situation.
Mr Patten:
They're talking about setting up these regional, local
structures.
Mr King.
We are proceeding with the task force groups. The mental health
task force groups would then look at how they can best effect the
community supports. It's local decision-making, having local
consumers on the committee.
We've just had our
experience with the first committee in the north. It's been a
very good experience. They have just made their recommendations
to the ministry, which we are reviewing at this time. I think
we're seeing that there is definitely local community involvement
in determining what's best for those communities that are going
to receive community supports with the divestment process.
Mr Helm:
In the interim, in terms of community investment and planning,
where there isn't a task force yet in place, the ministry is very
keen on making sure the process of divestment, of reinvestment,
is up and running. So ministry staff are taking the lead with the
community players in looking at the system design that should be
put in place post-divestment of the psychiatric hospitals. We're
leading the divestment of the psychiatric hospital process, and
we are also leading the community consultations and planning for
the allocation of the new investments.
We're proceeding, making
sure all that is moving along, and when the task force is up and
running, the ministry staff hand off to the task force the work
that they've been doing, because we don't want things to be on
hold until a task force is place. So we are doing our normal work
and then we will pass it on to the task force and support the
task force to make sure the momentum isn't lost.
Mr Patten:
One question that was asked this morning by Ms Mushinski was the
integration or integrity issue. I look at this in terms of there
being a whole variety of things that cross over between
ministries, and I'll tell you, it drives people crazy, no pun
intended, literally. They get played off against each other: "We
don't have money; go over and see them." The same
institution-different ministries literally have different
standards for physical design standards. It drives these
organizations nuts.
I think, for example, in
the area of mental health, of the children's mental health
centres, and I visited a number of them recently. I guess their
funding comes from Comsoc. How do you work together? Why isn't
that all under one rubric called mental health, regardless of
age, that you've got a responsibility to work through?
Mr King:
First of all, I believe our relationship with the Ministry of
Community and Social Services is very good. I think we're
actually improving on our coordination.
I spoke earlier about the
regional offices. The regional offices, where possible, when we
move them out to their communities, will be housed with the
community and social services teams. So that way we are building
on that integration of ministries. We have some joint cities now
that are dealing with this.
One area, if I can mention
it, that drives a lot of people crazy is the reporting and having
different reporting back for different ministries that fund the
same organization. In that way, we are also working very closely
with community and social services to streamline that process. We
have a joint cluster group dealing with information systems so
we're asking for the same information.
I really believe, sir, that
we are improving that relationship, and I think we're always
moving forward as best we can to help streamline the process.
We also have a joint position now for integrated
children's services which is between Comsoc and the Ministry of
Health and Long-Term Care. This will address a lot of children's
issues, a two-ministry team.
Mr Patten:
We all have a lot of questions, but I'll confine myself to one
more. The children's mental health centres' waiting list has
expanded, as you know. With the schools now having less funding
for special education, children who have some mental health
issues to work through in many cases are on a waiting list just
for assessment. So people are being forced to go privately. That
obviously puts pressure on children's hospitals etc, so it works
its way back into the system. There's a very critical situation
that is occurring here that requires some expeditiousness.
I'm going to ask you, in
light of those particular pressures and your planning frameworks,
do you have the resources to move ahead or to turn up the gas on
your timetables in terms of the target dates that you had before?
Even the restructuring commission is saying that, although I know
you don't want to comment on what they say. You had a choice how
you used that money. Remember that.
Mr Helm:
We have a specific plan in terms of investments for children's
inpatient reinvestments. Within the Ministry of Health we're
responsible for implementing the HSRC directives around new
children's mental health beds across the province. As we go
through that process, we work in partnership with MCSS to make
sure the beds we have been directed to put into a certain
community fit in with the MCSS overall children's service plan
for that community. So we are working with them.
In some cases where bed
enhancements require capital construction, which could take a
number of years, we have asked the hospitals to try and
fast-track proposals that come in to us: What can we do in the
next year or so, maybe in the existing building if it's
cost-effective etc, with the longer-term plan of having the beds
fully operational at the end of the day? We want to look at
immediately getting something in place and in the longer term to
completely fulfill the HSRC directives, and that's within our
responsibility, working in partnership with MCSS.
Also within our
responsibility, the Ministry of Health and Long-Term Care funds
21 children's mental health outpatient programs through
hospitals. We have been working very closely with our MCSS
partners to look at a number of things that would provide a
better service, perhaps standardized assessments in our system
and in their system, as an example.
The government's last
budget talked about a $20-million announcement to implement some
of the work that Margaret Marland did. We are working in
partnership with MCSS around those activities on common
assessments, and other service models are being looked at. We are
making progress and we want to fast-track the services to the
children's population as quickly as we can because of the need
that has been identified.
Mr Patten:
I'll come back later on.
The Chair:
That's 20 minutes, so I will turn back the-and I owe you five
minutes from the last time.
Interjections.
The Chair:
I plead guilty, and the auditor didn't even have to remind me. Go
ahead, Ms Munro.
Mrs Munro:
There seem to be some themes emerging from much of the discussion
that has taken place here today. I'd like to follow up on a
couple of those.
One of them is the whole
issue of best practices. I wondered whether you could give us
some insight into two aspects of best practices, the one from the
point of view of what you have seen as best practices to promote
mental health reform; secondly, I'd be interested in any comments
you might have with regard to other jurisdictions and where we
stand in relation to those other jurisdictions that you might
have looked at to provide us with some sense of our position with
regard to those other jurisdictions.
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Mr King: I
will lead off on that because I think you've raised a good point
on best practice and benchmarking. We can always learn from other
jurisdictions. We should not reinvent the wheel all the time. The
ACT teams, for example: We did pick that up from some of the
American system. The ACT teams are really a best practice. We are
seeing constant results from that. Personally, having been
involved in Windsor to see the ACT team working, which is also
involving the hospitals, the community, the mental health
agencies, long-term care-it involved London, St Thomas-there was
an incredible group of people working together to resolve this
issue of the patients, providing the best resource available in
the community. That is a specific example of best practice that
we have adopted here.
I'm sure Gail has some
other areas that she wanted to cover.
Ms Czukar:
When you're asking about other jurisdictions, I might address
both together. Best practices was the subject of a 1997
federal-provincial-territorial report that was put out by Health
Canada on behalf of a national working group. That report
detailed best practices and has in it examples from other
jurisdictions, both in Canada and outside of Canada, in terms of
what best practices are. There's a lot said in Making it Happen
about what the best practices are. As I said, we have many copies
of these documents that we'd be happy to provide. We don't have
them here, but we can get them to you.
I might just run through
what some of those best practices are. John has mentioned ACT,
assertive community treatment, teams that are being implemented,
as we reviewed this morning. Intensive case management is another
best practice. It's linked to assertive community treatment teams
but it's not the same thing. Crisis response services-there are
two levels of this. One is the service level, which I'm
addressing now, and the other is systemic best practices, and I
will get to those. There is crisis response, supportive housing,
outpatient care, consumer self-help and self-employment
initiatives, vocational, educational programming and family
self-help programs. Those are the services that this document
says are the best practices that we should look to be
implementing as we implement mental health reform. We are working
on all of those.
At the system level, it's
not enough to just have these discrete services. You have to have
some other things. You have to have integration and integrated
access, program evaluation, accountability mechanisms. We are
working on developing an accountability framework specific to the
restructured mental health system, in addition to general
accountability work that's going on in the ministry that John
referred to.
So those are some of the
best practices that are set out in the 1997 report, based on
experience in a number of jurisdictions.
Mrs Munro:
You've also touched on another theme. That is, of course, as
clearly emerges from your immediate comments and from comments
made earlier today, the whole question of the integration. That
was my opening question this morning, and we certainly have heard
in a number of ways where initiatives have gone in the direction
of creating greater integration.
When I asked the question
this morning, you talked about the regional offices. More
recently, this afternoon, you talked about the fact that, where
possible, those regional offices are being set up with MCSS as
well. I wondered whether or not down the road you see the
possibility of the inclusion of the ACTT group with the CCAC or
is there a possibility that they may work together? Obviously,
the ACCT is going to have to work with the hospitals and other
health care providers. I just thought we needed to know what the
crystal ball tells us.
Mr King:
Certainly with the regional offices, the regional teams will be
reaching out to those communities to involve mental health, the
hospitals, long-term care, which includes CCACs, in addition to
community health centres and public health, the district health
councils also being part of that. We see some focus groups coming
together and to locate some of the programs where they best
should be located. I would never say that we would never see that
occur, for example, an ACTT with the CCAC, because I think we're
very open to what works best at the community level.
The north is different than
the south. Things happen differently all over this province and
we need to allow the freedom for that to occur. So that really is
the vision that we're moving forward. Our ministry vision is as
close to home as possible and the affordability of the system in
the right place.
We have to be open to the
type of thing that you're proposing in the future and, of course,
we believe strongly in integrated systems that are working
together for the best interests of the patient, the client or the
resident.
Ms
Mushinski: I'd just like to follow up on that, if I may,
just for a minute. As the integrated services pertain to mental
health services in the province, I'd like to zero in a little bit
on children's mental health needs. Mr Patten touched on what I
believe is a serious problem and it's perhaps this entrenched
culture that is found within the bureaucracies; I'm not sure. If
we truly want to achieve one-stop shopping for the mental health
services of our kids, as well as all Ontario residents, how do
you overcome this traditional model of community social services?
On the one hand, Children's Aid is required legally to deliver
those services. If that is a barrier, how do we overcome that? If
we've identified these barriers, who deals with them? Are there
things that we should perhaps be suggesting as policy amendments
to deal with the removal of barriers to achieving this kind of
perfect model in a perfect world?
Mr King:
Again, I think that you picked up some themes; perhaps we have
also picked up some themes from you. We believe that we need to
move forward in integration not only within our ministry but with
other ministries. I believe you're going to see some new
developments with community and social services and health in the
future, especially in the area of children's services because
this is where it's been identified that there are some overlaps
and some areas we need to work on.
We agree with you. How
quickly we can make that happen and the barriers that we need to
overcome are something that we'll certainly bring forward if it's
an issue.
Ms Czukar:
I was just going to say that I will be very happy if we find the
perfect model for this system and address all of those barriers
in the near future. Dennis addressed some of the specific
mechanisms that we've been working on to try to integrate these
systems. I think common assessment tools are essential to
integration and we're certainly looking at those, not just in the
children's system and using those between the two ministries, but
across the mental health system. That's what long-term care did.
When you talk about CCACs, they started with assessments for
levels of care and assessments for community services and CCACs
use a standard assessment to determine what services people need
in the community. We have to move that way in the mental health
system, both for adults and children. It's a very important
mechanism.
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Mr Helm:
In addition to what I referred to earlier, I should have
mentioned as well that the MCSS initiative, Making Services Work
for People, is calling for coordinated access between all
children's activities. Local working groups are being established
under that sort of policy framework and the Ministry of Health
will be represented on all of those working groups. So that's
another example of us going the next step and working together
with MCSS in a very formal way.
Ms
Mushinski: So there are some real attempts to try to
remove some of the jurisdictional jealousies that have come along
with the system.
You may have touched on
this, although I'm not quite sure I heard it this morning. I know
you referred to the ratio of government funding to hospital-based
and community-based having changed. From 1994 to 1995, you said the ratio was 75%
hospital funding to 25% community funding, so there's been a
considerable shift in four or five years from that ratio to
60-40. Did you mention this morning-I can't remember if I heard
it or not-that the ministry had set some short-term and long-term
targets to change that ratio and, if so, how you want to
accomplish that?
Mr Helm:
The ratio at the beginning was 80-20, and that was 80%
institutions.
Ms
Mushinski: When you say at the beginning-
Mr Helm:
That was at the beginning of reform in 1992-93. The goal we
wanted to get to was a 60-40 ratio of 60% community and 40%
hospital. We're at a 60-40 ratio now, but it's 60% hospital and
40% community.
Ms
Mushinski: Did you set any time lines to that goal?
Mr Helm: I
think generally speaking we had said within the 10-year time
frame of reform.
Ms
Mushinski: So by about 2002-03.
Mr Helm:
Yes, 2002-03 was our initial goal.
Ms
Mushinski: You'd like to see the ratio change from 75-25
actually to 40-60.
Mr Helm:
Yes.
The Chair:
How many people are we talking about in total? When you're
talking about a ratio, do you have any idea as to how-excuse me
for just a moment.
Mr King:
We're talking about dollars.
Ms
Mushinski: That's government funding.
The Chair:
I understand.
Mr King:
It's split between the community and the institutional.
The Chair:
You have no idea how many patients this represents in total, is
that correct?
Mr King:
I'm sorry. I don't have those numbers.
Interjection.
Mr King:
When we're dealing with that, we're really just talking about the
health budget also.
Ms
Mushinski: I assumed you had mentioned those figures in
terms of mental health, but you're saying overall health
spending?
Mr King:
No. The question was, is this health as in mental health, not
community and social services? That's what I thought you were
talking about. It's just mental health targets that we're dealing
with here, but it's for the Ministry of Health and Long-Term
Care.
The Chair:
The percentages that you're talking about are the percentages of
dollars that you're spending in each, not the number of patients
who may either be in an institution or-
Mr King:
No. Percentage of dollars.
Ms
Mushinski: Is that consistent with Comsoc's targets as
well? We're talking about setting standards here.
Mr Helm:
I'm not aware of Comsoc having a fiscal shift ratio goal. It's
more of a policy thing.
Ms
Mushinski: It's a policy thing?
Mr King:
They don't really have institutions either, so it's not the same
that we would have.
Mrs
McLeod: I want to come back to a number of issues that
have been touched on already today. First of all, I think it was
a question Ms Mushinski asked earlier this morning, and that is,
the commitment to ensuring that all of the dollars that are saved
in the closure of psychiatric hospitals and psychiatric hospital
beds are going to be moved into community services. The first
part of my question is, does that mean that those dollars will
all stay in that community and region? My understanding is that
the dollars are going into a central pot for redistribution.
Mr Helm:
Yes. The reform strategy is that, as you mentioned before, some
areas are identified perhaps as being overbedded at this point.
Therefore, at the appropriate time, those beds could close and
the money be brought forward. Because of that, it was felt that
the best strategy is to bring the cost savings from those beds to
the ministry centrally, to then look at the provincial needs
across the province and allocate out where needed, maybe some
back to that home community, maybe to another community.
Our concern was that if a
community or region is overbedded for historical reasons, it
might not be equitable to close those beds and keep the money in
that community because it would maybe continue in terms of having
overreinvested, if that is the case. To have the best approach to
equity, it was decided to bring that money corporately and then
we would decide which regions are lacking or which were most in
need from an equity point of view.
Mrs
McLeod: I appreciate the intent, but I think we have
several dilemmas. I suspect that they're shared dilemmas, but let
me pose the questions.
You've indicated in the
auditor's report that your evaluation projects that are looking
at institution-based or hospital-based costs versus
community-based care are just in their early stages in terms of
beginning to yield information. We're talking about a 10-year
reform project that's now seven years into play, and we're
talking about evaluation projects that are now three years into
play and we still don't, as I understand it, have any data that
guides the resource allocations in terms of institutional versus
community, let alone the comparative costs of the two. Is that a
fair conclusion for me to come to, based on what your response to
the auditor's report is?
Mr King: I
would like to take a stab at that. I think that we certainly have
a better idea than that as far as, "Is this the best place to put
the dollars?" The less reliance on institutional care is well
documented-
Mrs
McLeod: I don't want to argue with you philosophically.
I agree. I'm really concerned about where we're going to get the
dollars to do this well.
Mr King:
The reinvestment is there, and the commitment's there for the
reinvestment into the community side.
Mrs
McLeod: Of existing dollars that are in the PPHs right
now?
Mr King:
Of existing dollars. There are some extra dollars going in too,
because we're also putting dollars in the system now that build
up the community supports. So I think that there has been a great
deal of investment and a great deal of thought given to this approach.
You're right; we do need to have more reporting on the evaluation
side, and perhaps we haven't moved as quickly on that side. But
this is a timing issue for us.
I think you've made some
good points, and we'll take that under consideration. I think
it's important that you've raised that.
Mrs
McLeod: I appreciate that. The timing issue's crucial. I
don't want to take time to get into a debate about philosophy,
because there is no debate about the philosophy. It's just a
question of, "Are we going to have the services in a combination
of community and facilities that we need?" I think everybody here
would agree that that's the goal.
Mr King:
Agreed.
Mrs
McLeod: I'm looking at the HSRC recommendations in terms
of community investments, and I'm not sure, given the fact that
we don't have the evaluation project data in yet, exactly what
they use to determine the dollars. But they are looking at a
$63-million to $87-million investment, depending on what standard
we're prepared to accept as far as a recidivism rate is
concerned. They state that this reinvestment translates to
$55,000 to $77,000 per PPH bed closed. Mr Helm earlier mentioned
that you'll have a cost per bed. Do you have that cost now, and
does the cost per bed that is being closed correspond in turn to
the reinvestment that the HSRC says is needed for community
service?
Mr Helm:
We've done calculations in terms of the average cost savings in
total per bed just as a general rule. It depends on the hospital
as well. Some hospitals have a lower per diem than others. But as
an average, $400 to $450 per bed per day is often a benchmark. We
have used the varying rates by PPH to determine, if those beds
close, what will the dollars be, the total amount that would come
back to us?
Mrs
McLeod: And the figure would be?
1430
Mr Helm:
About $48 million is identified as a rough benchmark for the
value of those beds.
Mrs
McLeod: That suggests to me that we're already close to
$30 million short of what the HSRC said was the minimal-I
shouldn't say "minimal"-that's enough for investment.
Mr Helm:
That's not our only source of funding. That is the cost related
to the beds. If they close, we have that money to keep and
reinvest. In addition to that, through our annual BPA process, we
are requesting and receiving new funding, like the $19 million
that was announced in December, the $60 million that was
announced in 1998. That is new money.
Mrs
McLeod: I'm appreciative of this. Here's where I'm
seeing this as a dilemma, because we've seen what has happened on
the acute care hospital side where the cuts were made to the
acute care hospitals before either the community supports or the
long-term-care supports were in place. We've had chaos for a
year.
You said very clearly and
the minister said-and for me it was a landmark decision I've
already acknowledged today was an important one-"There will no
closure of psychiatric beds until we are assured that the
community supports are in place."
But a few moments ago I
heard you talk about the process-and as you said, a timing issue,
Mr King-because the divestment process, which is being carried
out with the Ministry of Health's leadership in an essentially
closed-door situation, is going ahead. You said that you don't
want to slow down too much on it and that at some point it will
be ready to go and you'll turn it over to the implementation task
force.
By the way-and I want to
come back and talk about mental health agencies-I think there
should be more publicity given to the fact that your
implementation task forces are being put in place, because that
has been a huge issue of concern, as the HSRC identifies. Based
on what I've seen locally and what I'm hearing by word of mouth,
the people who are on the committee are good people and they
restore confidence, and you should be telling people about that.
But they have a 12- to 18-month reporting time before they can
come to you with advice on what is needed for community
support.
My dilemma is that I'm
really concerned that divestment is marching ahead and it's going
to be 18 months before we even know what we need in the
community, let alone how much it costs, because the evaluation
projects on how much it will cost to provide support in the
community aren't in place yet. How can we be sure that we're not
going to lose psychiatric beds through the divestment process
before we've got all the community supports in place as
promised?
Mr Helm:
When the divestment process goes ahead, it's important to look at
it as a transfer. I'll use Lakehead. Everything currently
operated at Lakehead will be transferred as is to St Joseph's.
There won't be any restructuring, no bed closures at all at that
time-everything is being transferred over-so at the time of
transfer, there shouldn't be a fear of downsizing that day.
When it goes over, then
there is clearly the HSRC directive that they need to plan for
closing 74 beds in Lakehead over a certain period of time. But
then it's our job, with the task force and with St Joseph's, when
they propose, "OK, now we're ready, we can close these beds," to
make sure that the community supports are in place-the community
investment fund money that we gave them a number of years ago,
some of the $19 million that we just announced in December. We
would have to be convinced that all of those are in place. One of
the conditions of funding some of that was a clear link with a
psychiatric hospital. Some clients could be, through the
patients' assessments, identified for discharge. We would need
clear documentation that with the community investment fund and
the $19 million, part of which went into the northwest, you can
now move maybe 50 clients.
If that is the case and
they have the supports, then the ministry would propose
internally to close a portion of the beds. Those 74 beds would
not close just like that, according to the schedule outlined by
the commission. It has
to be evaluated by us and with the community and, if it's not
ready, those beds will stay open until they are ready.
Mrs
McLeod: What is the target date now for the closure of
the psychiatric beds?
Mr Helm:
For those beds? Just on paper, the 74 beds, or 68 beds in
Lakehead, are to close in 2001-02. That's on paper.
Mrs
McLeod: Just staying with the local example, if the
implementation task force is just now having its first
meeting-
Mr King:
It's just beginning.
Mrs
McLeod: It's due to report in 18 months. I don't know if
we've got a target date on your evaluation project being
completed so that you have a good handle on the cost of community
care versus institutional care, but how does that tie in with
that target date for closing beds?
Mr Helm:
The task force, as soon as it's up and running, has a life of
about 18 months or longer. They can come forward with
recommendations as soon as they're ready. Two or three months
into their mandate they might be ready to make recommendations.
So it's the life of the task force that we're assuming is
approximately 18 months; we expect recommendations before that.
As I mentioned, the ministry staff have been working right up
until now looking at the system in the northwest and where
reinvestment should be put, and that will go to the task force.
So a lot of the work has been done, and hopefully the task force
will feel it's good work and they then move along on it and make
the recommendations.
Mrs
McLeod: Is the northwest one the second implementation
task force?
Mr King:
Yes, the second one.
Mrs
McLeod: Of nine.
Mr King:
Yes.
Mrs
McLeod: When do you anticipate the other seven being
established, and what do you see as their target dates?
Mr Helm:
We're hopeful that throughout the end of this fiscal year and
into the next fiscal year we will have them across the
province.
Mrs
McLeod: I just want to be sure I've understood what the
plan is. The plan is to wait until those implementation task
forces, one by one-not the whole province, but in any given
community there will be no shutdown of a bed until the
implementation task forces at the community level have made their
recommendations and those recommendations are fully funded and
operative at the community level?
Mr Helm:
Partially right. If a hospital comes forward in the interim with
a proposal that they feel they could close certain beds within
the HSRC directive, we would have to look at it from a business
case point of view to be convinced that it is ready. If there is
no task force in place or if the task force is about to be in
place, we would really want their input and their view in terms
of what the system should be. If that comes in before the task
force is in place, we would look at it very stringently because
we are very concerned that the timing is right. So we might defer
them. It depends on the information that day.
Mrs
McLeod: Will Hamilton be setting up an implementation
task force? Is that one of the areas?
Mr Helm:
It will have one, yes.
Mrs
McLeod: I'm not sure what the bed closure numbers are in
Hamilton, but that might be an example where they are ready to
move because it's a somewhat different divestment than it is in
other communities.
Mr Helm:
Hamilton is getting more beds, so they're not closing any.
Mrs
McLeod: But the commitment that has been made not to
shut down a bed-and you've repeatedly said and the minister has
said that that's until the community supports are in place.
You've now said at this stage in the process that the
responsibility for advising you on the community supports is to
be left to the implementation task forces. You've also indicated
that the dollars for that community support have to be in place
before you close the beds down. I was taking the HSRC's $76
million. So that means that before we see the shutdown of
psychiatric beds, we're going to see up front about $76 million
in community mental health. That's at least what it takes to
replace psychiatric beds and, sure, you can then maybe, depending
on what your evaluation study says, save some of that down the
road. But in the first instance we're going to see an increase of
about $76 million?
Mr King: I
think you keep emphasizing the fact that-we do have a plan and
we're following through on that plan, which involves local
community planning. That's when you have the task force groups
appointed to do the local planning, and it does take longer than
if we decided what the community supports would be. I think
you're highlighting the time frame here. We are working through
that process. We would like to see these task forces roll out
faster and, as soon as we can, try and get them moving so that
they can move quickly locally, but we need to take the time
that's necessary to plan for the community. You have basically
reinforced what the plan is.
Mrs
McLeod: I like the sense of the plan. I share the
concern of how long it may take, but I'm also concerned that the
dollars are going to be there, because it would be most unusual
to have these upfront dollars before the closures are made.
Let me give a specific
example, if I've got a few minutes left. One of the things that
HSRC did not deal with initially was outpatient services. I'm
looking at their reinvestment. You'll have to help me with this.
Are "general case management" and "community service support and
case management" jargon for outpatient services, or something
broader than that, or does it not include them at all? Somebody
is shaking their head back there. Is there some line that tells
me we're looking at outpatient services in the HSRC's
recommendation on community reinvestment?
1440
Mr Helm:
We would be looking at outpatient services as part of our
restructuring and our reinvestment in terms of allocation.
Bed-saving dollars, for example, would be to outpatient services
and community services like case management.
Mrs
McLeod: I'm just looking at these lines. I know it's not
supportive housing, I know it's not ACTT. There's intensive case
management, general case management and community services
supporting case management. I'm hoping that one of those three
lines says "outpatients." I'm hoping it is, because at the time
the HSRC made its recommendations in the Lakehead there was no
recognition of the fact that there were 1,000 outpatients being
dealt with between the two hospitals. There is still no capital
provision. In the hospital restructuring that's going on, as the
PPHs are to be closed, there has been no provision made for a
physical space in which to provide the outpatient services or
other community services. The HSRC still recognizes that in the
$76-million figure there's no provision for capital. Where does
the capital planning fit in? I know there's an acute care
hospital being built in Thunder Bay, they've already finished the
completions to the chronic care hospital and there's no space in
those places for outpatients. So where are they going to be
treated?
Mr King:
I'd like to ask Tom Peirce to comment on Thunder Bay because
that's part of the divestment.
Mrs
McLeod: I don't want to make it specifically Thunder
Bay. I think it's a general issue.
Mr King:
We have capital as part of all the PPH divestment and we're
dealing with them right now on the plans of the divestments and
where they're moving within the existing hospitals, or if they're
staying on existing sites or if they're building new buildings.
That is identified in the psych hospital vote, so those dollars
are there for capital.
Mrs
McLeod: Maybe mine is an anomaly, because it isn't.
Mr Tom
Peirce: My name is Tom Peirce. I'm a consultant with the
health reform implementation team and I have been leading the
local negotiations in Brockville, Ottawa, Kingston, Hamilton,
London and Thunder Bay for the divestment of the PPHs in those
communities.
With respect to the
transfer of services, the HSRC indicated the capital they felt
was required to transfer PPH programs to the receiving hospitals.
That funding, as opposed to the general HSRC project funding of
70-30, is being funded at 100% in those communities. Any program
being transferred from a provincial psychiatric hospital to a
receiving hospital is being funded at 100%.
Mrs
McLeod: That's on the bed side.
Mr Peirce:
For all the programs that were identified to be transferred, and
generally the hospitals are designed with ambulatory space
included to handle outpatient volumes. As well, in terms of the
savings, what is re-invested in the community may be reinvested
in hospitals as traditional hospital outpatient, but some of what
is considered outpatient activity may become community-based
activity with community providers.
Mrs
McLeod: That's exactly my point, though. I'd be
interested in knowing if there are available data in terms of
ambulatory space that is being provided for in the hospital
restructuring process. I'm certainly aware of the bed provisions
but I'm not aware of ambulatory provisions. My sense is that much
of it is being left to the community and what we used to call
outpatient is now a community-based service. My concern is
because I think they were largely left out of the mix and they've
been referred now to the community-based planning. Where is that
going to take place?
Mr King:
Rather than getting into specific details, in all of the local
negotiations that are going on, the host hospitals receiving
that, with the PPH as well as the ministry team, are planning
those resources. The out-patient programs are part of that
planning, and if parts of those outpatients are going to the
community, that would be part of the planning. That is all part
of the local negotiations. We can sit down and be specific about
each one, if you want, or off-line we can talk about that. Of all
the things that are happening, I think it's fair to say that we
have had very good success with the communities that we're
dealing with on the PPH divestment and moving to the local public
hospital. I think in most cases it has gone very well. I have
never heard of this concern raised, that we are not planning for
outpatient services. That has not come to my attention. I'm
assuming that has been part of the planning, but I'm going to
check into that now that you've raised it.
The Chair:
Just for clarification, are you behind in your critical path that
you've set for this? I'm looking at the critical path that was in
the HSRC advice to the minister, and this was supposed to have
taken place in March and June of last year.
Mr King:
Yes. We are behind somewhat in most of the restructuring projects
in the province, and it's mainly due to the fact that some of the
goals of the commission were very ambitious. We are somewhat
behind, but we are hopeful that most of the PPH movement will
occur this fall. We are behind, though, it's fair to say. You
have the timelines in front of you. It has been very ambitious,
for many reasons, whether it's acquiring land or zoning or
whatever. There are many issues involved in this. So we're
guilty. We're behind.
Mrs
McLeod: Let me assure you, Mr King, I think the ministry
has been put in a very difficult position with ambitious
timelines that were set by the commission, so I'm not faulting.
I'm anxious about the community component.
Mr King:
And we hear you.
Mr Patten:
Could I have a supplementary?
The Chair:
OK.
Mr Patten:
It's just on the same issue, the commitment around
decommissioning psych hospitals, and then we can go back to Mrs
McLeod. It's clear that, around the operational funds that is so,
but in certain circumstances-the one I mentioned as a specific
today, the Royal
Ottawa-where you've got a huge psych hospital that is going to be
closed down, is the value of that, whatever it is, whenever it's
assessed, also part to contribute to any capital requirements
that may be made as well? In other words, is that resource
included in the commitment of decommissioning the transfer of the
resource to the new constructs?
Mr King:
We have specific formulas in place for all of the movement,
whether it's operating costs, overhead costs of the new building,
or the new corporation, so to speak, and what will move with
them. That's all part of the local negotiations. I don't have the
specific-
Mr Patten:
Do you know what I mean? Do you understand my question?
Mr King:
The question is, if this is how much it costs to run this
facility here, will all those dollars be going, as well as the
overhead, to run that building?
Mr Patten:
No.
Mr King:
Excuse me. I'm sorry.
Mr Patten:
I'm saying that Brockville Psychiatric Hospital has an
operational budget of, let's say, $1 million.
Mr King:
Yes. Got you.
Mr Patten:
It also has a huge plant; it also has land that, when that's
decommissioned, has some kind of a market value. Is that market
value, whatever it is and however it's sold, part of the
commitment of the transfer of resources? Is that part of the
basket?
Mr King:
Now I understand you, but Tom's going to answer that.
Mr Peirce:
The resources associated with the exact physical facilities and
the sale thereof or decommissioning thereof are not part of this
overall equation, because those facilities, on behalf of the
government, are run by the Ontario Realty Corp, which handles all
the realty holdings of the province.
There will be an operating
budget provided to the receiving hospitals to conduct the
programs. They will have an interim lease to continue using the
facilities they are now in until such time as any capital
projects are completed to house beds, for instance in Ottawa, and
there will be capital allocations made through basically the HSRC
capital fund, through the Ministry of Health capital branch, to
build facilities in keeping with HSRC directions.
Mr Patten:
That will be separate?
Mr Peirce:
Yes.
Mr Patten:
Separate from the operational money that's being transferred?
Mr Peirce:
Yes.
Mr Patten:
Over and above?
Mr Peirce:
Again, it's funded at 100%.
The Chair:
It's funded at 100%?
Mr Peirce:
The approved capital costs associated with PPH program transfer
to the public hospital are being funded at 100%.
The Chair:
OK. Go ahead.
Mrs
McLeod: Where to go next? Let me stay on the issue
community supports. I'll leave the outpatient issue for now. I'm
still concerned about it. I'm not sure where it fits, but I'll
leave it for now.
1450
Mr King:
We do hear you.
Mrs
McLeod: One of the things that the implementation task
force has been charged with is to ensure that there's community
supports in place for the seriously mentally ill-again, the term
is being used repeatedly-and for discharged psychiatric patients.
I'm concerned about programs that have never been in place in
communities, or never been funded or adequately funded, and I'm
concerned about whether or not everything is on hold until the
implementation task force report comes out.
I will give you a very
specific local example: eating disorders clinics. They have not
been part of the psychiatric facility. I'm not sure where they
fit into your classifications of seriously or severe, but it
appears that requests for expansion or for funding are being put
on hold because of the restructuring process. That's what we've
been told locally. My question is, is that a fact? Are program
expansions like that being put on hold until the community
restructuring is complete? It's a long time to wait, given the
timelines we've been talking about. Or is the ministry open to
looking at proposals on a step-by-step basis in the interim?
Mr Helm:
Restructuring proposals are not being put on hold pending the
task force, because the task forces will be rolling out across
the province at different times. While acknowledging they will
have a critical role in making recommendations, the ministry
really wants to move things along so that we do not miss
opportunities. When funding is available for investment in a
certain community, ministry staff take the lead in the absence of
a task force. Whether it's looking at an eating disorder proposal
or a community treatment team or a forensic program, we work with
the community to identify where that money should be invested to
provide those services. If halfway through that process the task
force comes along, we will pass all of our good work to them to
finish off. But in the absence of a task force, the ministry
takes the lead, so we're not slowing down while waiting for a
task force. We want to move business along as quickly as possible
but always be ready to hand off the responsibility with the
appropriate supports from us to the task force when they're
ready.
Mrs
McLeod: I appreciate that. Was there a recent expansion
of the eating disorders clinic program in Ottawa?
Mr Helm:
Yes. In Ottawa and Halton there were recent expansions.
Mr King:
And we are specifically reviewing the eating disorders right now,
right across the province.
Mrs
McLeod: Are we out of time, Mr Chairman?
The Chair:
I'm not sure whether the government members still want some
time.
Ms
Mushinski: Yes. I don't have many more questions, but I
do want to return to this area of children's mental health and
the reinvestments that occurred as a result of my colleague's
excellent report on mental health. I believe it was called Beyond 2000.
That's, of course, Mr Newman's report.
My understanding is that
there were some specific announcements of reinvestments made as a
result of Mr Newman's report, or in direct response to his mental
health review. I'm wondering if we could visit a couple of those,
because I'm a little confused about how it works. It gets back to
what I was referring to earlier with respect to the delivery that
is actually done by Comsoc and how we can start to achieve some
consistency of approach in terms of perhaps looking at some
integrated services.
There was a $60-million
investment that included $6.7 million to increase the number of
institutional mental health beds, both forensic and acute. My
understanding is that some service enhancements pertaining to
operational requirements were pending construction and renovation
of some Comsoc beds for children's acute mental health needs. Is
that correct?
Mr King:
That's right.
Ms
Mushinski: Can you tell me what the status of that is
and how that fits into the overall need for those acute forensic
beds? I know Mrs McLeod alluded to those a little earlier. How
are they actually being administered? Are they being administered
by ComSoc through transfer payments from the ministry? If so, is
that consistent with the funding of children's mental health
requirements? Is it also consistent with the ministry's targets
with respect to moving away from institutionalized care to
community-based care?
The reason for my question
is because I want to see how it fits with the overall policy
direction that you're taking with respect to moving to
community-based care. I think it's as relevant for children as it
is for adults.
Mr Helm:
The $60-million announcement in June 1998 was in direct response
to Mr Newman's work, in terms of implementation. My response is
similar to what I touched on earlier: Increasing the capacity of
in-patient children's programs is the responsibility of the
Ministry of Health, because it's in the hospital setting. When we
do that, we work closely with our MCSS counterparts to make sure
that the bed numbers and location that we're planning fit in
directly with their children's strategy in that region.
Ms
Mushinski: I take it that that strategy is fairly
consistent with your ministry's strategy about the move from
institutionalized care to community-based care.
Mr Helm:
Yes. The move from institutional to community is a broad goal in
terms of the fiscal funding shift. At the same time, though, in
our strategy and with MCSS there is a need that we don't do that
totally at the expense of in-patient services. We have service
gaps on the in-patient side.
Even though we want to
shift the funding formula or funding ratios, we do invest in new
in-patient services which, actually, would increase the
institutional side, but for very specific cases: children's
mental health, forensic and acute. But overall we're spending
more, even on the children's side, in the community than we are
in the institutional side in terms of new money. It is consistent
with the shift in strategy.
Ms
Mushinski: I wonder if you could just explain what the
other reinvestments were with respect to Mr Newman's report and
how much of that went into the new directions that pertain to the
other 1999 report.
Mr Patten:
Making It Happen.
Ms
Mushinski: Making It Up?
Mr Helm:
We made up Making it Happen.
Ms
Mushinski: I thought that was a partisan shot, you know
that?
Mr Helm:
Directly out of Mr Newman's work was the requirement to look at
and allocate the $60 million in reinvestment and to develop
Making It Happen was also a direction to outline our
strategy.
In the $60 million from
June 1998-I'll quickly go over this-it was a provincial
allocation. Every part of the province received base money and,
in some cases, one-time funding as well for specific-
Ms
Mushinski: So no federal enhancements, I take it?
1500
Mr Helm:
No. Within the $60 million I'll just quickly run through the
categories: $6.7 million was dedicated to institutional care.
That means beds. This was forensic and acute beds specifically.
Part of our dilemma, in terms of scheduling, is that they can
only become operational pending construction and renovation,
because they are linked to that, and also planning work with MCSS
regarding children's acute care. So $6.7 million of that was for
institutions; $46.9 million was specific for increased community
mental health services in response to community needs and
hospital restructuring. This is the beginning where we wanted to
ensure that the community supports have the direct link to our
psychiatric hospitals so that we wanted community supports that
would clearly initiate or expedite the discharge of appropriate
people from PPHs into community programs. That was a link. So
included here would be assertive community treatment teams, case
management, crisis and diversion.
Then we allocated $5
million in one-time money. This was to help facilitate the
capital requirements of the new Centre for Addiction and Mental
Health in Toronto. The remaining $1 million was an education
program between long-term care and mental health to ensure that
there's a mental health worker in long-term-care facilities to
help address mental health service issues that arise.
Those together equal the
$60-million plan. And those are up and running.
Mr Patten:
You've got this plan that everybody likes so far to be
implemented, but I'm going to ask you, are you folks involved in
the pending amendments to the Mental Health Act? It's OK, I want
you to.
Mr King:
Actually, we also knew that we would probably have some questions
on legislation, so we have one of our legal counsel here, Diana
Schell.
Mr Patten:
One question is that I noticed in your literature, in reference
to the what's euphemistically, I guess, commonly called the
"community treatment orders"-I wouldn't personally use that
term-as an alternative
to institutionalization, which is part of one of the themes of
advancing the program beforehand, that it's not really addressed
here other than the more assertive work of the ACTTs.
Mr King:
This is Diana Schell, who is with our legal services branch for
mental health services. I'm sure she would be more than happy to
answer questions related to the legislation.
Ms Diana
Schell: I would be happy to talk a little bit about the
legislation with you and also the community treatment order
issue. Mr King and Ms Czukar, this morning, referred to the
minister's announcement in June 1998 with respect to the next
steps in mental health reform and, of course, included the
implementation plan making it happen. It included the educational
campaign with respect to the current legislation. And the third
piece is the review of the Mental Health Act and related
legislation.
The review has been ongoing
very actively for over a year now. It's primarily a legal review
involving an internal working group that I'm part of within the
Ministry of Health. It's a broad-ranging review. We're looking at
mental health legislation in other Canadian jurisdictions, so the
other provinces and territories. We're also looking at Europe,
Great Britain, New Zealand, Australia, some states in the United
States. I think other important sources of information that you
would be familiar with yourself, sir, are in inquest
recommendations, your own private members' bills. That's part of
the review. We have also received a number of submissions from
stakeholder groups-the Canadian Mental Health Association, the
Schizophrenia Society. We recently got a paper from the Centre
for Addiction and Mental Health, which just came across my desk
this morning so I haven't read that. There may be others that I'm
forgetting to mention. So, that's the nature of the review. For
the moment it's internal and it's focusing primarily on legal
sources of information.
With respect to the
community treatment order issue, I share your concern about using
the language "community treatment orders." People probably mean
different things by that. Just looking at Canadian jurisdictions
that say they have community treatment order legislation, we have
Saskatchewan, which since 1995 has had legislation which
specifically says "community treatment orders." A couple of years
after that, Manitoba came on board with a very different kind of
model that they called "community treatment agreements." More
recently, late last year, British Columbia proclaimed legislation
that it says has community treatment provisions, but they're
actually leave-of-absence provisions.
Some of the jurisdictions
that we've looked at elsewhere, for example, New Zealand, some of
the Australian states, I believe it's 38 states in the United
States, have community treatment order legislation which is of
interest. It doesn't necessarily look like the Canadian
legislation; the models vary significantly. But, given that there
seems to be such a focus of attention in other jurisdictions, and
it's certainly a focus of attention here for some groups, this is
included in the legislative review.
Mr Patten:
Can I have the estimate on the time? When is your estimate of
your review completion?
Ms Schell:
It's probably going to take some time to complete all of this. I
don't have a final timeline on this when it has to be
completed.
Mr Patten:
I won't take it to mean that that's when the minister will be
introducing legislation, by the way.
Ms Schell:
It's hard for me to answer your question, sir, because frankly,
given the size of the project, if I were working for the Law
Reform Commission they would take two or three years to do this.
There may be other requirements that have to be met which would
cause us to do the best job we can in a shorter time frame. I'm
sorry, that's the best answer I can give you.
Mr Patten:
Thank you very much. I appreciate that.
Mrs
McLeod: I just have a couple of other areas, and I'm not
sure if my colleagues have some further questions. Before we
leave the legislation, I think there's reference in the auditor's
report and the ministry response that with the supportive housing
changes and moving the people into the community there may need
to be changes to the Homes for Special Care Act. Is that an
ongoing consultation as well, and do you see the two pieces of
legislation moving forward simultaneously?
Ms Schell:
We will have to consider homes-for-special-care issues, but to
date, the mental health legislation review project within the
ministry has not specifically looked at that piece of
legislation.
Ms Czukar:
I might just add that in terms of developing the housing policy
and housing strategy, if there's a need to change the legislation
to implement this strategy when it's finalized as a result of
consultation with communities and so on and so forth, if there
were to be legislative changes coming forward on another front,
then obviously this would be a good time to do it.
Mrs
McLeod: Finishing up on my community-based program
concerns, is the funding being maintained now for all community
outreach programs that the psychiatric hospitals are currently
running, for example, vocational rehab programs? That funding is
maintained, there's no withdrawal of funding? So when we say no
beds will close, we're also saying no programs will close?
Mr Helm:
The programs currently funded by the PPHs are staying and being
transferred. We, with the Ministry of Community and Social
Services, are looking at programs that are being funded under the
employment label, cost-shared with the federal government.
Some of our programs within
the PPHs are in that category and we're doing a review. Do they
need the criteria of the federal-provincial cost-sharing around
employment? Our feeling is that they do meet and we don't
anticipate any changes in that area, but we're still working with
MCSS on that. But the intent is everything that's there now will
be transferred over and continue to operate, in the short term
anyway.
1510
Mr King: I
should add that the public hospitals that are receiving the
divestment are watching those budget lines very closely so that
there aren't dollars removed from it. They are very sure to check
and balance the system.
Mrs
McLeod: If Mr Sturtevant had been here, I might have
been tempted to use that as a springboard to talk about
rehabilitation more generally, but I won't. I'll save that for
another day. I know, Mr King. I could address the question to
you.
Mr King:
It's a little late in the day to start-
Mrs
McLeod: I know there's a big project underway.
The second-last area I
wanted to ask you about sort of comes from that last comment,
because you mentioned hospitals that are receiving the
divestments, and my concern still is on the community care
support aspects of this. One of my concerns throughout this
process-and I know it was a Ministry of Health concern too; I'm
not sure exactly where the whole thing got off the rails-was the
whole issue of governance of mental health. I'm extremely
concerned that we are divesting to hospitals.
Again, I recognize this
will take different forms in different communities. I know it's
not an issue, for example, in Hamilton, where essentially the
entire thing seems to be being divested to a hospital, including
a lot of responsibility for community programs that are already
in place, so maybe it will sort itself out there. But certainly
in my home community, and I think it's probably fair to say in a
lot of communities, we're going to have a presentation of
responsibility for the delivery of mental health. Some of it will
be to hospitals that are getting the divested programs from the
PPHs, but there it's divided.
When it comes to community
mental health, I'm not sure that I see anywhere in the system,
including Hamilton, a body which is responsible for advocacy for
mental health. The hospitals may advocate for their own
particular segment that they are mandated to provide care for,
it's the community health service system that gets left behind.
I'm concerned that there's a fragmentation. It shouldn't be
fragmented even if we can identify somebody who's responsible for
advocacy for community mental health.
One of the very few things
I probably agreed with the commission on was the establishment of
community mental health agencies because I saw those as being a
body that could represent advocacy-if not governance, at least
advocacy-on a community level for mental health. The
implementation task force I'm pleased to see in terms of its
advisory capacity. If the same thing is happening in other
communities as seems to be happening in mine, there will be a lot
of confidence around the people being appointed. But I'm worried
about what happens when they no longer exist and we're back to,
at best, a fragmented system of advocacy or governance and, at
worst, no advocacy or governance in the community mental health
system at all. I'd just like your response on where you see the
future in terms of community-based advocacy and governance.
Mr King:
Back to the mental health implementation task force, I believe
there will be some recommendations coming forward from those task
forces on some of the issues surrounding governance. But we do
not have that in the communities now. We have many agencies
delivering these services now. I hear what you're saying and I
think that's something we have to take under advisement for the
future as far as the governance issue related to community
programming is concerned.
Mrs
McLeod: Is it even possible that the implementation task
forces could recommend a third level of governance for mental
health and be received favourably?
Mr Helm:
We do look to the task forces to take the Making it Happen
documents, which are our marching orders in terms of
implementation, and theirs. In Making it Happen, we talk about
the need for streamlined access, perhaps a lead agency. So we
will be looking towards those task forces to do some of that work
and make very specific recommendations in their region that
program X perhaps should be the lead to coordinate access to the
others, to streamline the assessment processes. That is part of
their mandate, working very closely with the policy area and also
with the regional office and myself. We want to make significant
gains in those areas during the life of the task force, to
restructure and streamline, so that if a task force does end,
there is a legacy of improvement and coordination for outpatient
and community programs.
Mrs
McLeod: I did notice earlier on you mentioned the
important aspect of regionalization as being conveying a sense of
integration across the ministries, and one-stop access. I guess
my hope would be that that translates in the community into at
least integration of mental health itself, if not with other
ministries or within the Ministry of Health.
Mr King:
We actually expect that there will be recommendations forthcoming
on that.
Mrs
McLeod: Patient advocacy: Again we have a fragmentation
in terms of where the patients are located. I know this is a
sensitive issue for somebody from Thunder Bay to raise, but will
we have patient advocacy councils for mental health patients in
each of the settings in which there are mental health beds, or do
they become absorbed into the patient councils of that hospital
generally?
Mr King:
The provincial office, as you know, will carry on in the first
year of operation. We have offered that service to the new
centres to see how they want to handle that. They may want to
take it on their own after that, but they have to preserve the
rights of the mental health patient to be protected, so we have
to look at a mechanism for that. At the present time the patient
psych advocacy office will remain in place until we start the
divestment. We have negotiated that as part of the arrangement
with each of them.
Mrs
McLeod: But not necessarily the patient councils.
Mr King:
No, not necessarily the patient councils.
Mrs McLeod: So the future of
patient councils is somewhat in limbo?
Mr Helm:
The future of the patient council would really be up to the new
hospital.
Mrs
McLeod: So they could be absorbed into the overall
hospital patient council, if the hospital has one.
Mr Helm:
Possibly, or they could have it separate for the mental health
side, the same with the community advisory board of the PPHs.
Mr King:
Many of those hospitals now have patient advocacy offices also,
so they may just assume that role, as well as council.
Mrs
McLeod: Patients tend to feel that they're two very
separate things.
One last question: Maybe
I'll just throw this out and not really expect an answer yet,
because I don't think it's a fair question. For future reference,
I'm going to be very interested in knowing where mental health
fits with primary care reform, because if we're serious about
comprehensive primary care, then it has to include mental health
both for adults and for children. I think that's beyond the reach
at the moment of any of the models that have been contemplated,
but I hope it's something that is getting considered in ministry
thinking.
Ms Czukar:
Having worked on primary care prior to coming into this job a
little while ago, I can say that in Hamilton, which is one of the
primary care reform implementation sites, there had been in place
institutional grants that brought mental health practitioners
into health service organizations specifically to link up primary
care physicians and mental health resources. That is being
continued into the primary care implementation. I think the model
is changing somewhat, but there is a recognition that that was a
very positive aspect of what was going on in Hamilton and does
need to continue in some way. I know that the primary care reform
project is looking at that issue. It's not out there; it's being
done.
Mr Patten:
I just have one question, which may trigger two. You're looking
for a group to play a leadership role in different regions around
mental health. They may be hospitals, depending on the size of
the area. I'm trying to relate it to the other side of the coin,
outside of mental health. Governments-and I can remember being
part of one-were talking over 14 years ago about community health
and prevention and primary care, and it still ain't there. The
hospitals still dominate totally. I could give you a formula
right now that you would save hundreds of millions of dollars if
the government would implement it, and it still hasn't
happened.
What makes you think that
your model of governance will really work, other than that you do
have a mandate and you're going to perhaps impose the formula, so
even if it is a hospital that takes the leadership, they will
have to have these programs, and I think you've got a better
handle on it? I guess my question is outside the frame of
reference today, but in terms of general health care, why aren't
you doing the same thing? The same principles of better service
apply in that realm as well.
Mr King:
I'm not quite sure how to answer that question, other than that I
think the ministries are rolling out their offices and
integrating their services and working with the communities to
hopefully have some voluntary integration. That's where we're
moving at this time.
Mr Patten:
If you ever want that answer, just call me.
Mr King:
Did you say $100 million?
Mr Patten:
More than that.
The Chair:
I'd like to raise one issue very quickly, and it's because it's
in your business plan. I see that in 1998-99 you established a
fraud program within the ministry. Have any results come in on
that at all? Perhaps you're not the right people to ask about
that.
Mr King:
My colleague the assistant deputy minister for health services
programs is really responsible for the program, but it has been
fairly successful. I don't have statistics on that, but we could
certainly get that for you.
The Chair:
I have another question. I don't intend to embarrass anybody
here, but I reread your speech again just now while we were
talking and I noticed, when I added the figures on pages 3 and 4
as to how much has actually been spent in mental health, that the
figures don't add up to $2.4 billion, but to $2.6 billion. What's
the right figure?
Mr King:
Actually, it was $238 million before-it's actually $2.6 billion
because there is $200 million more that was added in there. We
didn't do that just to make it look better today.
The Chair:
No, no. I always add the figures up, you see.
Mr King:
Sorry. The 1994-95 investment in community health was $238
million. This year it's $406 million, and that's why the number
was changed. That made the difference of almost $200 million.
The Chair:
Thank you very much. I appreciate that. Anybody else?
I'd like to thank you very
much for attending here today and appreciate the answers you've
given to the committee.
The hearing is adjourned
until whenever we come back in April. We have a very short in
camera session, however, to deal with the Andersen report and how
you want to handle that.
The committee continued
in closed session at 1523.
