Best Practices in Mental Health Reform: Discussion Paper

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6. Implementing Best Practices Across Systems of Care

The summary of best practices from the literature review provides a comprehensive list of the key elements that should be present within a reformed system of care for persons with severe mental illness. They tell us what should be done. The descriptions in the situational analysis give us Canadian examples of some of the best practices. They demonstrate what can be done through innovative initiatives and factors that facilitate change. Yet, for the most part, they describe only selected aspects of systems reform. The question that needs further consideration is how to promote the implementation of best practices across entire systems of care. We need to achieve radical change on multiple fronts across an entire region, province or territory, without introducing further disorganization and confusion. The most successful example of broad-based mental health system reform in Canada has been in New Brunswick (Chapter 1, Situational Analysis, ANMH). There, planning and implementation were based upon a simultaneous re-configuration of philosophy, power relationships, resources and clinical programming. Achieving a true system of care will necessitate giving priority to those programs and strategies on the checklist of best practices that directly address the lack of continuity that currently exists. It should not be forgotten that generic community services and family/friends also are important sectors of support, and need to be acknowledged, fostered and formally involved in the care of individuals with serious mental illness.

6.1 Benefits of Integration and Accountability

It has been recognized for some time that what has been lost in the move from institutional to community-based care is overall accountability (Wasylenki and Goering, 1989). Because there is no system of responsibility in place, care has become poorly organized and inadequately coordinated and, as a result, inefficient and ineffective. Leonard Stein and colleagues (1990) described the typical state of affairs as follows: "A 'non-system' of mental health care is where a few patients get more than they need, many patients get less than they need and some get nothing at all. Patients may get lost in this non-system and no one feels obligated to look for them. Patients may refuse to follow a program's rules and be terminated from treatment by staff who believe that they had no other choice. Patients are moved from the community into the hospital and from the hospital back into the community such that the hospital, the community, the patient, and the family all feel mistreated." (Stein et al., 1990)    In order to remedy this situation it is necessary not only to put innovative services and supports in place, but also to ensure that they provide accessible, continuous care. Replacing a fragmented patchwork of isolated programs requires strong mechanisms for service integration to create a unified community support system with clearly designated responsibility for all aspects of care. These mechanisms must have sufficient influence to bring the four solitudes, i.e. Community Mental Health Programs, Provincial Psychiatric Hospitals, general hospitals and consumer and family initiatives together. They must overcome resistance to change, facilitate the shift of resources from inpatient treatment to community support and create a recovery-oriented system (Anthony, 1993).

An integrated mental health delivery system ² holds many advantages over a proliferation of unconnected agencies (Lehman, 1989). Integrated systems provide greater continuity, comprehensiveness and flexibility. Service gaps and service duplications are more readily identified and addressed. This reduces unnecessary burdens on consumers and their families, reduces the risks of poor clinical decisions due to lack of adequate communication, reduces negative interactions among providers and increases coordination of interventions.  Integration also more easily allows for improved efficiency in service delivery. New services may be substituted for more expensive programs. Improved communication may reduce costly omissions or duplication of services and incentives may be developed to enhance efficiency. Integration also permits better co-ordination of resources to improve the availability of trained personnel.

6.2 Timeliness of Integration and Accountability

There are many compelling reasons for giving priority to creating a more integrated and accountable mental health system now, at a time when the entire health care system is under great pressure and undergoing unprecedented change (Goering et al., 1996).

• Great strides have been made in the past decade with increasing consumer and family involvement in the planning and delivery of mental health services, but these new participants are rightly frustrated by endless planning discussions coupled with slow or non-existent implementation. Their valued collaboration and good will may be lost unless systems change can proceed in a more effective and responsive manner.
• Better integrated mental health systems offer a means to protect and defend our limited mental health budget envelopes. For example, hospital restructuring poses a real threat of drastically depleting the psychiatric resources located in general hospitals that are closed or merged, unless additional means of external control are put in place. While the last few years have seen closures and downsizing of provincial psychiatric hospitals across the country, provincial governments have not reliably fulfilled promises to provide transitional or bridge funding and redirect resulting savings back into community supports.
• Many jurisdictions are considering proposals for radical changes in how long-term care and primary care are organized and how family physicians are paid. In order to interface with new models of community care, our secondary and tertiary mental health service must first be better coordinated.

6.3 Separate Management of Mental Health

The question of whether management of mental health care should be separated from the rest of health care is the subject of much debate. In New Brunswick, the Mental Health Commission was brought into the Department of Health and Community Services after a very successful five year tenure and regional mental health has become the responsibility of a regional health director rather than a regional mental health board (see Chapter 1, Situational Analysis). Manitoba is in the process of creating regional health authorities that have mental health as one of multiple health mandates. Ontario is moving to a decentralized model of health care management but a government-appointed Health Restructuring Commission has recommended creation of local mental health authorities in a number of jurisdictions. Evidence from New Brunswick, England and many parts of the United States supports the need for a staged process of implementing mental health reform, with the first crucial step being creation of a stronger mental health system (i.e., evidence based, integrated, accountable, efficient, focused on serious mental illness, consumer centred, compassionate). A second phase would establish mental health care delivery within the "integrated delivery systems" that would be likely to develop in the rest of health care. In the interim, mental health would monitor closely all activity related to reform of primary care, long-term care and other health areas, and identify linking strategies to enhance access, quality and continuity of care.

2. The term "integrated delivery system" also has been used to describe a particular approach to organizing a continuum of care that includes capitation (Dickey and Cohen, 1993) and combines physical and mental health funding into one envelope and organizational structure. This is a different usage than employed in this discussion. (Back to text)