Improving Access and Coordination of Mental Health and Addiction Services

279 Pages·2017·3.1 MB·English

Improving Access and Coordination of
Mental Health and Addiction
Services: A Provincial Strategy for all
Manitobans
FINAL REPORT
VIRGO PLANNING AND EVALUATION CONSULTANTS INC.
TORONTO, ONTARIO
Final Report
March 31, 2018
Acknowledgements
We extend our thanks to the members of the Minister of Health, Seniors and Active Living
Logistics Committee for their tremendous support and dedication, without which this project
could not have been so well executed. Thanks go also to the members of the Reference
Group for their thoughtful advice along the way, and to the many individuals and
organizations which hosted VIRGO for a site visit and/or participated in telephone or face to
face interviews. We extend gratitude to everyone participating in the October and February
validation events. We also extend our appreciation to the organizations that conducted
special consultations on our behalf, including Block by Block, the Manitoba Harm Reduction
Network and the Addictions Foundation of Manitoba. This significantly extended the reach
and depth of input from community members and people with lived experience. We also
extend appreciation to the many organizations, too numerous to mention here, for special
briefings prepared for the Consultant Team. Lastly, we extend a heartfelt thank you to the
many individuals and family members with lived experience who so openly shared their
stories in the hope that their input would lead to improvements to access and coordination
of Manitoba's mental health and substance use/addiction services.
The VIRGO Consultant Team

“We are all on the same river but

paddling in different boats”.

- Strategy discussion participant

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Table of Contents
Executive Summary .......................................................................................................... vi
1.0 Introduction and background ....................................................................................... 1
2.0 Approach ..................................................................................................................... 5
3.0 The CONTEXT: Recognizing and responding to the need for investment in SUA/MH...... 8
3.1 International and national context ................................................................................... 8
3.1.1 Business case for government investment in mental health and substance
use/addiction ..................................................................................................................... 15
3.2 Manitoba planning context ............................................................................................. 18
4.0 The NEED: What is the burden of SUA/MH on Manitobans? ....................................... 30
4.1 Population trends ............................................................................................................ 30
4.2 Health-related indicators ................................................................................................ 31
4.3 Social and justice indicators ............................................................................................ 33
4.4 Mental health and substance use/addiction indicators ................................................. 35
4.4.1 Adults ........................................................................................................................ 35
4.4.2 Children and youth ................................................................................................... 40
4.4.3 Indigenous populations ............................................................................................ 41
4.5 Summary of needs and the implications ......................................................................... 43
5.0 The GOAL – Key aspirational features of SUA/MH treatment and support systems ..... 44
5.1 A tiered framework to help guide system enhancement ............................................... 48
6.0 CURRENT STATE ......................................................................................................... 52
6.1 System Description .......................................................................................................... 52
6.1.1 Manitoba’s Investment in SUA/MH Services and Supports ..................................... 61
6.1.2 Summary of system overview and implications ....................................................... 65
6.2 What We Heard from Stakeholders ................................................................................ 66
6.2.1 Manitoba on-line mental health and substance use/addiction survey ................... 66
6.2.2 Consultation with stakeholders .............................................................................. 106
6.2.3 Validation events and suggested priority directions .............................................. 163
6.3. Quantitative performance indicators and assessment of current coverage ............... 165
6.3.1 Wait Times and other Operating Statistics............................................................. 165
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6.3.2 Service Utilization ................................................................................................... 172
6.3.3 Quantitative Assessment of System Coverage ....................................................... 180
6.4 Summary of Current State: Integrating “What we Heard” with Quantitative Analysis 195
6.4.1 Final Validation Events ........................................................................................... 202
7.0 FUTURE STATE: Priority Areas and Recommendations .............................................. 206
7.1 The ideal future State .................................................................................................... 206
7.2 Vision for Manitoba’s SUA/MH system ......................................................................... 208
7.3 Principles for Manitoba’s SUA/MH system ................................................................... 208
7.4 Strategic priorities for Manitoba’s SUA/MH system ..................................................... 215
7.5 Enabling supports for Manitoba’s SUA/MH system ..................................................... 242
8. 0 Summary and Conclusion ........................................................................................ 255

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VIRGO team
Team Member Role
Dr. Brian Rush Co-Lead
Adair Roberts Co-Lead
Dr. Amy Cheung Consultant
April Furlong Project Manager
Jonathan Ramirez Data Analyst
Dr. Peter Butt Content Expert
Dr. Chris Mushquash Content Expert

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Executive Summary

1.0 Introduction and Background
The Government of Manitoba, as represented by the Minister of Health, Seniors and Active
Living, has commissioned a focused provincial Strategic Plan that will look at ways to improve
access and coordination of services (described below) for individuals with substance
use/addiction and mental health problems and illnesses (SUA/MH). In the context of informing
improvements with respect to access and coordination, the Strategy must support relevant
considerations for service delivery across a range of high need populations and across the
spectrum of approaches, including prevention and harm reduction, inter-sectoral partnerships,
human resources and knowledge exchange.
The key focus of the Strategic Plan:
Access to services is a complex concept and experts agree that several aspects are relevant. If
services are available and in adequate supply, then the opportunity to obtain service exists, and
a population may 'have access' to services. However, access is also related to the affordability,
physical accessibility and acceptability of services. Furthermore, services available must be
relevant and effective if the population is to 'gain access to satisfactory health outcomes'. The
availability of services, and barriers to access, have to be considered in the context of the
differing perspectives, health needs and material and cultural settings of diverse groups in
society.
Coordination of services can be considered at two inter-related levels. One can consider
coordination of individual or family treatment and recovery support (e.g., the work of a service
coordinator) as well as coordination of the overall network or system of service providers (e.g.,
the work of an inter-agency planning committee). A definition that is appropriate for both levels
refers to the process by which multiple services and recovery supports, often provided by
multiple sectors and service providers, are synchronized to address the needs and strengths of
each person and family seeking assistance.

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2.0 Approach
The VIRGO team, led by Dr. Brian Rush, implemented a comprehensive quantitative and
qualitative approach to an assessment of system-wide strengths and challenges with respect to
service access and coordination. The approach involved:
 Review of evidence: The extant research evidence concerning both SUA/MH system
design and effective service-level interventions was synthesized.
 Data indicators: A wide range of data were compiled to establish the nature and level of
needs related to SUA/MH.
 Document review: Approximately 275 documents were analysed, including previous
strategic planning work and reports of many projects and reviews.
 Consultations and discussions: Approximately 350 stakeholders from multiple sectors
and services were engaged in interviews/group discussions or were invited to submit
written statements.
 Validation events: Highlights of “what we heard” in the above consultations and
discussions were shared in a series of validation events to ensure the emergent findings
and implications resonated with the various stakeholder groups.
 On-line survey: Two on-line surveys – one for service providers (n=1723) and another for
the general public (n=2080) collected quantitative and qualitative perspectives about
many aspects of the province’s SUA/MH services.
 Data request: Quantitative information from SUA/MH service providers was analyzed to
inform an understanding of service capacity and utilization, wait times, and occupancy
rates, as well the development of an exhaustive “system mapping” exercise. Advisory
and project management processes: The VIRGO team gave regular updates to the
MHSAL Project Logistics Committee and presentations to the Project Reference Group,
the latter being a group of key stakeholders and leaders offering ongoing advice on the
process of the review and interpretation of findings.

3.0 The CONTEXT: Recognizing and responding to the need for investment in SUA/MH
International and national context
A decade ago the Surgeon General of the United States stated that “there is no health without
mental health.” This mantra has since resonated globally and the World Health Organization
(WHO) has been a particularly important champion for the message that mental health is an
integral and essential component of health. Mental health has come to be seen as a state of
well-being in which an individual realizes his or her own abilities, can cope with the normal
stresses of life, can work productively and is able to make a contribution to his or her
community. An important implication of this definition is that mental health is more than just
the absence of mental disorders or disabilities.
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As in all parts of the world, the pain and suffering of Canadian individuals and families
experiencing SUA/MH challenges translates into significant costs to society at large, including a
significant drain on the public purse. The most recent estimates of the economic burden of
mental illness in Canada, including SUA, is well over $50 billion annually. For SUA alone, the
economic burden on services such as health care and law enforcement, and the loss of
productivity in the workplace or at home resulting from premature death and disability, tallied
to an overall social cost in Canada in 2002 of $39.8 billion.
Many reports also highlight the high rates of SUA/MH among Canadian children and youth.
There are also many national indicators of the unique challenges faced by Indigenous people
with respect to SUA/MH. It is important to keep in mind that Indigenous health status in
Canada, including mental wellness, must be interpreted in the context of the social
determinants of health and historical trauma.
International research is unequivocal in its support for the effectiveness of SUA/MH services,
including services for people experiencing co-occurring challenges. It is also critically important
for policy makers and funders to recognize that the financial return of investment in services,
including prevention and health promotion efforts, is significant, thereby makes an
exceptionally strong business case for investment in treatment and support. Experts agree it’s
now a matter of government taking that seriously and acting on the evidence.
To reflect the growing concern over the level of need, as well as the human and economic
consequences, important national organizations, including the Mental Health Commission of
Canada (MHCC) and the Canadian Centre on Substance Use and Addiction (CCSA), have
articulated the importance of a broad “all of government” and “all of society” response.
Importantly, SUA/MH has been declared a national priority such that the 2017/18 federal
budget confirmed that $5 billion will be transferred to provincial and territorial governments
over the next 10 years to improve access to services and improve health outcomes. As well,
long-standing Indigenous issues have also been declared a priority at the national level; evident
in part by the work of the Truth and Reconciliation Commission, the National Inquiry into
Missing and Murdered Indigenous Women and Girls, and new funding opportunities such as
those under the umbrella of Jordan’s Principle.

Manitoba context

In Manitoba, the SUA/MH sectors have been in transition for the past two decades with
several significant strategic planning processes undertaken and changes made to specific
services, including the closure of the Brandon Mental Health Centre, re-direction of resources
to community programs in the local health regions, the establishment of Selkirk Mental Health
Centre (SMHC) as a provincial centre to address the needs of the long term mentally ill
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population, the transfer of patients to community resources, and implementation of the Co-
Occurring Disorder Initiative (CODI).

This review was undertaken in the context of significant recent changes in the SUA/MH system
in Manitoba, including the creation of the new Provincial Health Organization, also known as
Shared Health (SH); new federal funding opportunities resulting in new services being
developed for First Nations communities; and responses to the tragic opioid overdose crisis in
the province and the rapidly growing use of, and complex consequences associated with, crystal
methamphetamine. Major service changes either undertaken (e.g., consolidation of emergency
departments in the WRHA) or planned (e.g., additional PACT teams).
This review of past and current work also highlights that, while some investments have been
made in recent years to enhance the province’s SUA/MH system, these enhancements have
been made by multiple stakeholders in the system and without the benefit of an integrated,
comprehensive provincial plan. This reminds us again of the need for strong collaboration and
governance and the high interest in the development of this new provincial Strategy to, not
only fit into the new health system transformation, but also to present a unifying vision and
identify priorities to guide future investments.

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4.0 The NEED: What is the burden of SUA/MH on Manitobans?
Needs are extremely high: Manitoba stands out as the highest or very high on almost all SUA/MH
need indicators, including those related to health, social and justice-related factors. Behind the
“numbers” lies a huge financial drain on the province as well as an often tragic physical and
emotional drain on communities, families and individual Manitobans. Taken together, the overall
level of need clearly signals a call to action.
Needs are costly: A convincing economic argument is made that responding to this call for action
with wise, evidence-informed investments will return a positive economic benefit. Comparing to
other provinces, and in the context of the high need relative to other jurisdictions, Manitoba’s lower
contribution to SUA/MH, further reinforces the call to action from a “business case” perspective.
Doing nothing is itself costly. That being said, investment is not only about financial resources, but
also includes streamlining processes for maximum value.
Needs are population and region/community specific: The regional variability in a large number of
need indicators, and the association with specific disparity indicators and populations, including
Manitoba’s Indigenous people, is critically important in the pursuit of solutions. This includes
respecting cultural differences, understanding and acknowledging well-established root causes, and
working diligently to deal with real and perceived jurisdictional issues.
Needs are evolving: Several indicators highlight the evolving nature of needs, for example, the
trends in population growth and diversity, SUA, and increasing complexity of individual and
community situations. Implications for system enhancement include the need for flexibility in key
features of the system such as finely tuned surveillance systems, keeping services grounded as
closely as possible in the community to be constantly on top of emergent trends, and embedding
services in organizations that are adaptable and nimble.
Needs begin early in childhood: The data are compelling with respect to the impact of early
childhood mental illnesses, and that treatment can help prevent SUA/MH in later years.
Needs are complex: Needs for SUA/MH services are intertwined in very complex ways with physical
health, social and justice-related challenges. This has implications not only for ensuring person-
centered, individualized treatment and support, but also calls for a “whole-system, multi-sectoral
response”. A provincial governance model must support this multi-sectoral response and also
facilitate a truly bio-psycho-social-spiritual/cultural approach, including the solutions for access and
coordination specifically.
Needs do have solutions: As complex as this situation clearly is at a provincial, regional and local
level, the evidence exists for responding effectively. The purpose of the Strategy is to articulate and
prioritize these solutions in a way that facilitates improved access and coordination.

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