SPECIALIZED GERIATRIC MENTAL HEALTH OUTREACH TEAMS PROGRAM POLICY AND ACCOUNTABILITY FRAMEWORK

Transcription

1 SPECIALIZED GERIATRIC MENTAL HEALTH OUTREACH TEAMS PROGRAM POLICY AND ACCOUNTABILITY FRAMEWORK Ministry of Health and Long-Term Care Mental Health and Rehabilitation Reform Branch October 6, 2004

2 SPECIALIZED GERIATRIC MENTAL HEALTH OUTREACH TEAMS PROGRAM POLICY AND ACCOUNTABILITY FRAMEWORK SPECIALIZED GERIATRIC ME TAL HEALTH OUTREACH TEAMS... 1 PROGRAM POLICY FRAMEWORK ) I TRODUCTIO ) BACKGROU D... 2 I NEED FOR SPECIALIZED SERVICES... 2 a) Demographic Change... 3 b) Impact of Mental Illness on Seniors and their Families... 3 c) Current Obstacles and Service Gaps... 3 II PROVINCIAL POLICY CONTEXT... 4 a) Mental Health Reform... 4 b) Shared Service Models of Care... 4 c) Impact of Primary Care Reform... 5 d) Strategy for Alzheimer Disease and Related Dementias ) SPECIALIZED GERIATRIC OUTREACH TEAMS... 6 I NEED FOR PROGRAM AND POLICY DIRECTION... 7 II BEST PRACTICES FOR SPECIALIZED GERIATRIC OUTREACH TEAMS... 8 III PRINCIPLES FOR SPECIALIZED GERIATRIC OUTREACH TEAMS... 9 IV SUMMARY OF CORE FUNCTIONS a) Intake and Screening b) Specialized Assessment c) Care Planning, Treatment and Follow-up d) Consultation/Education and Support e) Program and System Development f) Service and Program Accountability APPLYI G PROGRAM ACCOU TABILITY MEASURES PROGRAM ACCOU TABILITY FRAMEWORK ) I TRODUCTIO ) CORE PROGRAM FU CTIO S, PERFORMA CE DOMAI S A D I DICATORS I INTAKE AND SCREENING II SPECIALIZED ASSESSMENT III CARE PLANNING, TREATMENT AND FOLLOW-UP IV CONSULTATION, EDUCATION AND SUPPORT V PROGRAM AND SYSTEM DEVELOPMENT VI DISCHARGE ) EXT STEPS Appendix A: Referral Sources... 1 Appendix B: Mental Health Accountability Framework... 2 References

3 Specialized Geriatric Mental Health Outreach Teams Program Policy and Accountability Framework PROGRAM POLICY FRAMEWORK 1) INTRODUCTION Most seniors are able to achieve a state of physical, mental and social well being, even in the presence of disease. Serious mental health problems, however, can intensify psychosocial and physical difficulties. Seniors with mental health problems require on-going support and treatment, primary and specialized care, and the active collaboration of the health and social service sectors to maintain their quality of life. Demographic change, the impact of mental illness on seniors and their families and obstacles and service gaps in the delivery of specialized services are driving the need to improve the interfaces between primary care, long term care and mental health. Meeting these challenges will require: a) improving the primary care system s ability to manage seniors complex health problems; b) ensuring the availability of specialized services when necessary; and c) strengthening linkages between different systems of care. Specialized geriatric mental health outreach teams target high-risk individuals and are a core service within the continuum of geriatric services. These programs have developed over a number of years in the absence of any formal Ministry of Health and Long-Term Care policy direction. This program policy and evaluation framework will assist programs to improve local services, deliver care on a consistent basis across the province and enhance the quality of life of older people with mental health problems and their families. Regional differences will impact the implementation of the program policy and evaluation framework; decision-making at the regional level will determine how resources will be aligned to deliver core functions and address service overlaps. 2) BACKGROUND I Need for Specialized Services The priorities and service delivery models adopted by specialized geriatric mental health outreach services are shaped by the factors defining the need for services including demographic change, the impact of mental illness on seniors and their families and current obstacles and service gaps. 2

4 a) Demographic Change Between 1996 and 2001 total population growth in Canada was 0.9% a year while the population aged 65+ grew at 1.8% and the population aged 80+ grew at 3.5%. 1 By 2031 it is estimated that approximately 21% of the Canadian population will be seniors and that those aged 85+ may comprise 45% of this group. 2 Dementia affects approximately 8% of all Canadians aged 65+ and approximately 35% of those aged Two-thirds of those with dementia in the community have not been formally diagnosed. 4 As many as 20% of Canadian seniors suffer from mild to severe clinical depression, representing between 5 10 % of seniors in the community and 30 40% of those in institutions. 5 Thirty-eight percent of women and 24% of men aged 85+ live in an institution: the number of long-term care beds is expected to triple over the next 30 years. 6 b) Impact of Mental Illness on Seniors and their Families About half of those with dementia live in the community and half live in institutions. 7 Mental health problems in late life usually occur in the context of medical illness, disability and psychosocial issues related to social or emotional isolation. Seniors are particularly at risk during critical transitions, including disablement, widow-hood, caring for a spouse with dementia or institutionalization. 8 Women represent 75% of informal caregivers of whom 23% are spouses and 28% are daughters. 9 Thirty per cent of caregivers are employed and 36% are over the age of Caregivers are at an increased risk for depression and psychological distress. 11 c) Current Obstacles and Service Gaps Primary care providers, long-term care facilities and community agencies are dealing with a significant and growing number of people with complex physical and mental health needs with associated behaviours, including: People with behavioural problems related to dementias, other neurological dysfunction and mental illness; Older people who develop serious mental illness, including those who require acute and ongoing mental health care as well as services provided by the long term care network; 3

5 Older people with long-standing serious mental illness who require complex care and/or have functional limitations; and People with age-related mental illness. Specialized geriatric mental health outreach teams are uniquely positioned to address these issues. However, a 1997 survey conducted by the Resource Inventory Task Group of the Provincial Steering Committee Mental Health and Long-Term Care 12 documented significant variations between the outreach teams related to clinical resources, caseloads and number of new referrals accepted on a yearly basis. Teams tend to be clustered in urban centres and it is unclear how well rural areas are served. In addition, teams vary in the strength of their linkages to other services, which may also impair their ability to deliver a high standard of care. 13 II Provincial Policy Context Over the past decade a number of major reports and government policies have addressed the mental health system and the needs of older adults with serious mental illness. These are relevant to the development of a program policy framework for geriatric mental health outreach programs. a) Mental Health Reform Making it Happen, the ministry s policy framework for mental health reform, provides overall direction for the development of program policy frameworks and standards. It identifies elderly clients suffering from dementia, psychosis and medical illness as requiring specialized services, and lists several functions for outreach teams including: consultation; assessment and treatment planning; case management; education; client advocacy; and service linkage. The use of outreach services is expected to expand service capacity and lead to the efficient use of limited specialized expertise, particularly where more than one treatment system is involved. 14 b) Shared Service Models of Care Making It Happen acknowledges that many consumers of mental health services, including the elderly, have multiple problems that cross a variety of service jurisdictions. Service delivery for these individuals requires collaboration between and among the interdisciplinary professionals 4

6 involved in care. Shared service approaches utilize the following strategies: Identification of the individual who will provide consistent mental health support to the client as he or she moves through different settings; Training and education to staff in a variety of disciplines; Cooperative treatment planning; Individualized treatment and service plans; Maintenance of community contacts through periods of institutionalization; and Primary/specialty care partnerships. 15 Local services will utilize the strategies identified in Making it Happen to ensure effective shared care delivery. c) Impact of Primary Care Reform Seniors with mental health needs are not a homogenous group; their care needs may be met through a range of services including community- based programs and long-term care settings. Today more than ever seniors are electing to remain in their homes and communities as long as possible. 16 As a result, primary care clinicians will increasingly be called upon to deliver basic health care to more seniors with complex needs. Primary care reform has created a unique opportunity to build new collaborative care models. 17 The goals of this reform are: 24/7 access in an integrated continuum; continuity of care; early detection and action; better information on needs and outcomes; and newer and stronger incentives for providers to participate in primary care approaches. Creating linkages between and among primary care, seniors services and mental health services extends system capacity, supports the seamless movement of seniors within and between systems and ensures that the most appropriate provider delivers the most appropriate care. 5

7 d) Strategy for Alzheimer Disease and Related Dementias The Ontario government invested $68.4 million over five years in Ontario's Strategy for Alzheimer Disease and Related Dementias. The Strategy s 10- point action plan was conceived to help people with Alzheimer Disease and related dementias, their caregivers and families. One of the Strategy s initiatives supported regionally selected agencies to hire 50 psychogeriatric resource consultants (PRCs). PRCs are natural partners to specialized outreach teams as their role is to: Support local long-term care facilities, Community Care Access Centres and community support services that serve people with dementia, other cognitive/mental health needs and associated challenging behaviours; Act as advisors, educators, facilitators and network builders; Enhance local knowledge and skills; Enhance awareness of existing linkages and support development and maintenance of other linkages, e.g., Dementia Networks; Provide case-based learning consultation; and Assist and support staff with the application and interpretation of assessment tools and with the development of care plans and interventions On a regional basis, it is expected that specialized geriatric mental health outreach programs will work closely with the psychogeriatric resource consultants. 3) SPECIALIZED GERIATRIC OUTREACH TEAMS Making it Happen indicates that outreach programs can avert hospitalization and support clients to remain where they are by increasing coordination and collaboration between care systems. Programs function to expand service capacity and support the efficient use of limited specialized level expertise, particularly where more than one treatment system is required. 18 The target population for specialized geriatric outreach services is older people with newly developed serious mental health problems and those with longstanding or recurrent mental health conditions who are newly experiencing an age-related illness, and their caregivers. 19 Service access is based on need rather than age, defined as: People aged 65 and over with serious mental illness and/or behavioural disturbances associated with cognitive impairment, which interferes with their ability to function independently, seriously affects their feelings of well-being or which adversely affect their relationship with others; and Persons under 65 years of age who have conditions more commonly associated with old age (e.g., Alzheimer's, dementia, etc.). 6

8 The overall objective for specialized outreach teams is to improve the quality of life of older individuals with complex mental health needs by providing expertise in geriatric mental health and supporting clinicians that are providing the primary services. Specialized geriatric mental health outreach teams deliver a core service within the continuum of specialized services for older individuals with severe mental illness. They provide interdisciplinary community outreach, consultation and community development services for the elderly with complex mental health needs. Responsibility for delivering primary health care to the older person rests with the family physician or alternative primary care provider, community agencies and long-term care facilities. Programs operate within a continuum of care that includes inpatient and outpatient services, general practitioners, long-term care facilities, and a range of other community services. Programs enhance continuity of care by: Helping to identify and support the needs of older people with mental health problems residing in long-term care facilities and community settings; Providing specialized, comprehensive individual assessments and developing individual care plans to maximize functioning and quality of life; Establishing linkages and alliances with local and regional community services, caregivers, the client and family; and Educating health and social service providers. In situations where resources exist, programs may provide direct treatment and follow-up. I Need for Program and Policy Direction Specialized geriatric mental health outreach teams have developed over the past two decades in response to community needs and characteristics. Service providers and policy makers have identified the need for a provincial program policy framework to guide program development and enhance consistency in program delivery. Further, in the context of other key reforms, such as senior s services, long-term care redevelopment and primary care, this is an appropriate time for service and system realignment. The development of this program policy and evaluation framework involved obtaining stakeholder feedback, and conducting inter-jurisdictional and literature reviews. Key stakeholders, representing over 40 programs that deliver specialized geriatric mental health outreach services, attended a March 2003 workshop and provided input on a draft framework. Common workshop themes included: Represent an ideal program within the context of regional differences; 7

9 Allow for individual program flexibility; Clarify how service agreements will fit with the performance measurement system; and Reflect the limits of clinical capacity in proposed outcomes - programs cannot cure dementia. Feedback was also obtained from the Mental Health and Long Term Care Advisory Committee and other relevant stakeholders. II Best Practices for Specialized Geriatric Outreach Teams There is an emerging best practice and research literature available to guide the continued development of specialized geriatric outreach teams. Psychogeriatric assessment includes a focus on physical and mental health, social and economic status, behaviour and self-care abilities and the individual s physical environment. 20 Integrated geriatric service delivery has been shown to reduce the risk of hospitalization and to reduce the length of stay when hospitalization is required. 21 Interdisciplinary teams are key to addressing the mental health needs of the elderly through community outreach, in-home assessment and treatment and support for caregivers. 22 This approach is based upon individual disciplines simultaneously and cooperatively evaluating the patient s needs and developing a joint care plan. 23 Services most likely to be required by seniors include diagnosis, treatment plan development, legal assessments, consultations to communitybased programs, and, education and training. 24 The outreach team will reflect a mix of professionals, skilled and knowledgeable in the care and treatment of older individuals with serious mental illness and complex needs and committed to meeting the performance expectations of the program. Those qualified include: Health professionals in medicine, nursing, psychology, social work, occupational therapy with skills and knowledge concerning the care and treatment of older individuals with serious mental illness and complex needs; Individuals with Baccalaureate or Masters-level degrees or equivalent qualifications in a related health science, a social science or gerontology degree with mental health experience; Individuals not described above whom in the opinion of the program managers have the skills, knowledge and expertise necessary to carry out program functions. The continued involvement of the client s family physician and other community service professionals is essential. 25 8

10 The most effective mental health services for the elderly have developed collaborative relationships with home and community care, psychiatric expertise, adult mental health and inpatient services. 26 Ongoing assessment is recommended in order to maintain the balance between the older person s desire to remain in the home and any potential safety issues. Shared care, education, and systems development are all means through which best practices are disseminated. 27 Best practices include: education-focused clinical consultations that incorporate educational materials into the clinical documentation; temporarily assigning hospital or community-based staff to a specialty geriatric mental health outreach team; and targeted educational projects in the community and long-term care sectors. These approaches emphasize experiential learning, enhanced clinical practice, the promotion of continuous learning through knowledge exchange and evaluation. 28 III Principles for Specialized Geriatric Outreach Teams The coordinated system of care that supports and serves older people with serious and complex mental illness must embrace the following principles: Client centered programs will respond to individual needs; clients and their families will have the ability to participate in service planning; Accessible individuals and their family members/care givers will have access to a full range of coordinated and integrated services and supports; specialized geriatric mental health outreach teams are one element in the continuum of services; Effective programs will assist clients to achieve symptom reduction and improvement or maintenance of function in the most cost-effective and flexible manner possible; Comprehensive programs will enhance service capacity through the development of key relationships to ensure the full range of mental health outreach program functions are available on a provincial basis; and Accountable accountability for services, supports and funding is a key component of the mental health system. 29 9

11 IV Summary of Core Functions Specialized geriatric mental health outreach teams are located in a variety of organizational settings including community agencies, teaching hospitals and community hospitals. Services are time-limited and geared to the needs of the older adult experiencing serious difficulties due to complex, age-related or mental health problems, their families and service providers within community and long term care settings. It is estimated that only 3% of seniors have problems that require specialized services. 30 Services at this level include specialized ambulatory services outreach teams, specialized inpatient services, complex continuing care and geriatric rehabilitation. Outreach programs may not have the resources to deliver all core functions and services; however, it is expected that through a shared care approach, all core functions and services will be locally available. Regional decision-making determines how resources will be aligned to deliver core functions. Core functions: a) Intake and Screening; b) Specialized assessment; c) Care planning, treatment and follow-up; d) Consultation, education and support; e) Program and system development; and f) Service and Program Evaluation a) Intake and Screening Intake and screening determines that the referred individual meets the target population criteria and resides in the outreach team s catchement area. The physical, mental or functional changes that have resulted in the referral will be determined. Additional information on falls, incontinence, confusion, impaired mobility and prescription drug use will also be reviewed. The intake and screening stage allows for a triage function whereby referrals to more appropriate services can occur. At present there is no ministry standard/mandated intake and screening tool. Referral sources vary but may include self/family, hospitals, family physicians, long-term care facilities or community agencies. 31 (A more inclusive list of referral sources appears as Appendix A). Ensuring that intake and screening mechanisms are user friendly is critical for the success of shared service models. The most responsible clinician should be advised of the referral in order to ensure continuity and coordination of care and to mitigate drug interactions and medical side effects. In the face of primary care reform and the implementation, in some cases the most responsible clinician may not be a physician. 10

12 b) Specialized Assessment Ideally, assessments should be undertaken in the client s environment in order to evaluate behavioural disturbances and obtain information from staff and family members who have regular contact with the client. The interdisciplinary, multi-dimensional comprehensive assessment provides the basis for a care plan and identifies appropriate treatments and support through reviewing all aspects of physical, cognitive and psychosocial status, functional abilities and environmental factors. 32 The assessment also addresses the provision of support and education for caregivers and clinicians. At present there is no ministry standard/mandated specialized assessment tool. c) Care Planning, Treatment and Follow-up Where resources exist, the outreach team may provide time-limited treatment and follow-up to clients with complex needs. 33, 34 The team s principal function is to assist the primary caregivers to develop the care plan and, through training and education, enhance their capacity to provide the appropriate treatment and support. The care plan describes the client s care requirements and support needs as well as the rationale for the recommended interventions. The plan should include clear goals and objectives and specify who is responsible for implementation/monitoring. The plan should also include crisis support strategies. It is essential that primary and/or first line and intensive mental health and long-term care services receive regular communication regarding client status. d) Consultation/Education and Support Specialized geriatric mental health outreach teams will enhance the capacity of the broader system of services to provide appropriate care. Consultation, education and support will be targeted to community agencies, family physicians, long-term care facilities, general mental health services and family members, utilizing a health promotion and illness prevention perspective. The team s activities will vary depending upon their resources and the availability of specialized educational services elsewhere in the community. Where other programs provide overlapping services, activities will need to be coordinated and formal linkages between the services established; this may be determined at the regional level. e) Program and System Development Specialized geriatric mental health outreach teams are well positioned to advocate for the needs of their clients and can enhance the community care system through the development of linkages with other services, both within and across sectors. Programs will: Establish service arrangements with partner agencies and organizations that provide the knowledge, skills and services required by the elderly with complex needs as their conditions change over time 11

13 Create linkages with acute care services, Community Care Access Centres (CCACs), rehabilitation programs, hospital-based services and long-term care facilities, specialized medical programs including Regional Geriatric Programs, Psychogeriatric Resource Consultants and primary care and mental health services. Community resources can be enhanced by: Establishing and maintaining alliances with the client, family and caregivers; Using new technologies, such as teleconferencing and video conferencing to maximize outreach; Promoting evidence-based practice and research initiatives; Engaging in joint programs and educational development; and Jointly planning to enhance services, promote coordination and linkages and facilitate evaluation. f) Service and Program Accountability Service and program accountability measures will focus on program and client outcomes through the use of self-reporting, professional reporting, performance-based measures, objective data or a combination of these. 35 The Ontario Mental Health Accountability Framework outlines eight performance domains and suggests indicators for mental health service monitoring. 36 The framework includes several indicators that would provide relevant data to evaluate specialized geriatric mental health outreach teams. The accompanying program evaluation framework addresses these issues in greater detail. Over time more specific outcome-based measures and data collection tools and requirements will be developed. APPLYING PROGRAM ACCOUNTABILITY MEASURES The following section articulates core program functions, activities, domains and indicators in order to: Provide a framework to ensure core services are available across the province; Assist the Ministry of Health and Long-Term Care and stakeholders in system and program realignment; and Enable service and program accountability. The proposed accountability measures will support consistent program implementation, participant characteristics, service delivery and client and program outcomes. At this time the framework consists of performance domains and indicators only. The next steps include the definition of outcome-based 12

14 performance measures. Once consistent data have been collected and are available, they will be used to develop best practices, benchmarks and standards for services, supports, service user outcomes, and the system as a whole. 37 PROGRAM ACCOUNTABILITY FRAMEWORK 1) INTRODUCTION This program accountability framework is based on the domains and indicators outlined in the Mental Health Accountability Framework developed by the Ministry of Health and Long-Term Care. 38 The core program functions proposed for specialized geriatric mental health outreach programs were derived from the review of the literature, developments in other jurisdictions, the consultation workshop with outreach programs held in March, 2003 and an analysis of the 1997 province-wide survey of outreach programs. The Ministry s Operating Manual for Mental Health Services and Addiction Treatment Services was also of assistance in aligning core program functions with performance domains and indicators. 39 2) CORE PROGRAM FUNCTIONS, PERFORMANCE DOMAINS AND INDICATORS The performance domains defined in the Mental Health Accountability Framework are listed in Appendix B. The specific core program functions identified for specialized geriatric mental health outreach programs have been aligned to these performance domains and their accompanying indicators. Several of the domains and indicators are appropriate for more than one program element; therefore there will be duplication across core program functions. The application of this program accountability framework is a first step and will support programs to identify service delivery benchmarks and standards for each program function. Core program functions include: I II III IV V VI Intake and screening; Specialized assessment; Care planning, treatment and follow-up; Consultation, education and support; and Program and system development. Discharge I Intake and Screening The Mental Health and Addictions Operating Manual indicates that programs will identify their target population and define the services provided. 40 Where clients do not meet admission criteria, they will be directed to another appropriate community agency or service. Programs will develop a waiting list policy that 13

15 indicates when clients may be placed on the list and how service priorities are determined. Agencies must also have a client complaint/dispute resolution process in place. Function : Intake and Screening Domains Acceptability Accessibility Appropriateness Continuity Consumer/Family satisfaction with service received Formal Complaint mechanism in place Cultural Sensitivity Service reach to persons with serious mental illness (SMI) Identify human resource gaps Wait times for needed services Denial of Service Early Intervention Client/Family perception of accessibility Treatment protocols for co-morbidity Client/family perception of appropriateness Availability of community services Continuity mechanisms Clear, visible and available points of accountability II Specialized Assessment Assessment is the critical first step in the provision of care and provides the basis for developing an understanding of the problems encountered by the clients, caregivers, or clinicians. The assessment should have two components: information collection and analysis. Information collection includes gathering history from the individual, caregivers, and other collaborative providers; observing the clients; and obtaining supportive investigations. The information is analyzed and decisions are made as to what expertise is required to address the problems encountered. A care plan is collaboratively developed, based on the assessment, and defines the responsibility of the program as well as the primary care system. The assessment will also address the provision of support and education for caregivers and clinicians. Ideally, assessments should be undertaken in the clients environment in order to evaluate behavioural disturbances and obtain information from staff and family members who have regular contact with the client. The outreach team is not responsible for the implementation of the care plan except in those few circumstances where they may be providing time-limited treatment and follow-up. Implementing the care plan is the obligation of the most responsible clinician, community agency, or institution. The Ontario Mental Health and Addictions Operating Manual indicates that programs must have policies in place to guide staff when they are required to disclose information. 41 These policies should address the circumstances of collection, use and disclosure of information in compliance with current legislation. 14

16 Function: Specialized Assessment Domains Acceptability Accessibility Appropriateness Competence Consumer/Family satisfaction with service received Consumer/Family involvement in treatment decisions Formal Complaints mechanism in place Consumer/Family involvement in service delivery and planning Cultural Sensitivity Consumer/Family choice of services Service reach to persons with serious mental illness (SMI) Access to psychiatrists and other mental health professionals Identify human resource gaps Access to primary care Wait times for needed services Denial of Service Early Intervention Client/family perceptions of accessibility Treatment protocols for co-morbidity Fidelity: adherence to best practices Best practices service/supports provided Level of service and setting appropriate to needs of individual Needs-based funding and spending Client/family perception of appropriateness Availability of community services Domains Continuity Effectiveness Efficiency Safety Continuity mechanisms Clinical status Budget and tools for evaluation and performance monitoring Documented discharge plans Clear, visible and available points of accountability Functional status Housing status Quality of life Physical health status Resources available to train staff to meet required competencies for role Resources available for on the job development and continuous learning Meets provincial certification/professional standards (where applicable) Critical incidents Risk management practiced III Care Planning, Treatment and Follow-up The Mental Health and Addictions Operating Manual indicates that programs will identify the target populations for their services, the rationale for serving that population, and the type of services they provide. In addition to this, agencies are required to develop and use admission, discharge and referral policies that reflect provincial criteria. As stated in the program policy framework, outreach teams provide time-limited treatment and follow-up to clients with complex needs. The outreach team s principal function is to assist the primary caregivers to develop the care plan and, through training and education, enhance the capacity of the primary caregivers to provide the appropriate treatment and support. 15

17 Function: Care Planning, Treatment and Follow-up Domains Acceptability Accessibility Appropriateness Competence Consumer/Family satisfaction with service received Consumer/Family involvement in treatment decisions Formal Complaint mechanism in place Consumer/Family involvement in service delivery and planning Cultural Sensitivity Consumer/Family choice of services Service reach to persons with serious mental illness (SMI) Access to psychiatrists and other mental health professionals Identify human resource gaps Access to primary care Wait times for needed services Availability of after hours care Denial of Service Consumer/family perception of accessibility Access to continuum of mental health service Domains Fidelity: adherence to best practices Best practices service/supports provided Treatment protocols for co-morbidity Time in program Level of service and setting appropriate to needs of individual Needs-based funding and spending Client/family perception of appropriateness Availability of community services Continuity Effectiveness Efficiency Safety Continuity mechanisms Community tenure Needs-based allocation strategy Documented discharge Mortality Unit costs and cost per plans patient Clear, visible and Clinical status Budget and tools for available points of evaluation and accountability performance monitoring Functional status Housing status Quality of life Physical health status Resources available to train staff to meet required competencies for role Resources available for on the job development and continuous learning Meets provincial/certification and professional standards (where applicable) Medication errors Medication side effects Critical incidents Suicides Risk management practiced Identify research/ practices to reduce adverse events and errors IV Consultation, Education and Support Specialized geriatric mental health outreach teams will enhance the capacity of the broader system of services to provide appropriate care. Consultation, education and support will be targeted to community agencies, family physicians, 16

18 long-term care facilities, general mental health services and family members, utilizing a health promotion and illness prevention perspective. The team s activities will vary depending upon their resources and the availability of specialized educational services elsewhere in the community. Where other resources are present, activities will need to be coordinated and formal linkages between the services established. Function: Consultation, Education and Support Domains Acceptability Accessibility Appropriateness Competence Continuity Efficiency Consumer/ Family satisfaction with service received Access to psychiatrists and other mental health professionals Identify human resource gaps Access to primary care Client/Family perception of accessibility Access to continuum of mental health services Fidelity/ adherence to best practices Best practices service/supports provided Needs-based funding and spending Consumer/family perception of appropriateness Resources available to train staff to meet required competencies for role Resources available for on the job development and continuous learning Meets provincial certification/ Provincial standards (where applicable) Clear, visible and available points of accountability Proportion of staff funding spent on administration and support Budget and tools for evaluation and performance monitoring V Program and System Development The Mental Health and Addictions Operating Manual states that the reformed mental health system will recognize the inter-relationship between the needs of the consumer, the organization of the service delivery system, and the performance and mandate of each Ministry-funded mental health program. These inter-relationships are a fundamental basis upon which the service delivery principles are built. As indicated in the program policy framework, specialized geriatric mental health outreach teams are well positioned to enhance the community care system through linkages with other services, both within and across sectors. 17

19 Function: Program and System Development Domains Acceptability Accessibility Appropriateness Competence Ensure patients legal rights and entitlements are respected Service reach to persons with serious mental illness (SMI) Access to psychiatrists and other mental health professionals Identify human resource gaps Wait times for needed services Availability of after hours care Denial of Service Consumer/family perception of accessibility Access to continuum of mental health service Domains Continuity Efficiency Safety Continuity mechanisms Clear, visible and available points of accountability Mental health spending per capita Needs-based allocation strategy Community/institutional balance Budget and tools for evaluation and performance monitoring Existence of best practice core programs Fidelity: adherence to best practices Best practices service/supports provided Treatment protocols for co-morbidity Level of service and setting appropriate to needs of individual Needs-based funding and spending Consumer/family perception of appropriateness Availability of community services Identify and disseminate research/practices to reduce adverse events and errors Resources available to train staff to meet required competencies for role Resources available for on the job development and continuous learning Provincial certification and professional standards exist (where applicable) VI Discharge The Ontario Mental Health and Addictions Operating Manual indicates that programs are required to develop and use admission, discharge and referral policies which reflect provincial criteria. 42 Programs will clearly outline service plans, including discharge plans, to clients and their caregivers. This information should also be communicated to other relevant service providers in accordance with applicable legislative requirements. Because the needs of older persons with serious mental illness and complex needs change in relation to functional, physical and mental health status, re-referral can occur when indicated by the primary care system. 18

20 Function: Discharge Domains Acceptability Accessibility Appropriateness Continuity Consumer/Family satisfaction with service received Formal Complaint mechanism in place Cultural Sensitivity Wait times for needed services delayed discharge Denial of Service Discharge protocols for co-morbidity Client/family perception of appropriateness Major symptom stabilization has occurred Risks to the client have been addressed A system of support has been activated Availability of community services Continuity mechanisms Documented discharge plans Clear, visible and available points of accountability Support/education of family members and caregivers has occurred 3) NEXT STEPS Mental health and long-term care supports and services must become more accessible, better coordinated and less fragmented to ensure that the growing population of older adults who require specialized services will receive the care and treatment they need. Specialized geriatric mental health outreach teams play a major role in reducing the impacts of complex age-related or mental health problems. Ensuring that core program functions are available on an equitable basis through the province and that there is flexibility to respond to local conditions in urban and rural/remote communities is a challenge. Responding to this challenge will require the involvement of clients, their families and caregivers, plus a wide range of service providers and planners in local communities across jurisdictions and at the local, regional and provincial levels. Now more than ever, programs are to be accountable for the services that they provide and the funding they receive. These program domains and indicators will assist specialized geriatric mental health outreach teams to align their service delivery for provincial coherence and their information gathering and reporting within the evolving ministry framework. As stated in the Mental Health Accountability Framework, the development of accountable mental health services is not a static process. 43 Next steps include the development of outcome-based performance measures, standards and data collection requirements. 19

21 Appendix A: Referral Sources Specialized geriatric mental health outreach teams accept referrals by telephone, mail, or fax from a wide range of sources that include, for example: Family Physicians; Nurse Practitioners; Psychiatrists; Long-term care facilities; Community Agencies; Community Care Access Centres; General hospitals (psychiatric and non-psychiatric units); Psychogeriatric Resource Consultants (PRCs); Complex Continuing Care Settings; Rehabilitation services; Rest & Retirement homes; Residential Homes e.g. Homes For Special Care; Family members/caregivers; Clients; and Mental health crisis services. 1

22 Appendix B: Mental Health Accountability Framework Domain Acceptability Accessibility Appropriateness Competence Continuity Effectiveness Efficiency Safety Definitions Services provided meet expectations of service users, community, providers and government. Ability of people to obtain services at the right place and right timed based on needs. Services provided are relevant to service user needs and based on established standards. Knowledge, skills and actions of individuals providing services are appropriate to service provided. The system is sustainable, comprehensive, and has the capacity to provide seamless and coordinated services across programs, practitioners, organizations, and levels of service, in accordance with individual need. Services, intervention or actions achieve desired results. Organizations / programs achieve desired results with the most cost-effective use of resources. Organizations / programs avoid or minimize potential risks or harms to consumers, families, mental health staff and the community associated with the intervention / lack of intervention or the environment. 2

23 References 1 Moore, Eric & Pacey, Michael Geographic Dimensions of Aging in Canada: SEDAP: A Program for Research on Social and Economic Dimensions of an Aging Population, Research paper No Mount Allison University, Canadian Studies. About Canada: Aging and the Canadian Population. Retrieved on the World Wide Web November 27, 2003 at 3 Canadian Academy of Geriatric Psychiatry and Canadian Coalition for Seniors Mental Health, Submission to The Standing Committee on Social Affairs, Science and Technology Mental Health and Mental Illness Seniors Roundtable June 4, 2003, p.5. 4 Canadian Study of Health and Aging, The Prevalence of Dementia: 1991 Baseline Study retrieved on the World Wide Web December 1, 2003 at %20Prevalence%20of%20Dementia%20.ppt 5 Health Canada Division of Aging and Seniors Healthy Mind, Healthy Aging Retrieved on the World Wide Web January 16, 2004 at 6 Conn, David K., Canadian Coalition for Senior s Mental Health: focusing on long-term care Journal of Geriatric Care, Vol 1 No 3 May/June Canadian Study on Health and Aging, op cit. 8 BC Psychogeriatric Association, Psychosocial Approaches to Mental Health Challenges of Late Life. Retrieved on the World Wide Web December 8, 2003 at 9 Canadian Study of Health and Aging, Caregiving: Results from the Canadian Study of Health and Aging. Retrieved on the World Wide Web at 10 Canadian Academy of Geriatric Psychiatry and Canadian Coalition for Seniors Mental Health, op cit., p Canadian Study of Health and Aging, op cit. 12 Resource Inventory Task Group: Report of the Resource Inventory Task Group to the Provincial Steering Committee Mental Health and Long Term Care Facility Sector volumes 1 4, Ibid. 14 Ontario Making it Happen: Operational Framework for the Delivery of Mental Health Services and Supports 1999; p Ontario Making It Happen: Implementation Plan for Mental Health Reform 1999, pp Coyte et al Forecasting Facility and In-home Long-Term Care for the Elderly in Ontario: The Impact of Improving Health and Changing Preferences June Retrieved on the World Wide Web January 26, 2004 at: 17 CPA/CFPC Working Group Shared Mental Health Care: Strengthening the Relationship Between Mental Health and Primary Care Providers April Retrieved on the World Wide Web January 19, 2004 at 18 Ontario, Operational Framework, op cit., p Based on the British Columbia Guidelines, British Columbia Ministry of Health Services, op cit., pp.4&5 20 British Columbia Ministry of Health Services Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities February 2002; p Bernabi, R. et al. Randomized trial of impact of model of integrated care and case management for older people living in the community British Medical Journal 1998; 316: (2 May) 22 Canadian Association of Gerontology Issues Paper: Issues in the Delivery of Mental Health Services to Older Adults retrieved on the World Wide Web at on November 28, Ibid., p Ibid., p Ibid., p British Columbia Ministry of Health Services, op cit., p.vii. 27 Sullivan M.P., Kessler L., & Le Clair J. K. Defining Best Practices for Specialty Geriatric Mental Health Outreach Services: Lessons for Implementing Mental Health Reform Canadian Journal of Psychiatry: Special Geriatric Psychiatry Section July 2004; Vol 49 No Ibid., p Based on the British Columbia Guidelines, British Columbia Ministry of Health Services, op cit., pp and Innovations in Best-Practice Models of Continuing Care for Seniors p.2 Retrieved on the World Wide Web December 18, 2003 at 30 MacCourt, Penny, Lockhart, Betsy & Martha Donnelly Best Practices for the Mental Health Care of Older Adults Retrieved on the World Wide Web September 17, 2003 at 31 Plan for the Development of Geriatric and Psychogeriatric Consultation Services in Grey and Bruce Countries: Executive Summary. Retrieved on the World Wide Web October 31, 2003 at 32 Regional Geriatric Assessment Program of Ottawa-Carleton: Retrieved on the World Wide Web October 31, 2003 at 33 In conversation: Victoria Madsen, Operations Service Manager, St. Joseph s Centre for Mountain Health Services, December 4,

24 34 Resource Inventory Task Group, Volume Three, op cit., p British Columbia Ministry of Health Services, op cit., p Ontario Mental Health Accountability Framework March, Ibid., p Ontario Mental Health Accountability Framework March Ontario Operating Manual For Mental Health Services and Addiction Treatment Services (Substance Abuse and Problem Gambling Services) Funded by the Ministry of Health and Long-Term Care December Ibid, p Ontario, op. cit., p Ontario, op. cit., p Ontario, op. cit. P.27. 4