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Health Systems Research
and Consulting
Dr. Paula
Goering, Head
 Informing and improving systems of mental health
and addiction service delivery -- this is the goal of the Health System
Research and Consulting Unit, the base of the University of Toronto
Department of Psychiatry's Health Systems Program (formerly the Mental
Health Systems Research and Development Program).
An interdisciplinary team draws on the expertise
of other jurisdictions, reviews current literature, interviews and consults
with local stakeholders, analyses data in existing administrative databases,
and gathers information through epidemiological and program evaluation
studies.
To maximize the possibility of these findings
being disseminated and translated into policy and practice, investigators
in the unit regularly assume roles as administrators, planners, consultants
and advocates to influence decision-making in the education, health
care and government arenas. The unit has assumed a leadership role in
this area after receiving a grant from the Ontario Ministry of Health
and Long-Term Care to develop the Research Transfer Training Program.
This program offered a course on knowledge transfer for the Department
of Psychiatry at the University of Toronto and for CAMH researchers.
The unit's consultation service is busy transferring knowledge and keeping
research staff in touch with front-line service delivery issues and
problems.
Members of the unit work in close collaboration
with the Ontario Substance Abuse Bureau on system-related issues, such
as performance measures and planning information. We have developed
partnerships with provincial and federal mental health policy groups,
are affiliated with the Department of Health Policy, Management and
Evaluation at the University of Toronto and have developed a collaborative
relationship with the Institute for Clinical Evaluative Studies. Unit
staff have cross-appointments with other departments at the University
of Toronto, including the Faculty of Nursing, Department of Public Health
Science and the Institute for Medical Science.
Hospital Report 2001 -- Mental Health Feasibility
Study
As part of the Hospital Report 2001 project conducted
through the University of Toronto's Department of Health Policy, Management
and Evaluation, we conducted a feasibility study concerning the use
of the Balanced Scorecard for hospital-based mental health care. We
used literature, data and site reviews and consultation with content
experts and stakeholders.
The project's final report, released this spring,
evaluated the Scorecard's usefulness and feasibility for mental health
care. Two modifications were recommended to improve the Scorecard's
applicability. First, the indicators chosen should reflect not only
the four Scorecard quadrants (system integration & change, clinical
utilization & outcomes, client satisfaction and financial performance
& condition) but also domains pivotal to Ontario's mental health
reform: accessibility, appropriateness, outcomes, consumer participation,
and system management. Second, the scope of the Scorecard should be
expanded to include provincial and regional governance levels in addition
to the individual hospital or mental health/addictions unit or program.
Using these recommendations, we developed a modified
framework along with example indicators, and proposed future directions
for development and implementation.
Community Mental Health Evaluation Initiative
Availability of evidence on the effectiveness
of different forms of community mental health support varies. A lack
of common client data usually prevents researchers from comparing interventions.
The Health Systems Research and Consulting Unit is the co-ordinating
centre for a multi-site evaluation research project to advance understanding
of the roles played by case management, assertive community treatment,
crisis services and consumer and family initiatives. A cohort of over
900 individuals enrolled in 18 different programs is being assessed
at three different points over an 18-month period. Most of the baseline
data have now been collected and analyses are ongoing. Communications
are being conducted in partnership with cmha-Ontario. This past spring,
we conducted a knowledge transfer workshop that produced "main
messages" for policy-makers and the public.
Explaining Outcomes: Critical Characteristics
of Community Support
Explaining Outcomes is a five-year project in
the Community Mental Health Evaluation Initiative. The goal is to develop
an instrument, or package of instruments, to measure the critical aspects
of community support programs for people with a severe mental illness.
Now in our third year of the project, the research team has developed
and field tested four versions of the instrument: one for consumers,
one for family members, one for service providers and one for program
administrators. The next step in the project will be to pilot test the
instruments, including a test-re-test of a subset of programs, to establish
reliability and validity.
Comprehensive Assessment Projects
This series of needs-based planning projects
originated in Ontario's psychiatric hospitals and expanded into the
community system. We are using a consistent and sound methodology to
assess current and recommended levels of care for people who use mental
health services, and to determine how well current care matches need.
Representative samples are weighted to provide data for service and
system planning. To date, eight hospital and five community projects
have been completed, and four are under way. We have presented our results
to Mental Health Implementation Task Forces across the province.
While results vary across settings, there are
some consistent findings. Most people currently using mental health
services are receiving very low (about monthly) contact and a small
group are receiving very high levels of support (i.e., inpatient care).
Yet about half of current psychiatric hospital inpatients could be living
independently in the community if intensive support were available.
Additionally, about 60 to 70 per cent of people who use community-based
services require more support than they are receiving. During the past
few years, assertive community treatment teams have been implemented
throughout Ontario, but these planning projects suggest that considerably
more system capacity is needed for delivery of intensive, community-based
mental health care.
Depression in the Workplace
Rising rates of disability due to depression
are of concern to multiple stakeholders. In response to a request from
the Ontario Roundtable on Appropriate Prescribing, we designed a study
called Depression in the Workplace: Examining Antidepressant Use and
Worker Characteristics and Their Associations with Disability. Three
Canadian companies with national employee bases were recruited as project
participants. Together, they represent over 65,000 workers.
The first findings from the Depression in the
Workplace study were published in the Journal of Occupational and Environmental
Medicine. This paper reported that as many as two per cent of the labour
force will take a depression-related short-term disability leave. Depression-related
leave accounts for 75 per cent of all leaves due to nervous and mental
disorders. In the study sample that represented 12 per cent of the financial/insurance
sector in Canada, this represented $20.5 million in lost productivity.
A larger proportion of employees who go on short-term
disability are in their mid-careers. They are people with work experience
who are vital to the operation of their companies. However, the majority
of people who go on depression-related short-term disability return
to work rather than go on to long-term disability. People on short-term
disability are not a homogenous group; for example, the severity of
their symptoms varies. Effective disability management programs take
these differences into account.
Best Practice for Concurrent Disorders
This project, funded by Health Canada, synthesized
research literature, expert opinion and consumer focus group input to
recommend improvements for community systems and services (screening,
assessment and treatment/support) for people with concurrent mental
health and substance use disorders. Recommendations called for a more
integrated approach at both the individual program level as well as
the system level. The advice concerning specific research-based interventions
differed within different clusters of concurrent disorders (e.g., mood
and anxiety versus severe and persistent mental illness). The report
has been completed and released by Health Canada.
Drug and Alcohol Treatment Information System
Drug and Alcohol Treatment Information System
(datis) is a provincial information system that collects, summarizes
and reports information on the volume and characteristics of people
being treated for alcohol, drug and gambling problems in Ontario. Staff
of the unit help select performance measures within datis and analyse
and interpret trends that are useful for planning, accountability and
research. Unit staff use the resulting databases to address research
questions and report the findings in the research literature. This year,
we completed the first provincial report on client characteristics and
service utilization.
Systems Integration
In this project, we reviewed and synthesized
findings on mental health system integration to examine strategies for
creating more integrated mental health service systems, and to evaluate
the effectiveness of these strategies in enhancing client accessibility,
continuity and quality of care. We reviewed published and unpublished
literature, looking at key studies and descriptive work. We analysed
Ontario and other integration projects to identify strengths, challenges
and lessons learned. We sought expert opinion by interviewing key informants
and consulting with an advisory panel formed for this project.
In collaboration with the Mental Health Rehabilitation
Reform Branch, the unit organized a provincial policy forum on systems
integration for the Mental Health Implementation Task Forces, provincial
organizations, consumers and families on October 17, 2001, in Toronto.
This forum generated considerable discussion and provided advice to
the Ministry on this issue.
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