Diabetes and Serious Mental Illness: Future Directions for ...€¦ · • Beth Ward, Scott...

Diabetes and Serious Mental Illness:

Future Directions for Ontario

A Report from the March 30, 2009

Think Tank on Diabetes and Serious Mental Illness

April 30, 2009

180 Dundas Street West, Suite 2301, Toronto, Ontario M5G 1Z8 416.977.5580 www.ontario.cmha.ca

Diabetes & Serious Mental Illness: Future Directions for Ontario (CMHA, Ontario report)

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Acknowledgements

Canadian Mental Health Association Ontario would like to acknowledge the contributions of the

following individuals and organizations who contributed to making the Diabetes and Serious

Mental Illness Think Tank a success:

• Betty Harvey, Nurse Practitioner, Primary Care Diabetes Support Program, St. Joseph’s

Health Care London for the presentation on Disparities in Chronic Disease Prevention &

Management for Individuals with Serious & Persistent Mental illness, and for serving on

the organizing committee.

• Joan Canavan, Team Lead Acute Services and Chronic Disease Unit, Ministry of Health

and Long‐Term Care for the presentation, Provincial Approach to Chronic Disease

Prevention and Management, and for serving on the organizing committee.

• Christine Sansom, Director of Clinical Services, WOTCH Community Mental Health

Services for developing the case study used for small group discussion, and for serving

as a member on the organizing committee.

• Alice Strachan, AMS & Associates for agenda development and facilitation.

• Kate Pautler of Caislyn Consulting Inc. for her contributions in organizing and writing of

this paper.

• Beth Ward, Scott Mitchell, Sandi Kendal, Kendall Bradley and Jennifer McVittie for note‐

taking in small group discussions, and Susan Teslak for her assistance with logistics.

• 31 participants from primary health care, diabetes, community mental health, the LHINs

and the Ministry of Health and Long‐Term Care. (See Appendix 1.)


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Table of Contents

Acknowledgements 2

Background Information 5

Overview of the Think Tank 8

Presentations 9

Disparities in CDPM in Individuals with Serious & Persistent Mental Illness 10

Ontario’s CDPM Framework 20

High Level Outcomes of the Think Tank 21

Information from the Field 24

Strategies and Recommendations 28

POLICY

1. Formally identify this population as a high risk population 29

SURVEILLANCE

2. Set standards and benchmarks 30

3. Track appropriate data 31

4. Define risk assessment and screening processes and tools 32

SURVEILLANCE & CAPACITY BUILDING

5. Engage public health 34

KNOWLEDGE EXCHANGE

6. Evaluate existing initiatives 35

7. Inventory existing initiatives , promising practices and information 36

8. Identify core competencies 37

9. Training in CDPM framework, psychosocial rehabilitation and recovery principles 38

10. Support the transfer of knowledge into practice 40


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CAPACITY BUILDING

11. Create regional leads 43

12. Improve funding models to promote collaborative/integrated care 44

13. Encourage collaboration with peer support and social recreational programs 46

14. Create system navigation capacity 48

15. Increase capacity for team‐based primary health care 49

16. Increase efficiency of primary health care 50

17. Ensure appropriate incentives in primary health care 51

EQUITABLE ACCESS

18. Increase access to alternatives methods of care 52

19. Integrate care for ethnocultural/ethnoracial populations 53

PREVENTION MESSAGES

20. Include mental illness in diabetes prevention 55

Appendices

1. THINK TANK PARTICIPANTS 56

2. BACKGROUND READINGS 57

3. CASE STUDY 58

4. RISK ASSESSMENT QUESTIONS 60

Works Cited 61


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Background Information

The Ministry of Health and Long‐Term Care (MOHLTC) has recently established key priorities in

the area of chronic disease prevention and management (CDPM) in recognition of the

increasing burden of these diseases on the health of Ontario citizens and rising costs to the

heath care system. The MOHLTC is responsible for providing the policy framework to guide

efforts towards effective prevention and management, and engaging stakeholders in a

systematic approach to responding to chronic disease.

The MOHLTC initiated the overall implementation of the Ontario CDPM Framework (Lee, 2006)

by addressing diabetes as the first priority. The driving forces were that approximately 8.8% of

the province’s population currently has diabetes, and the cost of dealing with this disease and

related complications annually exceeds $5.5 billion (Ministry of Health and Long‐Term Care,

2008). In 2006, an Expert Panel was convened to examine research and best practices from

around the world and define a strategy to focus on meeting the needs of Ontarians with

diabetes. As a result, the MOHLTC made a series of announcements in both 2007 (Ministry of

Health and Long‐Term Care, 2007) and 2008 (Ministry of Health and Long‐Term Care, 2008),

culminating with the provincial diabetes strategy. Major elements of the strategy include:

• Increasing access to team‐based care with an infusion of $290 million to expand current

programs, align care and fund new initiatives.

• Investing $6 million in prevention programs including education campaigns to raise

awareness of risk factors (e.g., physical inactivity, poor nutrition and obesity) that

contribute to the onset of type 2 diabetes focusing on high risk populations (e.g.,

Aboriginals, Hispanics, South Asians, Asians, African‐Canadians, lower income families

and people aged 50 and older).

• Creating a diabetes registry that will provide instant access to information and

education tools to help people with diabetes manage their care; assist physicians to

check patient records, access diagnostic information and send patient alerts.


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• Extending the Insulin Pump Therapy program to all adults with type 1 diabetes with a

$62 million investment and reviewing the evidence to see if the pump program should

be extended to adults with type 2 diabetes who are insulin dependent.

• Expanding the Chronic Kidney Disease Program with $220 million in funding to improve

access to all services available under the program, focusing on early identification of

kidney disease. Diabetes is a common risk factor associated with kidney disease.

• Improving access to bariatric surgery for people with obesity, with $75 million in funding

in recognition of the fact that more than 50% of type 2 diabetes cases in the province

are associated with obesity. (Ministry of Health and Long‐Term Care, 2008)

With the shift in Ontario’s health care system towards chronic disease prevention and

management, CMHA Ontario published three papers in 2008, a backgrounder on the

relationship between mental health and physical illness, a discussion paper on the fit between

mental health, mental illness and Ontario’s CDPM Framework, and a policy paper with

recommendations to address co‐morbid mental illness and chronic physical conditions. . While

the framework recognizes mental health elements in treating chronic physical conditions and

the fact that many people with chronic diseases are at risk of depression, suitability of this

approach to treating people with serious mental illness who also have chronic physical health

conditions has yet to be fully tested. A strength of the Ontario CDPM Framework is “the

potential for integrating physical and mental health care… [and this is of] value in improving

physical health care of people with serious mental illnesses, a population whose physical health

is often poor and who are at high risk of developing diabetes and heart disease” pg. 1 (Canadian

Mental Health Association ‐ Ontario, 2008 – discussion paper).

The Ontario CDPM Framework is also a potential means to address the long‐standing inequities

people with serious mental illness (SMI) face in accessing primary and preventative health care.

Many people with SMI are “orphan patients” in terms of primary health care – they are treated

within the mental health care stream that traditionally has not been structured or funded to

support prevention and management of other health conditions. At the same time, there are


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people with serious mental illnesses and chronic physical conditions being seen in primary

health care settings who are not connected to mental health services. Primary health care

settings alone are not equipped to address the complex needs of these individuals, which

usually extend beyond issues of direct health care. Diabetes education programs also need

support in order to adequately address the diabetes needs of people with serious mental

illnesses.

Serious mental illness is a significant risk factor for the development of a number of chronic

diseases including chronic obstructive pulmonary disease, breast cancer, colon cancer, lung

cancer, stroke, heart disease and diabetes. This high risk of serious health conditions among

people with serious mental illness means that prevention services, health screening and regular

access to primary health care should be of high priority (Bazelon Center for Mental Health Law,

2004). Increased coordination, collaboration and shared care between health care sectors will

increase the capacity of each sector and will improve health care outcomes for people with

mental illness and chronic diseases.

It is important to add that underlying factors that put these individuals at high risk of chronic

conditions and complicate their capacity to manage these illnesses must also be addressed. This

is a population living with high rates of poverty. The impact of poverty on diabetes has been

well‐documented. (Health Council of Canada, 2007)


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Overview of the Think Tank

Under the provincial diabetes strategy, the MOHLTC provided funding to CMHA Ontario for a

one‐day Diabetes and Mental Illness Think Tank session to bring together representatives from

primary care, diabetes, community mental health, the LHINs and the MOHLTC. The focus of the

session was to identify strategies to increase collaboration and cross sectoral support to

improve diabetes prevention and management for people with serious mental illnesses, and to

plan action steps. Prior to the think tank, participants were provided with background reading

materials related to diabetes and serious mental illness. (See Appendix 2.) Brief overviews of

the issue, current policy and the Ontario CDPM Framework were provided at the outset of the

think tank. Discussion groups were populated with representatives from the various sectors

and asked to identify and strategize care responses using a case approach (See Appendix 3.)

Continuing in small groups, participants then discussed the system level needs and potential for

collaboration. The group recommendations were prioritized and shared in the larger audience.

Overall, participants were impressed with the quality of knowledge exchanged and appreciated

the amount of time dedicated to discussion and strategy development. They welcomed the

opportunity to have input and felt all perspectives were valued throughout the process.

There was also a great deal of sharing of information among the participants as they were

encountering “new” colleagues with unique information. They also noted that their level of

awareness of the diabetes and mental illness issue was appreciably enhanced as a result of

their participation. One of the most valuable aspects of the Think Tank expressed by

participants was the opportunity to have a meaningful exchange of information between

sectors in small groups so that people could have full discussion of the issues and approaches in

various sectors and organizations.

Several organizations and individuals indicated that they would be willing to continue to work

with CMHA Ontario to further the actions steps outlined in this report.


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Presentations Promoting a common understanding of the relationship between mental illness and diabetes is

vital to all cross sectoral initiatives. Betty Harvey, Nurse Practitioner with the Primary Care

Diabetes Support Program, at St. Joseph’s Health Care in London, Ontario, presented on

Disparities in Chronic Disease Prevention & Management for Individuals with Serious &

Persistent Mental illness. (The slides are included here with permission.)


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Disparities in Chronic Disease Prevention & Management for Individuals with Serious

& Persistent Mental illness

Betty Harvey, BScN. MScN, RNECNurse Practitioner SJHC Primary Care Diabetes Support Program

Primary Care Diabetes Support Program

1

Discussion Points….• Chronic Diseases – an overview

• The disparity in Diabetes Burden for individuals with Mental Health conditions.

• Reducing disparities through System redesign

2Primary Care Diabetes Support Program


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Chronic Disease ‐ a Global Health Issue

WHO. World Health Statistics. 2008.Kelly T. Int J Obesity. July 8, 2008.

(57.8%)

20302005

(33%)

By 2030, chronic conditions will cause 75% of all deaths globally

4

Primary Care Diabetes Support Program

Industrial Revolution

Chronic disease in Ontario…

• 80% of Ontarians over age 45 have a chronic health condition and 70% of these, have 2 or more chronic conditions.

(Ontario Health Quality Council Report , 2007)


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CDPM Disparities for Individuals with Serious and Persistent Mental illness

(SPMI) …• Higher rates of COPD, Breast Cancer, Colon Cancer, Lung Cancer, Stroke, Heart Disease.

• 2X greater risk of Cardio‐Vascular mortality rate (Dixon Et al , Schizoph. Bul, 26:903‐912, 2000).

• 10 yr risk of Coronary Artery Disease in individuals dx with Schizophrenia is 50% higher for Women and 34% higher in Men compared to the general population. ( Brown et al , J. Psychiatry, 171:502‐508, 1999)

• a 25 yr less life expectancy (CDC, 2006).

Primary Care Diabetes Support Program 6

Why the Disparity?


Under Diagnosis &

Under Treatment


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Diabetes ‐ the “Test Case” for CDPM system redesign in Ontario

www.eatlas.idf.org.Dawson KG. Diabetes Care. 2002.

ADA. Diabetes Care. 2008.

Canada: In 1998, direct medical costs associated with diabetes were between US $4.76 and $5.23 billion

USA: In 2007, total costs were estimated at US $174 billion

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Primary Care Diabetes Support Program(Slide Courtesy of S. Harris)

IMS Health Canada. 2007.

A Frequently Diagnosed Disease IN CANADA

Top ICD‐9 office‐based billing code claims, 2007

Rank Diagnosis

1st Hypertension

2nd Health check up

3rd Diabetes4th Depression5th Anxiety6th Acute upper respiratory infection7th Normal pregnancy supervision

8th Hyperlipidemia

Slide Courtesy of S. Harris)


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Prevalence increased by 24% between 2000/01 and 2004/05 (from 3.8–4.7%).

2004/05

Prevalence HAS INCREASED (2000–2005)

Age‐standardized to 1991 Canadian population

Percent

5.0

4.0

3.0

2000/01 Year2001/02 2002/03 2003/04

Males Females Total

PHAC. Diabetes in Canada (NDSS 2004/05).2008. (Slide Courtesy of S. Harris)

15

25

20

10

5

0

1–19

20–24

25–29

30–34

35–39

50–54

40–44

45–49

55–59

60–64

65–69

70–74

75–79

80–84

85+ Age

Overall incidence

6.0187,901

Age‐standardized to 1991 Canadian population

Incidence (2004/05)

Incidence**

Males Females Total

PHAC. Diabetes in Canada (NDSS 2004/05).2008.

**per 1000 pop.

(Slide Courtesy of S. Harris)


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Diabetes ‐morbidity

PHAC. Diabetes in Canada (NDSS 2004/05).2008. CDA. Can J Diabetes. 2008.

www.statcan.ca.

Neuropathy (40–50%)

Diabetic retinopathy (~40%)

Anxiety (~40%) and depression (~15%)

Foot ulcers(15%)

Erectile dysfunction (34–45%)

Obesity (80–90%)

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75% of Ontarians with T2DM have other co morbidities

(Slide Courtesy of S. Harris)

Diabetes ‐morbidity

PHAC. Diabetes in Canada (NDSS 2004/05).2008.

Hypertension or heart failure

X 4

StrokeX 3

Heart attackX 3

Lower limb amputationsX 24

Chronickidney disease

X 7

14Primary Care Diabetes Support Program(Slide Courtesy of S. Harris)


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Driving Forces ‐ Adult Obesity IN CANADA

• 59% of adult Canadians are overweight and 23% are obese• Obesity rates are highest among people aged 45–64 and those with

SPMI

Lau DCW. CMAJ. 2007.Tjepkema M. Nutrition. 2005.Statistics Canada. CCHS. 2007.

Obesity rates increased from 11% in 1972 to 24% in 2005

Percent

35

30

25

20

15

10

5

1970 1980 1990 2000 2010 Year

CanadaUnited States


• Of immigrants who came to Canada from 2001–2006, ~80%were from populations at high risk for Type 2 diabetes.

• Increasing numbers have SPMI

Immigration FROM HIGH-RISK POPULATIONS (2006)

Statistics Canada. 2006 Census.

Immigration from HIGH‐RISKpopulations

ASIA(including

the Middle East)

10.6%

CENTRAL/SOUTH AMERICA & CARIBBEAN

AFRICA

58.3%

10.8%



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A Disease OF THE POOR

• Diabetes is disproportionately clustered:– In the lower socioeconomic status quintiles– In neighborhoods with lower average household

incomes, high proportions of visible minorities and/or recent immigrants

• People in lower income brackets and with fewer years of education also report:– Higher rates of smoking– Less physical activity; and– Higher rates of overweight

Hux JE. ICES. 2003.Glazier RH. ICES. 2007.

Willi C. JAMA. 2007;298:2675‐2676.Raphael D. North York Heart Health Network; 2001.

Statistics Canada. National Population Health Survey 1998–1999.

All modifiable risk factors for diabetes


Disparity in Diabetes Burden for Individuals with SPMI…

• Under diagnosed 25‐33% incidence of previously undiagnosed Pre‐Dm and Dm in community based cohorts. (Schiz. Bul, 80:19‐32, 2005).

• Higher Prevelance ‐ 2‐4 times greater Prevalence compared to the general population.(Schiz. Bul, 80:19‐32, 2005).

• Undertreated resulting in higher rates of DM related complications on setting sooner (Brown Et al Br J Psychiatry, 177:2112‐217, 2000; Osby et al , Schizophrenia Res, 45:21‐25, 2000)



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Why the Disparity?


Under Diagnosis &

Under Treatment

Less likely to be screened

Self‐care capacity /Resource

System Navigation barriers

Poor access to Primary care

Weight gain

Disconnectedness of “Physical “ & “Mental” heath care systems

Diagnostic “Overshadowing” –missing 30‐50%

Medications

Cognitive, Affective and behavioral symptoms of SPMI

Poverty

Reducing the Diabetes Disparity?


Under Diagnosis &

Under Treatment

Less likely to be screenedAssertive Surveillance (24% )

Self‐care capacity /Resource gapsSupportive/assertive Case

management

System Navigation barriers

Poor access to Primary careOther PHCP eg RNECs

Weight gainAssertive

support/monitoring at Start of RX. – (mean 16 lb loss /ye)

Disconnectedness of “Physical “ & “Mental” heath care systemsIntegrated models –

(earlier Dx Ca colon, TB, CAD, PVD, CRF) (48% at LDL target, 67% at A1c target)

Shared –Care (35% > BPAT, 18% > A1c at target)

Diagnostic “Overshadowing” –missing 30‐50% Managed Care ‐RegistriesEMR Prompters

(Vet. Health Admin.)

Second Generation Anti‐Psychiotics

Cognitive, Affective and behavioral symptoms of SPMIFacilitated referralsSupportive/assertive Case

managementPoint of Care /contact

delivery

Poverty


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In Summary…Chronic diseases like diabetes, are the leading causes of death and disability in Canada.

Individuals with Mental health conditions are disproportionately affected

Under diagnosis and under treatment are key drivers.

A fundamental Health System “Redesign” is underway in Ontario.

Today is about tapping into our collective wisdom about how best to leverage this “redesign” to better serve all Ontarians.



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Ontario’s Chronic Disease Prevention and Management (CDPM) Framework

Joan Canavan, Team Lead Acute Services and Chronic Disease Unit, Ministry of Health and Long‐

Term Care presented the Ontario Chronic Disease Prevention and Management Framework

(Ministry of Health and Long‐Term Care, 2009).1 She reviewed the transformation agenda of

the MOHLTC and how this Framework is providing the means to move from an illness to

wellness orientation. Joan highlighted that one of the MOHLTC’s objectives in implementing

the Ontario CDPM Framework is to engage stakeholders in a systematic approach to addressing

chronic disease. While many jurisdictions are pursuing the chronic diseases prevention and

management approach, Ontario’s implementation is beginning with the provincial diabetes

strategy.

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1 The full presentation, “Provincial Approach to Chronic Disease Prevention and Management”, is available on CMHA Ontario’s website at http://www.ontario.cmha.ca/admin_ver2/maps/provincial_approach_to_cdpm.pdf.


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High Level Outcomes of the Think Tank

Role Perspective

Participants represented a variety of role perspectives – front line clinicians, agency/program

executive directors, program managers, planners, policy analysts – and so approached the tasks

through various lenses. Even though participants were selected because of leadership in their

respective sectors, a high level of knowledge exchange on the issues relating to diabetes in this

population was evident. A key finding from the Think Tank was that participants varied

considerably in their level of knowledge as well as in their understanding of current services

and capacities in the other sectors.

Positive feedback from participants included that they would be looking at their approaches

and practices in light of the new information they obtained. People also made connections

with others they intended to follow up after the Think Tank. The need for frequent and

accessible exchange of information between sectors that are expected to collaborate must be

acknowledged and supported.

Response to the Ontario CDPM Framework

There were different responses to the Ontario CDPM Framework among the various sectors

represented, all coming to the day with different values, cultures and ways of working. For

many participants, this was their first exposure to the Framework. Indeed, the Framework is

beginning to inform a number of health care system transformation initiatives like primary care

renewal via family health teams, public health renewal and the e‐health strategy. However, it is

still being tested in its early application.

The degree of fit for the Framework within the various organizational/sectoral approaches

merits examination. There was discussion in some groups and then, the larger audience, about

the application of this framework to the population of people with serious mental illnesses.

Some mental health participants questioned whether the intent of the Ontario CDPM


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Framework was to classify mental illness as a chronic disease – a move that could conflict with

the recovery philosophy/approach2 now guiding mental health sector reform both provincially

and nationally (Ministry of Health and Long‐Term Care, 2009) (Mental Health Commission of

Canada, 2009). Others saw the Framework as useful in terms of prevention and management of

mental illness and diabetes and other chronic physical illnesses, and a few people said they

believe the Framework and recovery approach have similar elements.

Ensuring Successful Collaboration

The variety of perspectives highlights the importance of all partners in cross sectoral initiatives

developing a common understanding of the guiding frameworks and their components and

how multiple perspectives may work together. Engagement of partners in a systematic

approach that will be required for responding to the complex needs of people with serious

mental illness at risk of and living with diabetes must begin with building a foundation of

common understanding and establishing complimentary roles.

Perhaps the strategies being used in the implementation of family health teams may serve as

precedent in this regard. Forming teams consisting of many types of professionals requires

time, attention and resources to ensure success. The MOHLTC has funded an initiative to

support this change, the Quality Improvement and Innovation Partnership3 (QIIP), which

2 The recovery approach does not frame mental illness n terms of chronicity or illness management but rather highlights how people working within the larger social context, may deal with their mental illness and live productive lives. It moves away from a medical view that a person with serious mental illness is defined by their diagnosis. “Although recovery is a deeply personal process, it is one that must always be seen in a complex social context. Recovery’s partners – excellent services and supports, a positive way of understanding and making sense of illness, and the personal base of strength and resilience needed to cope successfully – are an integral part of the picture” (Trainor, Pomeroy and Pape, 2004, p.23). 3 Quality Improvement and Innovation Partnership (QIIP) Learning Collaborative is a peer‐based collaborative model that serves as a vehicle to support and accelerate change in health care. In Ontario, the QIIP is supporting family health teams to improve the care they provide by use of evidence‐based change packages, structured monthly reporting on a common set of measures, technical assistance from expert faculty and subject matter experts as well as practice facilitators in the field, use of web‐based technology to assist in communication and shared learning among teams and to support a knowledge management portal, monthly teleconferences and periodic face‐to‐face learning opportunities (Ontario Health Promotion E‐Bulletin, 2009).


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supports family health teams through learning collaboratives. Similar investments must be paid

to support cross‐sectoral work.

The Ontario CDPM Framework provides a unique opportunity for collaboration and integration

of care for this special needs population. Cross‐sectoral collaboration is a starting point to

ensure that the Framework is introduced to all sectors and that there is dialogue and efforts

made to develop shared care approaches. There are many information gaps to be addressed.

For example, many participants were not aware that the majority of family physicians practice

in group settings. Diabetes educators and family health care providers need to learn more

about current community mental health care in their communities – some did not know there

is an inventory of community mental health resources available via telephone/internet (Connex

Ontario4). Updates on changes and new initiatives within sectors need to be shared so that

working knowledge is kept current by all practitioners and fosters “systematic” approaches.

4 Connex Ontario operates the Drug and Alcohol Registry of Treatment (DART), the Ontario Problem Gambling Helpline (OPGH), and Mental Health Service Information Ontario (MHSIO), which provide information and referral to services in Ontario. See www.connexontario.ca.


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Information from the Field

Given the mix of people present at the Think Tank, there was a wide range of feedback and

discussion in the small groups, not all of which are reflected in the action steps identified in the

next section. These represent recent developments, overarching issues, opportunities, and

ongoing concerns.

Overarching Issues

• Social determinants of health are very relevant in a discussion of serious mental illness

and chronic diseases. Advocacy regarding these social determinants is required.

Ontario Disability Support Program payments significantly limit people making healthy

choices in housing, food/nutrition, fitness and social involvement.

• Intersectoral work must address the fact that agencies/programs come with unique

organizational culture and values. Resources must be provided at the

organizational/system level to build capacity to work across programs/agencies.

• People with complex needs must be welcomed anywhere they enter the system and be

able to get coordinated care from that point on. Coordinated access across providers

must include a “no wrong door” approach.

• Assertive outreach is needed to reach disenfranchised people with mental illness and

diabetes who are not “rostered” anywhere or do not have access to primary care.

• A new approach to patient “non‐compliance” is needed; we should not assume non‐

compliance per se, but rather address barriers and conditions that make it difficult for

people to follow through.

• Prevention approaches are still not a major focus – wellness programs are important.

• Funding needs to be available for evaluation and knowledge transfer of what works ‐

what works in collaborative care, in prevention, in self‐management – to ensure that

programming is effective. For example, there are short term behavioural programs

available in some communities but the evidence shows that support for behaviour

change must be sustained for a year, so these are not effective initiatives. The fear is


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that more of these kinds of programs will be funded, rather than funding effective

initiatives.

Specific Issues

• Many community health centres, aboriginal health access centres, family health teams

and primary care practices have closed their practices to new patients. For some people

this means walk‐in clinics are the only available source of primary health care. In some

parts of the province there are no walk‐in clinics and people’s only access to physical

health care is through emergency rooms.

• Some mental health service providers expressed fear that with a focus on numbers

served, there is a risk that quality of care will suffer and people with complex needs will

not get the support they need.

• There are many underlying risk factors for diabetes in people with mental illness –

poverty being one of them. A focus on prevention is needed, but interventions must be

evidence‐based. Providing nutrition education and cooking classes may be helpful, but it

is difficult to support healthy eating when people cannot afford to buy healthy foods.

• Wage disparities cause integration barriers and staff loss. Community programs train

people and then lose them to higher paying institutions. For example, a community

health centre was unable to take on the diabetes team from the hospital because of the

difference in levels of pay.

• There are differences in roles between sectors and this causes confusion and conflict.

For example, case management models in community care access centres and mental

health programs differ in philosophy and scope.

• Information needs are numerous: at the level of the client, there needs to be sharing of

information among professionals and agencies/programs; LHINs need to have good

information with which to identify local needs, plan and fund service delivery; system

data are required to build solid business cases for investment of resources.


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• “Intermediary” organizations in health care (e.g. provincial associations) are a resource

that should be used. They need to know what is available and how to refer people to

appropriate access points or information.

• What are alternatives for people when anti‐psychotic medications cause weight gain

and increase the risks for developing diabetes?

• Videoconferencing and telemedicine are very important to increasing equitable

distribution of specialist resources, increasing access and improving patient

engagement.

Opportunities

• There are now very few solo family practitioners in Ontario. The majority of family

doctors are working in group practices. Community partners are able to access group

practices through the lead doctor. Group practices may have capacity to work with

community agencies.

• Community mental health agencies have sessional fees in their budgets which are

usually used for psychiatric consultation. Some organizations are using these funds to

hire family physicians to support their teams to address diabetes and to provide care for

clients who do not have a primary health care provider.

• Functional collaboration is increasing between mental health and primary health care

providers. There is a range of models being tried in these partnerships. For example,

some family health teams are contracting with mental health providers to provide

supervision and/or workers. This can ensure that mental health workers in primary care

settings are not working in isolation from their peers, are following best practices for

working with people with serious mental illnesses, and can also allow for community‐

wide mental health strategies.5

5 Other models include primary care staff hired into mental health agencies, co‐located staff/agencies, structured referral protocols between organizations, and fully integrated organizations. (See “Opening Doors to Better Care”, Network, Winter 2008 http://www.ontario.cmha.ca/network_story.asp?cID=25489.)


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Language and cultural issues

• Chronic disease management and prevention strategies for people with serious mental

illness must be available in French and in other languages.

• The high needs of aboriginal people must be recognized.

• Barriers facing newcomers and ethnocultural/ethnoracial populations must be reduced.

Suggestions related to particular health professions

• Nurses working in mental health programs agencies need retraining with regards to

physical health care.

• Endocrinologists are doing a lot of primary diabetes care and are not being utilized by

primary care physicians in some parts of the province to support the complex care of

people with diabetes and mental illness. The current funding model does not support

endocrinologists as consultants to primary health care. A funding model where these

specialists provide support to primary care providers could support the latter in dealing

with complex diabetes care.

• Programs are in place to support psychiatric consultation to family physicians. Family

physicians outside of FHTs and CHCs are not funded for consultation time, reducing their

involvement in these programs.

• Primary care nurse practitioners as well as family physicians must be trained in working

with people with serious mental illness and be able to access specialists for referrals and

consultation.

• Nurse practitioners working in mental health settings could provide training to others. A

network of nurse practitioners in mental health settings was suggested, for consultation

and support.

• Pharmacists may also play a role in terms of monitoring people, dispensing medications

and diabetes care.

• It was suggested that the role of psychologists in chronic disease prevention and

management, diabetes care, and primary care be considered. Psychologists are not

currently publicly funded in Ontario’s health care system.


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Strategies and Recommendations

Enhancement of prevention, identification and management of diabetes in people living with

serious mental illness will set the stage for addressing other chronic diseases in this population.

The Think Tank process was successful in identifying a range of opportunities, strategies and

recommendations for system redesign that will build and sustain effective approaches and

promote integration of care between mental health, primary care and prevention providers.

These items emerged through the combination of small group discussions and synthesis of

ideas in the larger audience. There were also some post hoc analyses of data generated during

the day.

The strategies are grouped by themes. Group comments are presented to reflect the context in

which the strategies were formed. Some strategies have opportunities or recommendations

attached and where possible, specific organizations, groups or sectors are identified as

potential leaders of initiatives or as sources of information and expertise.


29

THEME: POLICY Strategy 1:

The provincial diabetes strategy should formally identify people with mental illnesses as a high

risk population.

Discussion/Context:

Special populations at high risk of diabetes, such as people who have serious mental illnesses,

are easy to overlook unless they are specifically identified in policy documents or initiatives.

The provincial diabetes strategy should identify people with mental illness as a high risk

population.

Opportunities, Action Steps:

1. The provincial diabetes strategy should identify people with mental illness as a high

risk group for the development of diabetes.

2. Local Health Integration Networks should allocate specific funding and targets to

ensure that local capacity is developed to prevent and manage diabetes in people with

serious mental illnesses.


30

THEME: SURVEILLANCE Strategy 2:

Develop standards and benchmarks for co‐morbid diabetes and mental health prevention and

management in Ontario

Discussion/Context:

As standards and benchmarks for diabetes care are developed, attention should be paid to the

same for the subpopulation of people with serious mental illness living with and at risk of

diabetes. Such standards are very useful to the mental health, primary care and diabetes

professionals working with this population as they are provide a focus for practice and program

delivery. They are necessary components for implementation of the Ontario CDPM Framework

in relation to the “provider decision‐support” processes.


1. Identify/develop standards of care and benchmarks for co‐morbid diabetes and

mental health care.


31


Ensure that the provincial diabetes registry includes relevant data to track co‐morbidity of

diabetes and mental illness and to support local planning.

Discussion/Context:

Participants acknowledged that there are data needs at all levels of healthcare. The MOHLTC

needs information to allocate resources across the province. LHINS need data to support

planning and funding decisions based on local needs. Public health units now have a role in

population level surveillance of chronic diseases and development of prevention and health

promotion programming based on local needs.

Information systems, like the diabetes registry, should be developed in a way that ensures the

data will answer predetermined questions. The registry should include information about

people with co‐morbid diabetes and mental illnesses (including those from diverse

communities) and it should produce local data that can be used for local planning for high risk

populations.


1. Development of the provincial diabetes registry should occur in consultation with the

full range of providers and in liaison with other e‐health initiatives and activities to

ensure appropriate indicators are included.


32


Define risk assessment and screening processes and tools appropriate for the various service

sectors for early identification of people with serious mental illness at risk of developing or who

have diabetes.

Discussion/Context:

Participants identified risk assessment and screening for diabetes to be an important steps in

mental health, diabetes education and primary care settings. Appropriate processes and tools

with supporting guidelines and follow up protocols, need to be identified for each location.

A number of related points were identified by participants: Family physicians are in need of

assessment tools to guide annual health reviews and that are general in nature, covering the

typical problems that each age group is most likely to encounter. WOTCH Community Mental

Health Services has a set of screening questions that are used to identify key risk factors for

diabetes in mental health clients. (See Appendix 4.) A common assessment process and tool is

currently being piloted in mental health programs and there may be an opportunity to include a

short series of diabetes screening questions in that tool.

Screening tools for diabetes exist. Participants asked that a preferred tool(s) be identified for

use in the various service settings so that screening processes are standardized from the start.

Participants raised concern about screening in the absence of readily available resources.

Capacity is required to do the screening and to direct people to appropriate programs and

supports along the prevention‐treatment continuum.


33


1. Define an appropriate risk identification and screening strategy for implementation

across mental health, diabetes and primary care programs.

2. Select a preferred instrument(s) suitable for the various health care settings.

3. Liaise with the Ontario Common Assessment of Need (OCAN) Project Team to

investigate the opportunity for inclusion of diabetes risk assessment questions in the

common assessment tool.

4. Provide organizational policy tools that ensure screening for diabetes is followed up

by appropriate intervention.


34

THEME: SURVEILLANCE & CAPACITY BUILDING Strategy 5:

Engage public health providers in discussions about diabetes and mental illness to understand

their role and contribution to this area.

Discussion/Context:

New programs standards have been released for public health units in Ontario. There are many

public health programs relevant to the issue of mental illness and diabetes such as smoking

cessation and healthy lifestyles. The special challenges faced by people with serious mental

illness in making life style changes require attention.

Health units also have surveillance and program evaluation responsibilities that could include

the surveillance of this co‐morbidity and the evaluation of prevention programs for this

population.


1. Within Ministry of Health and Long‐Term Care ‐ and in partnership with the Ministry

of Health Promotion ‐ engage public health in policy processes addressing the issue of

mental health, mental illness and chronic disease (including diabetes) prevention and

management.

2. Encourage the inclusion of public health partners in local and regional efforts

addressing serious mental illness and diabetes. Promote understanding and

integration of public health’s role into the prevention/treatment continuum.

3. Ensure that public health programs are developed to take into account the particular

barriers to lifestyle change faced by people with serious mental illness.

4. Support mental health and primary health care providers to direct individuals with

serious mental illness to appropriate public health programs that may support them

to improve their physical health.


35

THEME: KNOWLEDGE EXCHANGE Strategy 6:

Ensure evaluation of emerging programs.

Discussion/Context:

There are a small number of emerging programs scattered across the province that address the

needs of people with serious mental illness living with and at risk of diabetes. Although some

have been evaluated, many have not. These programs merit formal evaluation so that their

impact on individual and program outcomes are verified and brought forward systematically

into program and system design. Knowledge exchange about effective programs will be

enhanced by a formal evaluation process.


1. The Ministry of Health and Long‐Term Care (MOHLTC) and the Ministry of Health

Promotion (MHP) should fund the evaluation of the innovative programs focusing on

diabetes/serious mental illness.

2. Evaluation results should be reviewed and integrated in the provincial diabetes

strategy by MOHLTC and MHP.


36


Develop an inventory of available programs, promising practices and general health information

relating to chronic disease prevention and management for people with serious mental illness

at risk of or living with chronic physical conditions.

Discussion/Context:

Participants attended from various initiatives and services throughout the province and had the

benefit of sharing information about programs and resources. Many resources and innovative

programs are operating “under the radar”. They are not well‐known within and across sectors.

A need to develop an inventory of available programs, best/promising practices and

information relevant to diabetes and mental health care became evident.

Participants were not equally informed about existing websites such as Connex Ontario or the

Canadian Diabetes Association website. They recommended linkages be strengthened between

existing information sources rather than creating another stand‐ alone website/directory about

diabetes and serious mental illness.

The challenge is to provide information in a forum accessible to mental health, diabetes

educators and primary health care providers that is searchable by risk factor and geography.


1. Initiate a joint project with representatives from the Ministry of Health and Long‐Term

Care, Canadian Diabetes Association, Connex Ontario, and regional champions/leaders

to develop the resource inventory and coordinated links to promote the exchange of

practices and program information.


37


Identify core competencies to address the co‐morbidity of diabetes and serious mental illness

and educate mental health diabetes education and primary health care providers in those that

are appropriate to their profession, setting and level of care.

Discussion/Context:

Participants from each of the respective sectors recognized the need for collaboration to

identify core competencies and a common knowledge base in order to more effectively serve

individuals at risk. Professionals are bound by limits in their scope of practice but may be

missing opportunities to take an active role in addressing co‐morbid physical and mental health

issues. For example, early identification and monitoring of individuals with mental illness at

high risk of diabetes before they develop the illness is a key factor in reducing the impact of

diabetes in this population. Some basic skills in identifying and monitoring risk factors for

diabetes, as well as tools for doing so, can be put in place in all sectors.


1. Work with programs and services that have been the leaders in an integrated/

collaborative approach to diabetes and mental illness care to identify core

competencies.

2. Develop core competencies for each sector, profession and level of care.

3. Work with regulated health and allied health professional organizations and sector

organizations to clarify scope of practice issues and to develop professional training

resources.


38


Provide training to mental health, diabetes educators and primary care practitioners regarding

the implementation and application of the Ontario CDPM Framework and psychosocial

rehabilitation and recovery principles to address the needs of individuals with serious mental

illness who are living with or at risk of diabetes.

Discussion/Context:

The mental health sector has been working with recovery and psychosocial rehabilitation

principles in the provision of services to people with SMI living in the community. Elements of

this approach are compatible with the Ontario CDPM Framework. Continuity of care, care

integration, collaboration, self management, and use of family/community supports are

elements of both. Some participants recognized the value of the Ontario CDPM Framework but

identified the lack of exposure and cross sectoral education in its application. For many, this

not a familiar framework.

Diabetes educators, primary care practitioners and chronic disease prevention staff in public

health are not familiar with recovery and psychosocial rehabilitation principles. One of the

barriers to physical health care for this population is the mistaken belief that people with SMI

cannot manage their own illnesses, a lack of understanding of the role of mental health workers

as supporters of recovery for these individuals, and the belief that people with mental illness do

not recover. Mental health training should incorporate consumers as educators.


1. The Ministry of Long‐Term Care should expand knowledge of the CDPM framework in

mental health settings to serve as a basis for future activities and collaboration in the

management of diabetes and other chronic illnesses within the mental health

population. As a first step, the resources mental health programs require to


39

incorporate the Ontario CDPM Framework into their practices should be identified.

2. Primary health care, diabetes educators and chronic disease prevention staff should

be educated in psychosocial rehabilitation and recovery principles in order to better

understand how to work with people with mental illnesses. Consumer educators

should be involved in this training.

3. Provincial level mechanisms (e.g., provincial organizations, professional

colleges/associations) should be enlisted to disseminate information and teach health

professionals about the Ontario CDPM Framework and psychosocial rehabilitation and

recovery principles.


40


Support the transfer of knowledge about the prevention and management of serious mental

illness and diabetes into practice, including an understanding of the particular issues faced by

ethnocultural/ethnoracial populations.

Discussion/Context:

There is need to increase the awareness, knowledge and skills of workers in the mental health

sector about chronic diseases. In turn, this will allow them to assist with risk assessment,

identification, referral to treatment and prevention services, system navigation, and provide

supports for adopting healthy lifestyles. Some mental health organizations are able to

incorporate this knowledge through hiring primary care nurse practitioners with expertise in

chronic disease care, where funding allows. Others are doing it through innovative

partnerships. For example, diabetes education programs at Trillium Health Centre and the

Diabetes Education Community Network of East Toronto (DECNET) are working with mental

health case managers in their communities to help them understand diabetes and how to

support their clients.

Mental health workers can also provide support and education to diabetes, primary and

prevention health care providers to remove barriers (e.g., stigma, fear, myths regarding mental

illness, lack of awareness of the context of people’s lives and the broader issues they are facing)

and help them create the supports needed to work with this population effectively.

The transfer of knowledge between sectors can involve informal or formal training, developing

new procedures and policies for care, and providing tools and other resources. Organizations

are rarely funded to provide this kind of knowledge transfer across sectors. MOHLTC and the

LHINs should recognize the importance of this kind of knowledge transfer and support it

appropriately.


41

An understanding of the root causes of the health disparities facing people with serious mental

illnesses, and those facing people from ethnocultural/ethnoracial groups experiencing serious

mental illness is also important, along with the knowledge of what can be done to address

these disparities, in particular through addressing the social determinants of health. An

understanding of cultural differences in approaches to mental illness is also needed.

In addition, for change to occur in health care delivery through the implementation of best

practices and standards, support for learning and implementation is critical. Family health

teams are being supported by the QIIP in this regard; similar support processes are being

developed in public health. The needs of family physicians outside of family health teams and

diabetes educators also need to be addressed through existing or new mechanisms.

The mental health sector does not have an obvious mechanism to support knowledge exchange

related to specific practices, although the Ontario Mental Health and Addiction Knowledge

Exchange Network (OMHAKEN )6 provides a possible direction for development of such a

mechanism.

There are innovative programs in place that may serve as examples of emerging best practice in

the assessment and management of diabetes care for people with serious mental illnesses.

These programs are exploring how collaborative care is improving the health outcomes of

people with serious mental illness at risk of and living with diabetes. Participants noted that

while there have been informal opportunities to learn about these programs, formal processes

need to be funded. They have developed useful tools, procedures and practice policies and in

some cases they also have evaluation findings that are not readily available to others (for

6Information about OMHAKEN is available at https://www.ehealthontario.ca/portal/server.pt?open=512&objID=1401&PageID=0&cached=true&mode=2&userID=11862.


42

example, the evaluation of the Primary Health Care Transition Fund project in London Ontario

that integrated diabetes, primary care and mental health care7). Such resources and findings

need to be widely disseminated.


1. Develop training opportunities to enhance knowledge exchange and collaboration

between mental health, primary care, diabetes education and chronic disease

prevention settings and to identify common tools/practices.

2. Develop training opportunities for service providers/policy makers/ etc to learn about

the issues facing people with serious mental illnesses from ethnocultural/ethnoracial

communities and what needs to be in place to overcome them.

3. Fund formal mechanisms to support the transfer of knowledge into practice related to

co‐morbid serious mental illness and chronic physical conditions.

4. Identify mechanisms for sharing of tools, procedures and practice policies across

service sectors, province‐wide.

5. Planning efforts should identify local needs and opportunities to support knowledge

exchange in this area.

7 See “Diabetes Screening and Risk Management (DSM) in a High Risk Mental Health Population – Pilot Project” , presentation at the 2007 Shared Mental Health Care Conference, Quebec City, June 2007, http://www.google.ca/search?hl=en&q=Diabetes+screening+and+risk+management+in+a+high+risk+population&btnG=Google+Search&meta=cr%3DcountryCA&aq=f&oq=


43

THEME: CAPACITY BUILDING Strategy 11:

Create a regional lead to support mental health, primary care and diabetes partnerships to

collaborate efficiently and effectively.

Discussion/Context:

A lead/champion role should be developed in each LHIN to expand the capacity for integrated

physical and mental health care for this population. Lead organizations would work with local

practitioners/partners with the goals of increasing awareness and understanding of the

diabetes/serious mental illness issue, building/enhancing cross sectoral linkages, ensuring

development of collaborative care approaches within local resources and increasing access and

capacity to care.

Participants emphasized that starting points will differ in local communities and where

opportunities currently exist they should be leveraged to full advantage. In some areas, there

are programs/organizations that are well suited to take on a lead role, being identified as a

centre of excellence, because they are already providing innovative and integrated models of

mental and physical health care. CMHA Windsor‐Essex’s City Centre Health Centre is one such

example. WOTCH Community Mental Health Services’ diabetes clinic is another.

This role could be implemented through LHIN processes or alternatively through a dedicated

FTE position (similar to the concurrent disorder positions in the mental health and addictions

sector).

Opportunities, Action Steps :

1. Local Health Integration Network planning should consider the need for care capacity

to meet the needs of people with mental illness living with or at risk of diabetes.

Existing opportunities for leadership should be identified and pursued.


44


Improve funding models to promote collaborative/ integrated care.

Discussion/Context:

Participants discussed the limits of current funding models and the barriers created when

providing care to individuals presenting with complex health care needs as a result of serious

mental illnesses and diabetes. Mental health programs and most primary health care are

funded differently making it difficult to entertain joint planning or service provision activities.

Interdisciplinary health care teams and specialized diabetes programs such as those found in

community health centres and family health teams are promising but available to a limited

number of people.

Individuals with serious mental illness and chronic health conditions are often not well

connected to primary health care; the fee for service structure and limited access to family

physicians further impacts access to care. Models and incentives that enhance access are

required to address these complexities.

Some mental health programs are beyond capacity and would require additional funding to

incorporate chronic disease prevention and management. Mental health programs may be well

positioned to offer primary health care services to clients but may have difficulty accessing

funding to do so.

Diabetes education programs are not generally funded to partner with mental health programs

to offer adequate education and support to this complex population. The Trillium Health

Centre’s partnership with local mental health organizations has been developed without

funding. The Diabetes Education Network of East Toronto, on the other hand, has been funded

to do assertive community outreach to high risk populations not accessing services, including

those with mental illnesses.


45

Flexibility in funding and mandate is required to take on the challenges of a more integrated

health care approach.


1. Funding models and incentives that enhance collaboration between primary, diabetes

and mental health care organizations to provide appropriate care for people with complex

health care needs are needed. These models and incentives need to be linked across

funders (The Ministry of Health and Long‐Term Care funds most primary care while the

Local Health Integration Networks fund community mental health, community health

centres and diabetes education programs).


46


Encourage collaborative partnerships between mental health peer support and social

recreational programs, public health, diabetes education and other community based programs

to address healthy living, prevention, education and self‐management.

Discussion/Context:

One participant cited research demonstrating that a year of support is required to sustain

behavioural changes relevant to chronic diseases. Others concurred that, with current emphasis

being to treat people quickly, this undermines the ability to provide longer‐term support so that

people successfully change their personal behaviour.

Mental health providers noted that there is a significant opportunity in social recreation8 and

peer support programs9 to provide longer‐term support to people with mental illness and

diabetes. These programs are also ideal places to deliver the messages about the risks of

diabetes and mental illness proactively before the disease develops and to offer programming

to support prevention. The participation of other partners to deliver programs in a group

format and develop skills fitting in the self‐management module of the Ontario CDPM

Framework is welcome. Many types of supportive programming like cooking classes, access to

a dietitian and so on may be delivered on a group basis.

8 An example of one such initiative is “Minding Our Bodies”, a MHP‐funded initiative of CMHA Ontario to increase the capacity of mental health organizations to promote active living in the population of people living with serious mental illnesses. See www.mindingourbodies.ca. 9 Information on peer support programs is available from the Ontario Peer Development Initiative (OPDI). OPDI is the provincial organization of mental health peer support organizations and consumer/survivor initiatives. http://www.opdi.org/images/uploads/OPDI_Brochure.pdf.


47


1. Encourage partnerships between mental health social recreation and peer support,

public health and diabetes education to offer preventative and self‐management

programming that addresses risk factors relating to diabetes for people with serious

mental illness.

2. Fund peer and social recreational mental health programs to offer long‐term

preventative/self‐management programming relating to co‐morbid conditions like

diabetes.


48


Create system navigation capacity to assist people with serious mental illnesses living with or at

risk of diabetes to access primary health and mental health care.

Discussion/Context:

Participants identified the system navigation function as a promising approach to assisting

individuals to access the care they need in a timely way through accompanying them to

appointments, advocating on their behalf, increasing individual and provider knowledge and

awareness. In some health care systems, this function has been implemented through the

funding of system navigator positions. In others, the function has been added as a specific

responsibility for case managers, discharge planners, social workers. There needs to be a

discussion as to how and where to develop this capacity in Ontario as it has relevance to many

special populations.


1. Local Health Integration Networks should examine the need for system navigation

capacity in their local systems.


49


Increase capacity to deliver more team‐based primary care.

Discussion/Context:

While increasing efficiencies are being achieved in the delivery of primary health care (and the

plan is for more to be achieved in shifting the system away from an acute illness approach),

there are still many shortages of primary health care professionals and underserviced areas

across the province. Focused attention on high risk populations means that more people will be

diagnosed with co‐morbid conditions and their care will necessarily be more intensive.

Increased capacity via team based approaches is supported as best practice.


1. Increase funding to develop additional capacity in primary health care, particularly

team‐based models of care.


50


Increase the efficiency of primary health care services to better address co‐morbid mental

illness and diabetes

Discussion/Context:

Participants cited many needs, barriers and opportunities to the expansion of primary health

care for people who have mental illnesses. It was noted that nurse practitioners in mental

health settings could do more diabetes care with medical directives permitting them to do

needle pricks and other procedures for which they are trained but not currently permitted to

do without a medical directive. Others raised the point that family doctors outside of family

health teams and community health centres are not paid for their time consulting with

specialists and likewise, some specialists, like endocrinologists are not paid to provide

consultation to other physicians.

Given the limits in capacity to deal with health care needs, efficient use of resources such as

nurse practitioners, telemedicine, specialists, pharmacists, and allied health professionals in

more creative ways is required. Changes in funding, use of tools such as medical directives,

refinement of scope of practice regulations, and specialist consultation to include indirect

consultation would allow an expansion of capacity within existing primary health care services.


1. The Ministry of Health and Long‐Term Care should continue to take appropriate

actions to increase the efficiency of primary health care approaches through

refinement of funding mechanisms, incentives, scope of practice regulations, specialist

consultation and telemedicine.


51


Reduce unintended disincentives in current funding schemes and replace with positive

incentives for family physicians to assume the care of people with co‐morbid diabetes and

serious mental illness.

Discussion/Context:

Incentives are required to ensure that family physicians take on complex patients such as those

having serious mental illness and diabetes. OHIP funding has created many unintended

disincentives such as time limits on appointments with primary care physicians; these leave

little time to address the complex care needs of this group, highlighting the importance of

interdisciplinary collaboration and models of care. Also noted by some participants is the cap

on the number of complex clients for which physicians in funded in capitation models of

funding, another disincentive to accepting patients with complex conditions.


1. The Ministry of Health and Long‐Term Care should assess current funding schemes for

unintended disincentives to family physicians taking on patients with complex

conditions.

2. Further incentives to physicians for providing care for patients with serious mental

illness and diabetes should be explored.


52

THEME: EQUITABLE ACCESS Strategy 18:

Increase access to alternative methods of care, in particular those that are accepted as effective

in cultural communities.

Discussion/Context:

Many people are choosing to use services offered by alternative and holistic health care

practitioners. Traditionally, mainstream medicine has not looked favourably upon these types

of services and use was not encouraged. However, there has been recent acknowledgement

that some alternative approaches have merits and prove to be effective.

To be truly culturally appropriate we need to be able to offer people opportunities to access

modes of care that have worked in their communities/cultures for centuries (for example,

aboriginal healing practices, traditional Chinese medicine, yoga etc.). These opportunities need

to be accessible through the publicly funded system.


1. Expand our understanding of the validity and efficacy of alternative models of care.

2. Look for concrete opportunities to promote knowledge exchange between traditional

and alternative health care providers.

3. Allocate resources to make these alternatives more accessible.

4. Increase awareness and understanding of relevant alternative and holistic health care

options when working with people from diverse ethnocultural/ethnoracial

communities.


53

THEME: EQUITABLE ACCESS Strategy 19:

Ensure that best practices for treatment and support of people with diabetes and serious

mental illness are culturally sensitive, attentive to health disparities in

ethnocultural/ethnoracial populations and integrate care for these populations into

mainstream organizations.

Discussion/Context:

There are many health disparities in the population of people living with serious mental

illnesses relative to the general population. At the level of responding to individuals in needs,

such disparities act as significant barriers to the person receiving effective care. At the local

system level, disparities may be perpetuated, ignored or exacerbated if sufficient

understanding and/or attention is not paid to needs of unique populations.

Many ethnocultural/ethnoracial groups are at high risk for diabetes. (Health Council of Canada

2007) Ethnocultural/ethnoracial diversity presents a major challenge in the health care system

as the disparities experienced by these groups are the most pronounced due to lack of access

to not only culturally appropriate care, but also the inherent discriminations embedded in our

systems (based on race, culture, sexual orientation, etc). Culturally specific supports are

required along with a deeper understanding of the root causes of these disparities and what

can be done to address them at the individual, organizational and systemic levels (look at social

determinants of health).

Across Boundaries is a mental health organization in Toronto that responds to the needs of

diverse ethnocultural/ethnoracial groups, and also provides outreach education to mainstream

organizations. The Executive Director of Across Boundaries participated in the Think Tank and in

a follow‐up conversation provided more detail. She identified a need to develop ways of

documenting the needs of ethnocultural/ethnoracial populations so that proper supports and


54

funding can be ascertained. Compared to the US or UK, Canada doesn’t have a culture of

capturing necessary data. Therefore we don’t have the ability to speak to best or better

practices specifically for these communities. Often efforts to create equitable access stop at

creating a small add on service or one‐time projects that are not sustainable. We also need to

think of the experiences of the community in the global context and its impact on health and

mental health and work from a position of critical analysis (be it anti‐oppressive, social justice

etc.) Finally we need to find ways of ensuring mainstream organizations are equipped with the

skills to serve all communities appropriately rather than this being the task of ethno‐specific

agencies only.

Across Boundaries has indicated an interest to assume a provincial role in developing a centre

of excellence to address health disparities relating to ethnoracial communities.


1. Work with ethnoculturally/ethnoracially based mental health and primary care

programs to identify key elements that must be considered in the development of

treatment and supports for people of specific ethnocultural groups that have both

diabetes and serious mental illness.

2. Ensure that existing ethnocultural/ethnoracial programs are well documented and

included in knowledge exchange forums.

3. The needs of diverse communities need to be included in mental health/diabetes

initiatives.

4. Create a virtual centre of excellence to address health disparities for ethnoracial

communities.


55

THEME: PREVENTION MESSAGES Strategy 20:

Include mental illness as a risk factor and people with serious mental illness as a high risk

population in diabetes prevention messaging.

Discussion/Context:

Participants noted that the Ministry of Health Promotion is undertaking a social marketing

campaign on diabetes. They suggested that this campaign include messages aimed at people at

risk for mental illness and diabetes. If possible, the campaign should have some approaches

designed to reach people who do not usually access services.

In general, the high risk of diabetes in the population of people living with serious mental

illnesses should be included in any messaging related to diabetes prevention.


1. The Ministry of Health Promotion should expand its messaging on diabetes prevention

to include diabetes and mental illness.

2. In any social marketing campaign, the methods used should attempt to reach people

who do not usually access health care services, as well as people with serious mental

illnesses, their friends, families and the people who work with them.


56

Appendix 1 –Think Tank Participants

Vani Jain

Manager, Policy & Community Relations

Schizophrenia Society of Ontario

Tiffany Barker

Senior Policy Adviser Ministry of Health and Long‐Term Care, Chronic Disease Unit

Annette Bradfield

Primary Health Care Nurse Practitioner

Canadian Mental Health Association (CMHA), Ottawa

Sheila Braidek Executive Director Regent Park Community Health Centre

Gabriella Sim Canadian Diabetes Association, Ontario

Joan Canavan

Team Lead, Acute Services and Chronic Disease Unit

Ministry of Health and Long‐Term Care

Jennifer Clement Nurse Practitioner Sudbury District Nurse Practitioner Clinic

Patricia Dwyer Planning and Integration Lead South West LHIN

Anne Ferguson Lead Physician CMHA Toronto

Anne Finigan Advanced Practice Nurse Regional Mental Health London

Dr. Rohan Ganguli Executive Vice President Centre for Addiction and Mental Health

Carol Gold Senior Policy Advisor Ministry of Health and Long‐Term Care

Michelle Gold Senior Director, Policy and Programs CMHA, Ontario

Angelika Gollnow Senior Integration Consultant Toronto Central LHIN

Susan Griffis Chief Executive Officer Northern Diabetes Health Network

Betty Harvey

CNS/Nurse Practitioner, SJHC Primary Care Diabetes Support Program

SJHC Family Medical Centre, London

Pam Hines Chief Executive Officer CMHA, Windsor‐Essex County

Anne Marie Hoelscher Mental Health Worker Parry Sound Family Health Team

Stacey Horodezny Clinical Lead, Diabetes Program Trillium Health Centre, Etobicoke

Michelle Hurtubise Executive Director London InterCommunity Health Centre

Jan Kasperski CEO Ontario College of Family Physicians

Helen Kroeker Nurse Practitioner Niagara Health Systems‐New Port Centre

Michele Mach Practice Facilitator Quality Improvement & Innovation Partnership

Clark MacFarlane Director of Operations CMHA, Cochrane‐Temiskaming

Kavita Mehta Executive Director South East Toronto Family Health Team

Barbara Neuwelt Policy Analyst CMHA, Ontario

Grahame Owen Physician Niagara region

Christine Sansom Director of Clinical Services WOTCH Community Mental Health Services, London

Aseefa Sarang Executive Director Across Boundaries, Toronto

Sandy Stockman Executive Director Grey Bruce Community Health Corporation

Kirsti Tasala Project Lead, Diabetes Strategy North West LHIN


57

Appendix 2 – Background Readings

The following readings were sent to participants ahead of time as background to the Think Tank.

The Relationship between Mental Health, Mental Illness and Chronic Physical Conditions. Canadian Mental Health Association ‐ Ontario. (2008, December). http://www.ontario.cmha.ca/backgrounders.asp?cID=25922

Diagnostic Overshadowing: Worse Physical Health Care for People with Mental Illness, Simon Jones, Louise Howard & Graham Thornicroft. Editorial published in Acta Psychiatr Scand 2008: 118: 169–171 Diabetes and Mental Illness: The Mirror Has Two Faces. Danielle Pacaud & Robin Conway. Editorial published in Canadian Diabetes, Spring 2008, Vol. 21, No.1. “ADA: Medical Monitoring Guidelines for Antipsychotics Largely Unheeded,” (June 10,2008). News report from the 2008 American Diabetes Association annual meeting, reported on MedPage Today, http://www.medpagetoday.com/MeetingCoverage/ADA/9746. Canadian Diabetes Association Position Paper: Antipsychotic Medications and Associated Risk of Weight Gain and Diabetes. Vincent Woo, Stewart B. Harris, Robyn L. Houlden, on behalf of the Clinical & Scientific Section, Canadian Diabetes Association. Published in the Canadian Journal of Diabetes 2005; 29(2):111‐112.


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Appendix 3 – Case Study: Story of Robin

You will be in a group of 7 or 8 people who come from a variety of sectors: primary care,

diabetes, and mental health. The group will read the story of Robin and discuss the questions

below. If you find all the detail in the story useful, use it. If not, just use the basic story:

Basic Story:

- 38 year old male or female with bipolar disorder, fibromyalgia and a history of

alcohol/pain medication abuse as well as a history of suicide attempts

- has been stable for the last few years other than 1 admission last year after going off

psychiatric medications

- history of going off psychiatric medications because they cause weight gain, which leads

to psychiatric crises.

- overweight, high blood pressure, urinary incontinence

- has a psychiatrist and used to have a family doctor but uses walk‐ins now

- recently diagnosed with diabetes

Detailed Story:

Robin is 38 years old and has been diagnosed with Bipolar Disorder, Fibromyalgia and has a

history of substance abuse (alcohol and more recently pain medications, prescribed after a car

accident). Robin has been dealing with Bipolar Illness since the age of 18 years and has had

more than 11 different admissions to hospital for suicide attempts. Robin has been very stable

over the last few years with only one admission last year. Decide as a group whether Robin is

from a particular cultural background.

Decide as a group whether Robin is homeless or housed. If housed, Robin has been on ODSP

(Ontario Disability Support Program) since 2001 and has been living independently in own

apartment since June 1, 2004. Prior to this Robin lived in a supported living environment for 2

years to develop life skills and coping skills to live alone after a long admission at the psychiatric

hospital.


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Robin has many medical problems which need attention on a regular basis ‐ overweight

smokes, has high blood pressure and urinary incontinence. Robin is currently taking Seroquel,

Epival, Ativan, Cogentin and Diovan‐HCT. Robin lost 40 lbs over the last year after going off of

medications but became ill and had a brief hospitalization for psychiatric reasons.

Robin had a family doctor but the family doctor retired a year ago and Robin has been using a

walk‐in. Robin has recently been diagnosed with diabetes.

Robin’s psychiatrist reports that numerous medications were tried to stabilize Robin’s mood

and Robin responded well to Epival and was able to work at a part‐time job for more than 4 yrs

as a personal support worker at a nursing home. Unfortunately, the Epival caused a large

weight gain, making Robin reluctant to take it. When Robin stops medications, Robin’s mood

deteriorates quickly. Robin becomes depressed, isolates, sleeps all day and isn’t interested in

social activities or conversation and misses appointments. Robin often drinks coffee and

smokes, skipping meals and “won’t” follow through with activities of daily living.

Imagine Robin coming to you for service at:

a) Your mental health agency, or

b) Your Diabetes Education Centre, or

c) Your primary care setting (FHT, CHC or family practice).

Answer the questions from the perspective of your organization. In answering the questions,

keep in mind how much of the above info you are likely to know, what you need to know and

what you’ll need to do to get it.

1. What can my organization do for Robin?

2. What can’t my organization do for Robin but I wish we could?

3. What do I wish was available to Robin and/or myself/my organization/my sector to

better address this need?


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Appendix 4 – Risk Assessment Questions

WOTCH Community Mental Health Services in London Ontario has developed a set of questions

to be asked as part of intake that assess an individual’s risk for diabetes. These questions are

routinely asked of all clients by the intake workers, who are not necessarily trained in physical

health care. The answers to the questions are reviewed by a nurse. Based on the answers to

these questions, nurses can assess whether clients should be screened for diabetes.

WOTCH clinical director, Christine Sansom, emphasizes that even if an agency does not have a

diabetes clinic, integrating these questions into regular intake and assessment can help staff

assess the level of risk of diabetes and refer appropriately.

1. Are you over 40?

2. Does your mother, father or siblings have diabetes?

3. Are you on, or have you ever taken Clozaril, Zyprexa, Seroquel or Risperdal?

4. Do you exercise less than 30 min/day?

5. Do you smoke?

6. Have you ever given birth to an infant weighing more than 9 lbs?

7. Do you feel thirsty and hungry all the time?

8. Do you have to get up and urinate more than once during the night?

Other risk factors that can be assessed on sight:

Are they overweight?

Do they tend to carry fat around the tummy area?

Do they have a diagnosis of Schizophrenia?


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References Cited

Bazelon Center for Mental Health Law. (2004). Get It Together: How to Integrate Physical and Mental Health Care for People with Serious Mental Illness. Washington: Bazelon Center for Mental Health Law.

Canadian Mental Health Association ‐ Ontario. (2008, August). Recommendations for Preventing and Managing Co‐Existing Chronic Physical Conditions and Mental Illnesses. (Policy Paper) Retrieved April 5, 2009, from: http://www.ontario.cmha.ca/admin_ver2/maps/cmha_chronic_disease_policy_paper.pdf.

Canadian Mental Health Association ‐ Ontario. (2008, December). The Relationship between Mental Health, Mental Illness and Chronic Physical Conditions. (Backgrounder) Retrieved April 2, 2009, from: http://www.ontario.cmha.ca/admin_ver2/maps/cmha_chronic_disease_backgrounder.pdf.

Canadian Mental Health Association ‐ Ontario. (2008, August). What is the Fit Between Mental Health, Mental Illness and Ontario's Approach to Chronic Disease Prevention and Management? ( Discussion Paper) Retrieved April 5, 2009, from: http://www.ontario.cmha.ca/admin_ver2/maps/cmha_chronic_disease_discussion_paper.pdf.

Health Council of Canada. (2007, March). Why Health Care Renewal Matters: Lessons from Diabetes. Retrieved April 26, 2009, from: http://www.healthcouncilcanada.ca/docs/rpts/2007/HCC_DiabetesRpt.pdf.

Lee, J. (2006, May 30). More Prevention=More Cure. Ontario's Chronic Disease Prevention and Management Framework. Retrieved April 5, 2009, from: http://www.toronto.ca/health/resources/tcpc/pdf/conference_lee.pdf.

Mental Health Commission of Canada. (2009, January). Toward Recovery & Well‐Being, A Framework for a Mental Health Strategy for Canada. Draft. Retrieved April 27, 2009, from: http://www.mentalhealthcommission.ca/SiteCollectionDocuments/Key_Documents/en/2009/Mental_Health_ENG.pdf.

Ministry of Health and Long‐Term Care. (2009, March 24). Information about the provincial plans for a mental health and addiction strategy was retrieved April 27, 2009, from: http://www.health.gov.on.ca/english/public/program/mentalhealth/minister_advisgroup/minister_advisgroup.html.


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Ministry of Health and Long‐Term Care. (2008, July 22). Diabetes Strategy: Backgrounder. Retrieved April 25, 2009, from: http://www.health.gov.on.ca/english/media/news_releases/archives/nr_08/jul/diabetes_strategy_bg_final_20080722.pdf.

Ministry of Health and Long‐Term Care. (2007, February 6). McGuinty Government Strengthening Diabetes Care. (News Release). Retrieved April 25, 2009, from: http://www.health.gov.on.ca/english/media/news_releases/archives/nr_07/feb/diabetes_black_creek_nr_07_20070205.html.

Ministry of Health and Long‐Term Care. (2007, February 6). McGuinty Government Strengthening Diabetes Care: Backgrounder. Retrieved April 5, 2009, from: http://www.health.gov.on.ca/english/media/news_releases/archives/nr_07/feb/diabetes_black_creek_bg_02_20070205.pdf.

Ministry of Health and Long‐Term Care. (2008, July 22). Ontario Launches Diabetes Strategy: $741 Million Plan Will Make Patients Partners in Care. (News Release). Retrieved April 5, 2009, from: http://www.health.gov.on.ca/english/media/news_releases/archives/nr_08/jul/nr_20080722.html.

Ministry of Health and Long‐Term Care. (2009, March 30). Provincial Approach to Chronic Disease Prevention and Management. Retrieved April 15, 2009, from: http://www.ontario.cmha.ca/admin_ver2/maps/provincial_approach_to_cdpm.pdf.

Ontario Health Promotion E‐Bulletin. (2009, April 3) The Quality Improvement and Innovation Partnership (QIIP) Learning Collaborative ‐ Building a Learning Community to Improve Primary Healthcare. Feature Article. Retrieved April 25, 2009, from: http://www.ohpe.ca/index.php?option=com_content&task=view&id=10430&Itemid=78.

Trainor, J., Pomeroy, E., & Pape, B. (2004). A Framework for Support. Third Edition. Toronto: Canadian Mental Health Association, National Office. Retrieved April 5, 2009, from: http://cmha.ca/data/1/rec_docs/120_Framework3rdEd_Eng.pdf.

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