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Exploring Mental Health- or Addictions-Related Use of Emergency Departments by Racialized Populations in Ontario: Highlights from the March 26, 2013 Think Tank Event

Community of Interest for Racialized Populations and Mental Health and Addictions Page 1 http://eenet.ca/the-racialized-populations-and-mental-health-and-addictions-community-of-interest/

Community of Interest for Racialized Populations and Mental Health & Addictionsinvites you to a think tank exploring:

Community of Interest (COI) for Racialized Populations and Mental Health and Addictions

Think Tank: Exploring Mental Health- or Addictions-Related Emergency Department Use by Racialized

Populations in Ontario: Highlights from the March 26, 2013 Event

September 15, 2014Toronto, Ontario

Prepared for the COI for Racialized Populations and Mental Health and Addictions by:

Emily WongSheela Subramanian (Canadian Mental Health Association, Ontario)

Angela Yip (Evidence Exchange Network, CAMH)Rossana Coriandoli (Evidence Exchange Network, CAMH)

Exploring Mental Health/Addictions Use of Emergency Departments by Racialized Populations in Ontario


COI Steering Committee Organizations (2012-2014):

With support from:

http://www.eenet.ca/

http://www.addictionsandmentalhealthontario.ca/

http://toronto.cmha.ca/

http://ontario.cmha.ca/

http://www.camh.ca/en/hospital/Pages/home.aspx

http://www.ryerson.ca/omh/

http://www.opdi.org/

http://www.rainbowhealthontario.ca/

http://www.ryerson.ca/index.html

http://www.wellesleyinstitute.com/

http://www.whiwh.com/

http://workingforchange.ca/

http://www.yorku.ca/web/index.htm



Contents

Acknowledgements ....................................................................................................................................... 4

Executive Summary ....................................................................................................................................... 5

Introduction .................................................................................................................................................. 8

About the CoI ................................................................................................................................................ 9

About the Think Tank .................................................................................................................................. 10

Introduction and Findings from COI Literature Review and Sector Scan ................................................... 13

Understanding Emergency Department Use by Racialized Populations .................................................... 15

Findings from COI Consultations with Service Providers and People with Lived Experience ..................... 17

Strategies for Implementing Effective Police-Emergency Department Protocols in Ontario .................... 19

Peer Support in the ED: Value, Opportunities and Challenges ................................................................... 21

Mental Health Shared Care Models: A Response to ED Usage and Racialized Women ............................. 22

Keynote Address ......................................................................................................................................... 25

Participant Discussion ................................................................................................................................. 29

I. Looking beyond the health sector ....................................................................................................... 29

II. Provincial health system ..................................................................................................................... 30

III. Hospital and community collaboration.............................................................................................. 31

IV. Emergency Department dynamics..................................................................................................... 33

Promising Practices ..................................................................................................................................... 34

Shared Care Model ................................................................................................................................. 34

CATCH-ED Pilot Project ........................................................................................................................... 34

Hong Fook Connecting Health Nurse Practitioner-Led Clinic ................................................................. 35

Using Peer Support in Emergency Departments .................................................................................... 35

Concluding Remarks.................................................................................................................................... 36

References .................................................................................................................................................. 37



Acknowledgements The Community of Interest (COI) for Racialized Populations and Mental Health and Addictions is indebted to Bob Gardner (1948-2014), a committed COI Steering Committee member. This report, and indeed all of our work, is informed by Bob’s leadership, strategic thinking and vision for health equity in Ontario. He will be terribly missed.

The COI would like to acknowledge the following individuals for their contributions to our work: Anne Bowlby (Ministry of Health and Long-Term Care), Rossana Coriandoli (Centre for Addiction and Mental Health (CAMH), Debbie Ezard (St. Michael’s Hospital), Frank Fournier (St. Michael’s Hospital), Elizabeth Fox (Canadian Mental Health Association (CMHA), Ontario), Sepali Guruge (Ryerson University), Ian Messam (Across Boundaries), Sharon Navarro (Toronto Central Local Health Integration Network (LHIN)), Camille Orridge (Toronto Central LHIN), Zarsanga Popal (CMHA Ontario), Nazilla Khanlou and Meghan Saari (York University), Barbara Steep (CAMH), Vicky Stergiopoulos (St. Michael’s Hospital), Wangari Esther Tharao (Women’s Health in Women’s Hands Community Health Centre), Andrew Tuck (CAMH) and Sajedeh Zahraei (CAMH).

Special thanks to the participants of our consultations with people with lived experience of racialization and mental health issues and community-based service providers for sharing time, knowledge and expertise with our team.

We also wish to acknowledge the support of the live and virtual participants and note taking team from our March 2013 Think Tank event whose contributions are reflected throughout this report.

2013-2014 COI Steering Committee members include Branka Agic (CAMH), Raymond Cheng (Ontario Peer Development Initiative), Deqa Farah (Community Resource Connections of Toronto), Dawnmarie Harriott (Working for Change), Bob Gardner (Wellesley Institute), Monika Goodluck (Women’s Health in Women’s Hands Community Health Centre), Sepali Guruge (Ryerson University), Karen O’Connor (CMHA Toronto), Aseefa Sarang (Across Boundaries), and Sheela Subramanian (CMHA Ontario, COI Lead). The 2012-2013 COI Steering Committee also included Uppala Chandrasekera (CMHA Ontario), Carolina Berinstein (CMHA, Toronto), Nazilla Khanlou (York University) and Mary Susan Thomson (Ontario Multicultural Health Applied Research Network), Notisha Massaquoi (Women’s Health in Women’s Hands Community Health Centre), and Devan Nambiar (Rainbow Health Ontario). Knowledge exchange support was provided by three dedicated EENet Knowledge Brokers based at CAMH: Julia Greenbaum, Angela Martella and Angela Yip.

This work would not have been possible without project management support from the invaluable Jenna Hitchcox and Florence Heung.

This report was compiled by Emily Wong, Sheela Subramanian, Angela Yip and Rossana Coriandoli.

The graphic recordings used in this report were created live during the COI’s March 2013 Think Tank event by Patricia Kambitsch of Playthink.

http://www.playthinking.wordpress.org/



Executive Summary This report explores the use of mental health- and/or addictions-related (MH&A) emergency departments (EDs) by racialized populations in Ontario. It presents key findings from the work of the Community of Interest (COI) for Racialized Populations and Mental Health and Addictions, an Ontario-based partnership.

The COI chose to explore the topic of ED use by racialized populations related to MH&A issues for the following reasons:

• The Ontario Ministry of Health and Long-Term Care and Local Health Integration Networks (LHINs) have prioritized the reduction of avoidable ED wait times, including a focus on mental health- and/or addictions-related and repeated visits;

• While we do not have full evidence, it would appear that EDs may be a key entry point to the mental health and/or addictions system for racialized populations. Crucial issues include whether this is the most appropriate entry point, how well the mental health and/or addictions needs of racialized populations are being met by primary care and other providers, and whether acute, primary and community-based services are effectively integrated;

• Important innovations are underway that address avoidable mental health- and/or addictions-related ED use that can be shared and built on. A question here will be how these innovations have taken account of and affect racialized populations;

• Dialogue and collaboration in this area could be improved across the range of stakeholder groups involved (mental health and addictions stakeholders, policing, primary care, community service providers and others).

A range of activities contributed to the development of this report: • Literature review • Provincial survey to identify service provider concerns and promising practices related to ED use

by racialized populations • Consultations with racialized people with lived experience of mental health issues (PWLE) • Consultations with community mental health workers who work with racialized PWLE • Think Tank event with over 90 participants and presenters

Key findings from these activities include:

• In our consultations with racialized people with lived experience, we heard that individuals experience marginalization both as people with MH&A issues and as racialized individuals. For these individuals, ED usage increased when there were changes to the social determinants of their health, such as a housing or employment situation. Although some ED visits were made by choice, others were made involuntarily, accompanied by service providers or the police. Reasons for ED visits ranged from the lack of access to primary or psychiatric care to the need for a prescription renewal. Individuals experienced stigma, language barriers, lack of communication, and the use of force both outside and inside the ED.



Factors that influence the use of EDs by racialized individuals with MH&A issues include the social determinants of health (social factors that can affect a person’s health), the provincial health system, the relationship between hospitals and community organizations, and the ED itself. In the following order, guest speakers at the think tank event spoke of these four main themes and provided some insights for solving this complex issue:

• Introduction, Goals, and Findings from COI Literature Review and Environmental Scan Sheela Subramanian, Policy Analyst, Canadian Mental Health Association, Ontario Aseefa Sarang, Executive Director, Across Boundaries

• Understanding Emergency Department Use by Racialized Populations Anne Bowlby, Manager of Mental Health and Addictions Unit, MOHLTC

• Findings from COI Consultations with Service Providers and People with Lived Experience Deqa Farah, Community Mental Health Promoter, Community Resource Connections of Toronto

• Strategies for Implementing Effective Police-Emergency Department Protocols Uppala Chandrasekera, Planning and Policy Analyst, Canadian Mental Health Association, Ontario, and Policy Advisor, Provincial Human Services and Justice Coordinating Committee (HSJCC)

• Peer Support in the ED: Value, Opportunities and Challenges Frank Fournier, Community Support Worker, St. Michael’s Hospital

• Mental Health Shared Care Models: A Response to ED Usage and Racialized Women Notisha Massaquoi, Executive Director, Women’s Health in Women’s Hands Community Health Centre

• Keynote Address Camille Orridge, CEO, Toronto Central LHIN

Participants also separated into groups according to four themes: beyond the health sector; the provincial health system; hospital–community collaboration; and ED dynamics. Some of the main points that arose include: Beyond the Health Sector It is important to look beyond the health sector due to the social determinants of health to better understand how, why and when racialized PWLE use the ED. A number of community and social service supports can be leveraged to help prevent avoidable ED visits for racialized population. There are promising practices for promoting collaboration and coordination between the broader community and social services sector and the health system Provincial Health System Provincial policy, programs and health system planning inform how, when and why racialized populations use the ED for MH&A reasons, both upstream and downstream from the ED itself. At the overall health system level there is a need for better ways to collect and use socio-demographic data to ensure that policy planning considers the needs of different populations. For example, there need to be more accessible formats for data collection, such as the use of standardized questions, which also can be



used for hospital planning purposes. At the LHIN level, initiatives such as Community Health Links, use of the Health Equity Impact Assessment tool, and funding for peer support positions can play a significant role in improving coordination and collaboration. Hospital–Community Collaboration Participants identified that a number of key issues impact on hospital and community collaboration within the mental health and/or addictions system including that policing services are not always at the table in terms of planning and decision-making, but play such a key role. There are promising practices for hospital-community collaborations that address emergency department use for people living with mental health and addictions issues, and specifically for racialized communities, such as the Mental Health Commission of Canada’s At Home/Chez Soi project.

Emergency Department Dynamics Hospital emergency department dynamics themselves contribute to the experiences of racialized populations with MH&A issues, such as the effectiveness of patient/staff communication, degree of access to and collaboration with community services, and tracking of individual pathways to and beyond the ED. It was identified that many contributing factors can improve services and continuity of care for racialized or other marginalized populations, including strong institutional leadership and improving organizational capacity and resources to prioritize health equity and the needs of marginalized populations. This report concludes with briefs on promising practices in Ontario and concluding remarks.

http://www.health.gov.on.ca/en/pro/programs/transformation/community.aspx

http://www.health.gov.on.ca/en/pro/programs/heia/



The COI for Racialized Populations and Mental Health and Addictions follows the Ontario Human Rights Commission in using the terms “racialized individual” or “racialized population” rather than “racial minority”, “visible minority” or “non-White” to refer to individuals or groups that experience racism or racialization. It is important to note that racialized populations are not homogenous and experiences at the ED may vary significantly by individual and group.

Introduction There is considerable concern from front-line health service providers and emerging research evidence that racialized populations face significant challenges in accessing the mental health and/or addiction services and supports they need. People with lived experience (PWLE) report experiencing double marginalization, both as people with mental health and/or addiction issues and as racialized individuals.i

These challenges bring together critical provincial health system priorities. Mental health and addictions is a major priority of the Ministry of Health and Long-Term Care, and a comprehensive provincial strategy has been developed. Equity is recognized as one of the key components of a high-quality health care system and is enshrined in the Excellent Care for All Act.

Embedding equity into mental health strategy, policy and service delivery requires multi-pronged action. This includes planning, incorporating equity into performance management and accountability systems, targeted programs addressing access barriers or disadvantaged populations, and investing up-stream in mental health promotion and community services.

In 2012, the Community of Interest (COI) for Racialized Populations began work on one emergent mental health and addictions issue impacting racialized populations in Ontario to concretely demonstrate how the specific needs of racialized populations can be better met through improved planning, service delivery or coordination, and how an equity-based approach could offer insight into a provincial health system priority issue. The COI decided to concentrate on mental health and/or addictions-related emergency department (ED) use by racialized populations because of the following:

• The provincial government and Local Health Integration Networks (LHINs) have prioritized the reduction of avoidable ED wait times, including a focus on mental health- and/or addictions-related and repeated visits;

• While we do not have full evidence, it would appear that EDs may be a key entry point to the mental health and/or addictions system for racialized populations. Crucial issues include whether this is the most appropriate entry point, how well the mental health and/or addictions needs of racialized populations are being met by primary care and other providers, and whether acute, primary and community-based services are effectively integrated;

• Important innovations are underway that address avoidable mental health- and/or addictions-related ED use that can be shared and built on. A question here will be how these innovations have taken account of and affect racialized populations;

• Dialogue and collaboration in this area could be improved across the range of stakeholder groups involved (mental health and addictions stakeholders, policing, primary care, community service providers and others).



Improve policy, planning and

practice related to racialized

populations and mental health and

addictions

Create provincial forum for knowledge exchange and collaboration

Share innovative

knowledge and practices

Strategically leverage

existing or emerging evidence

Convene a critical mass of stakeholders to

identify and respond to key

issues

This report focuses on a think tank event on the topic hosted by the CoI on March 26, 2013, at St. Michael’s Hospital in Toronto, Ontario.

About the CoI The COI is a provincial forum for knowledge exchange and collaborative knowledge creation about racialized populations and mental health and addictions. The COI has three goals:

1. Strategically leverage existing or emerging evidence to improve provincial, LHIN and provider policy, planning and practice related to racialized populations and mental health and addictions

2. Share innovative knowledge and promising practices of CoI partners and other stakeholders 3. Convene a critical mass of stakeholders from across and beyond the mental health and

addictions system to identify and respond to issues impacting racialized populations

The COI was launched in 2012 and currently is a partnership of Across Boundaries: An Ethnoracial Mental Health Centre; Addictions and Mental Health Ontario; Canadian Mental Health Association, Ontario; Canadian Mental Health Association, Toronto; the Centre for Addiction and Mental Health (CAMH); Community Resource Connections of Toronto; Ontario Peer Development Initiative; Ryerson University; Wellesley Institute; Women’s Health in Women’s Hands Community Health Centre; and Working for Change. Previous partners include Health Equity and Race Ontario; the Ontario Multicultural Health Applied Research Network; Rainbow Health Ontario; and York University. Between 2012 and 2014, seed funding was provided by the Evidence Exchange Network (EENet).

The COI has a broad understanding of evidence that includes community-based and lived experience as well as peer-reviewed academic research and other sources of knowledge. This approach to evidence informs all COI activities.



About the Think Tank On March 26, 2013, the COI hosted a think tank event to increase understanding and promote meaningful dialogue about mental health and addictions-related ED use by racialized populations in Ontario. The event was designed to convene a range of targeted stakeholder groups including mental health service providers, health system planners, policy makers, the policing sector, broader health and community stakeholders, and people with lived experience). The purpose of the event was to increase understanding about mental health and addictions-related ED use by racialized populations in Ontario by:

• Increasing dialogue among stakeholders • Clearly defining the issue, with policy, planning and practice implications identified • Sharing innovative practices, relevant knowledge and data • Identifying concrete next steps (see figure on next page).

The event brought together over 120 participants from over 80 organizations across Ontario, including 75 in person participants and 50 online participants who joined the event via a live streamed webinar. Participants reflected a range of stakeholder groups including community mental health and addictions, Consumer/Survivor Initiatives (CSIs), community health centres and other primary health care providers, hospitals, Local Health Integration Networks, the Ministry of Health and Long-Term Care, academics and other researchers, broader community and social service organizations, policing and first responders, as well as people with lived experience (PWLE).

The think tank agenda was structured to provide participants with a multi-dimensional perspective on the issue. To inform the event, the COI established a multi-pronged initiative to analyze key issues:

• Stakeholder consultations and environmental scan to scope the issue and focus

• Research review of available literature • Identification and documentation of Ontario-based

promising practices through a broad survey • Consultations with people with lived experience and

community mental health service providers

Through this process, important evidence – including PWLE and service provider perspectives, academic and community-based research, and innovative practices taking place across the province – was identified. In addition, four thematic areas emerged, each of which contribute to mental health- and/or addictions-related ED use by racialized populations in different and important ways:

• The importance of looking beyond the health sector to identify and address the impacts of the social determinants of health and the broader community and social services sector

“What stood out for me about the Think Tank was the wonderful collaboration between organizations such as funders, healthcare, service providers, people with lived experience of mental health issues and the police. Having everyone at the table allowed people to share and network around the barriers they face, work to alleviate silos when providing services, improve supports and help to reduce ER visits for racial populations.”

Think tank participant



• The provincial health system, where policy-making and health planning come together • The value of hospital and community collaborations and opportunities for upstream and

downstream partnerships and planning • Dynamics within the ED itself

The event’s speakers focused on these main themes and offered insight into how to better understand and address the issue:

• Introductions and Findings from COI Literature Review and Sector Survey Sheela Subramanian, Planning and Policy Analyst, Canadian Mental Health Association, Ontario Aseefa Sarang, Executive Director, Across Boundaries

• Morning Keynote Address: Understanding Emergency Department Use by Racialized Populations Anne Bowlby, Manager of Mental Health and Addictions Unit, MOHLTC

• Findings from COI Consultations with Service Providers and People with Lived Experience Deqa Farah, Community Mental Health Promoter, Community Resource Connections of Toronto

• Strategies for Implementing Effective Police-Emergency Department Protocols Uppala Chandrasekera, Planning and Policy Analyst, Canadian Mental Health Association, Ontario, and Policy Advisor, Provincial Human Services and Justice Coordinating Committee (HSJCC)

• Peer Support in the ED: Value, Opportunities and Challenges Frank Fournier, Community Support Worker, St. Michael’s Hospital

• Mental Health Shared Care Models: A Response to ED Usage and Racialized Women Notisha Massaquoi, Executive Director, Women’s Health in Women’s Hands Community Health Centre

• Afternoon Keynote Address: Improving Quality of Life and Exploring Mental Health and Addictions-Related ED Use and Racialized Communities Camille Orridge, CEO, Toronto Central LHIN

Below are summaries and key messages of these presentations.



Figure 1: Think Tank Goals



Introduction and Findings from COI Literature Review and Sector Scan Sheela Subramanian, Planning and Policy Analyst, Canadian Mental Health Association, Ontario Aseefa Sarang, Executive Director, Across Boundaries In the fall of 2012, the COI conducted a sector scan and literature review to identify existing evidence, knowledge and promising practices related to MH&A-related use of EDs by racialized populations in Ontario. Findings were then validated through consultations with service providers and PWLE. The literature review included the following key findings:

• Emergency departments are a key entry point to the health system, including for mental health and/or addictions-related issues. While some mental health and/or addictions-related ED visits are appropriate, others can be diverted through increased access to primary health care or community-based mental health services and supports.ii

• Although there is little published literature on MH&A-related ED use by racialized populations in the Canadian context, research shows that people experience more frequent use of the ED for mental health and addictions-related reasons when they experience inequities related to the social determinants of health.

o A London Ontario-based study found that some people with mental health and/or addictions issues presenting at the ED were seeking support for socio-economic stressors such as housing, financial issues and the legal systemiii.

o In Northern Ontario, where ED use for mental health reasons was over double the Ontario average in 2004/2005, some individuals used EDs for routine medication renewalsiv.

o An Alberta-based study found that First Nations children and those whose family receives social assistance or other low-income subsidies had disproportionately more ED visits for mental health purposes and returned to the ED sooner.v

• It is important to note that while some MH&A-related ED visits are appropriate, others can be diverted to primary health care or community-based mental health services.vi

• There is little population-level data about race and other equity-relevant dimensions with respect to ED use, because this information is not systematically collected across the provincial health system.

• However, an Ontario-based study of pathways to care for early psychosis intervention found that Asian (Chinese, Japanese, Southeast Asian, Korean, South Asian, West Asian, Filipino, and Arabian) participants were four, and Aboriginal and Latin American individuals were three, times more likely to use EDs as a first point of entry to the mental health systemvii.

• Within the ED, people with mental health and/or addiction issues may experience stigma or discrimination which can impact on the quality and effectiveness of service deliveryviii.

Looking specifically at racialized populations, it is important to note that although the population of Ontario is changing significantly, racialized populations continue to experience racism. The Mental Health Commission of Canada concluded that racialized populations may face a greater risk of poor mental health due to socio-economic factors (known as the social determinants of health) and barriers faced when accessing services and supports, including stigma, lack of language interpretation, inadequate cultural competence, and lack of information or awareness about available services.ix



For details of the literature review findings regarding policing and ED visits, please see pages 17 to 19. While there is little Canadian research available about the links between police, racialized populations and the ED, a 2005 Montreal-based study found that racialized individuals hospitalized with psychosis are more likely to have been brought to the ED by police or ambulance6. Even while controlling for age, gender, marital status, and number of psychotic symptoms, the study revealed that being Afro-Canadian was independently and positively associated with police or ambulance referral to emergency services. The study concluded that Afro-Canadians admitted to the hospital with psychosis are overrepresented in police and ambulance referrals to emergency psychiatric services.

The COI’s sector scan was designed to gather information about relevant innovative or promising practices currently underway across Ontario. A survey was launched and distributed through COI partner networks, major provincial listservs and other knowledge exchange tools. A number of practices were identified in the following areas:

• Increasing access to primary care for racialized people with mental health issues o See the Reducing Emergency Department Visits and Increasing Access to Primary Care

for Racialized People with Mental Health Issues - The HF Connecting Health Nurse Practitioner - Led Clinic promising practice brief

• Community-based crisis management programs • Police-ED protocols including Mobile Crisis Intervention Teams and clear channels of

communication between police and community MH&A service providers • Community-hospital collaborations, including community-based discharge planning models

o See the Women’s Health in Women’s Hands Community Health Centre Shared Care promising practice brief

o See the Reducing Emergency Department Visits for People with Mental Health and Substance Use Needs – The Coordinated Access to Care from Hospital Emergency Departments (CATCH-ED) pilot project promising practice brief

• Innovative practices within the ED itself such as the presence of peer support workers o See the Value of Peer Support for Improving Emergency Department Experiences for

Racialized People with Mental Health Issues promising practice brief

A number of promising practices were highlighted during the plenary session and also over the lunch hour through a slideshow. These promising practices identified from stakeholders across Ontario through the survey, include:

• Mental Health Emergency Department Placement Coordinator (MHEPDC) • Hospital to Home Partnership • Shared Care • Emergency Department Diversion (EDD) Program • Coordinate Access to Care from Hospital Emergency Departments (CATCH ED)

http://eenet.ca/wp-content/uploads/2014/05/HF-Connecting-Health-Nurse-Practitioner-Led-Clinic.pdf



http://eenet.ca/wp-content/uploads/2013/06/WHIWH-Promising-Practice_FINAL.pdf

http://eenet.ca/products-tools/coordinated-access-to-care-from-hospital-emergency-departments/



http://eenet.ca/products-tools/peer-support-in-the-emergency-department-experiences-for-racialized-people-with-mental-health-issues/


http://eenet.ca/wp-content/uploads/2013/03/Mental-Health-Emergency-Department-Placement-Coordinator-MHEPDC.pdf

http://eenet.ca/wp-content/uploads/2013/03/Hospital-to-Home-Partnership.pdf

http://eenet.ca/wp-content/uploads/2013/03/Shared-Care.pdf

http://eenet.ca/wp-content/uploads/2013/03/Emergency-Department-Diversion-EDD-Program.pdf

http://eenet.ca/wp-content/uploads/2013/03/Coordinate-Access-to-Care-from-Hospital-Emergency-Departments-CATCH-ED.pdf



Understanding Emergency Department Use by Racialized Populations Anne Bowlby, Manager of Mental Health and Addictions Unit, MOHLTC

Ontario is committed to supporting the mental health and addictions (MH&A) sector and shifting how Ontarians access services. The aim is to create a health care system that is sustainable over the long term. To do this, the government in 2011 launched Open Minds, Healthy Minds: Ontario’s Comprehensive Mental Health and Addictions Strategy.

The first three years of this strategy have focused on children and youth. During that time, 770 new mental health workers were added in the health, education, and children’s mental health sectors, and a new evaluation framework and scorecard for MH&A was implemented.

It is increasingly important to provide faster access to better quality primary care. A priority of Ontario’s Action Plan for Health Care is faster access to stronger family health care, so that individuals will rely less on EDs for their primary care needs. To improve access to key health services and reduce the time spent in the ED, the province launched the Wait Time Strategy in 2011/2012 and increased funding for community MH&A services. There also has been a focus on developing early psychosis intervention (EPI) standards to reduce the number of hospital visits and to result in shorter stays in hospital.

In addition, the Local Health Integration Networks (LHINs) now have performance indicators to track unplanned visits to the ED and ensure that those individuals who need care for a mental health or substance abuse issue are referred within 30 days.

Ontario is also putting emphasis on stronger health care at the community level:

• Systems Improvement Through Service Collaboratives (SISC) initiative – These groups of local, coordinated, mental health service providers are identifying health priorities and delivering a continuum of mental health and addiction services to a region or community. The first four Service Collaboratives are in Thunder Bay, Ottawa, Simcoe/Muskoka, and London. The priority in Simcoe/Muskoka is on the coordination of care for youth ages 14-24; in London, it is on better transitions from youth to adult services and pathways from hospital–emergency to community services for youth with MH&A. There are now 18 Service Collaboratives across Ontario.

• Community Health Links – These networks of service providers in a community focus on the top 5% of Ontario’s health care users — often those with chronic diseases and mental health problems — who account for approximately two-thirds of Ontario’s health care dollars. One of the main goals of Health Links is to ensure patients have regular access to a primary care provider.

At the provincial level, gaps and opportunities have been identified in addressing the needs of racialized populations. Advancing health equity is part of the ministry priority to improve quality of care. There are legal and ethical reasons to take action on health equity, as well as cost and value implication for our health system. To that end, the ministry has developed the Health Equity Impact Assessment (HEIA) Tool to help a range of stakeholders address and anticipate unintended health impacts that a plan, policy or program may have on vulnerable or marginalized populations groups.

http://www.health.gov.on.ca/en/common/ministry/publications/reports/mental_health2011/mentalhealth.aspx

http://www.health.gov.on.ca/en/common/ministry/publications/reports/mental_health2011/mentalhealth.aspx



Currently, there are significant data gaps that make population-based planning challenging. Collecting data on all groups, particularly vulnerable groups provides a baseline and future measure for change. Once needs are measured and understood, then targeting resources or programs specifically to addressing disadvantaged populations or key access barriers becomes an option.

In exploring ED use by racialized populations for MH&A reasons in Ontario, it is important to consider how we can improve demographic information collection in the ED, but also consider any unintended consequences of asking for this information.



Findings from COI Consultations with Service Providers and People with Lived Experience Deqa Farah, Community Mental Health Promoter, Community Resource Connections of Toronto The Community of Interest (COI) for Racialized Populations and Mental Health and Addictions held consultations with two groups to learn more about how, when and why racialized individuals in Ontario use the emergency department for MH&A reasons:

• Nine persons with lived experience who are from racialized communities and have direct experience using the ED;

• Eleven service providers from community-based mental health organizations who work with racialized communities, are familiar with their needs, and are able to share thoughts about how and why their clients use the ED.

The COI wanted to hear from these two groups to understand why and how racialized clients use the ED for mental health and/or addictions reasons and the challenges or barriers associated with this use. It is important to note that due to resource and capacity-related reasons, we were unable to consult more widely with hospital staff, the policing sector, and individuals with lived experience who do not speak English. While all of the participants with lived experience had used the ED multiple times, they noted that their frequency of use depended on context and their overall life situation. The social determinants of health played a critical role in ED use; in many circumstances, changes in the social determinants such as housing, income or access to services contributed significantly to the frequency of ED visits. Reasons for using the ED were both internally and externally motivated:

• Internally, increased distress, fear or worry due to changes in the social determinants of health played a significant role. For example, one individual indicated that he began visiting the ED three times per week after moving to a shelter where he was surrounded by drug use and also began using drugs to cope with fear. For others, the ED became a place to seek support during times of heightened distress or suicidal thoughts.

• Externally-motivated reasons also emphasized the important role played by the social determinants of health:

o For some individuals, the ED provided shelter for the night and temporary relief from homelessness, particularly when individuals had no social networks or connections in the city.

o In other cases, individuals visited the ED due to a lack of access to primary care or community-based mental health services or because other services needs were unmet. As one service provider stated, “Clients go to ER to get medication refills or, due to the wait times, to see a psychiatrist.” This problem was exacerbated for newcomers to the city or country without existing access to the mental health system and few resources to increase that access.

“Sometimes clients go to ER to get med refills, or due to the wait times to see a psychiatrist.” Service Provider



o Although some individuals went to the ED voluntarily, others were accompanied involuntarily by colleagues, family members, and police officers.

Regardless of the reasons for ED use, the consultations highlighted a number of issues:

• People with lived experience of MH&A issues and racialized experience marginalization due to both their MH&A issues and race. Although some individuals did not specifically name racism as a factor, they indicated that their skin colour played a role in their experience of the ED.

• A combination of language barriers and poor-quality interpretation resulted in treatment delays and poor quality services for individuals; often family members or services providers, rather than professional interpreters, were asked to translate.

• Use of force by hospital security staff and police services emerged as a significant issue for individuals. PWLE who were consulted often could not distinguish between hospital security or police officers. One person described being treated “like a livestock” when security guards tackled him, placed their knee on his face, restricting breathing, and jabbed a syringe into his leg.

• Individuals also noted the value of clear communication between PWLE, police, hospital security, and hospital and community service providers. In many cases, an intentional or unintentional lack of communication contributed to confusion about the why the PWLE was in the ED at all, which led to questions or concerns, which then contributed to a perception that the individual was non-compliant or a security threat.

• Patient follow up is often inconsistent, and often depends on whether or not a community-based worker is present in the ED with the PWLE or if there is an ongoing collaboration between a community-based mental health agency and the hospital.

Racialized individuals with MH&A issues are within the margins of an already marginalized population. The social determinants of health significantly inform reasons for ED use by PWLE who are racialized and there are clear opportunities to improve the quality of mental health services that racialized individuals receive, at the ED as well as upstream and downstream.

“Communication towards patients is important. Let patients know why they’re there, what’s the problem. Don’t just grab them and tie them and inject them”. PWLE



Strategies for Implementing Effective Police-Emergency Department Protocols in Ontario Uppala Chandrasekera, Planning and Policy Analyst, Canadian Mental Health Association, Ontario. Policy Advisor, Provincial Human Services and Justice Coordinating Committee The Provincial Human Services and Justice Coordinating Committee (HSJCC) is a network that coordinates resources and services for people with developmental disabilities, acquired brain injuries, fetal alcohol spectrum disorder, and/or MH&A issues who come into contact with the law. A working group of police officers, ED staff, and MH&A providers, developed the HSJCC Info Guide: Strategies for Implementing Effective Police-Emergency Department Protocols in Ontario. The Info Guide sets out protocols to reduce wait times for individuals experiencing a mental health crisis who are brought to the ED by police. According to the Mental Health Commission of Canadax:

• 15% of interactions between the police and people with mental health conditions are initiated by the person, 20% are initiated by a family member, and 25% are initiated by police;

• 1 in 20 police dispatches or encounters involve people with mental health conditions; • 2 in 5 encounters between the police and a person with a mental health condition involve

situations that are unrelated to criminal conduct; • 3 in 10 people with a mental health condition have had police involved in their health care

pathway; • 1 in 7 referrals to emergency psychiatric inpatient services involve the police.

Although the majority of people with mental health and addictions conditions rarely come into contact with the criminal justice system, mental health-related emergencies do occur. In most cases someone has dialed 911, and police, by virtue of their role as emergency responders, are called upon to assist in the crisis. Criminal and non-criminal situations can arise from these police interactions. In Ontario, the Mental Health Act xi permits police officers to apprehend individuals if the officer has reasonable grounds to believe that a person is acting in a disorderly manner and is a threat or at risk of causing harm to themselves or others. Once the apprehension is made, the officer accompanies the individual to an examination by a physician, typically to an ED.

In 2011, the Provincial HSJCC released a report, Police & Mental Health: A Critical Review of Police/Mental Health Collaborations in Ontario,xii which offers a provincial examination of issues related to police encounters with the mental health system, its service providers and service-users. This report highlighted successes and challenges of collaboration across the policing and health care sectors, including issues that occur in the ED.

According to the Provincial HSJCC, police officers are often subjected to extended wait-times during police-accompanied visits to the ED. The report states, “These waiting periods can be quite costly as two officers typically escort the individual to the ER. Moreover, this can result in public safety issues because police officers are waiting in the ER instead of being out on patrol ensuring the safety of the community. Informants indicated that ER wait-times should be reduced for police officers and individuals being accompanied by police should be triaged faster” (pg. 7).

http://www.hsjcc.on.ca/Resource%20Library/Policing/HSJCC-Police-ER-InfoGuide-FINAL.pdf

http://www.hsjcc.on.ca/Resource%20Library/Policing/HSJCC-Police-ER-InfoGuide-FINAL.pdf



The 2013 HSJCC Info Guide narrowed in on this issue. This info guide was developed based on a survey completed by police, hospital staff, and community MH&A providers. Survey responses highlight several issues:

• Although crisis intervention services have been effective in diverting daytime ED visits, their limited availability puts pressure on the ED at night;

• Wait times range from 2 to 8 hours and, in northern communities, 24 to 30 hours, usually because individuals with MH&A are a low triage priority;

• A cyclical “revolving door” often occurs when physicians do not have enough evidence for an involuntary admission, so the person is released back into the community without appropriate resources, and is soon apprehended by the police again.

The info guide further explores how police-accompanied ED visits impact each group differently: • Police frequently are asked to play the role of security guard in the ED; extended wait times

take up costly police services resources; • Individuals who have mental health issues face additional stigma when they are accompanied to

the ED by police; they may not feel comfortable speaking freely in the presence of police or security;

• Stigma, discrimination, and racial profiling of racialized and Aboriginal communities leads to increased police accompanied visits to the ED more often than the general population, which compromises the care they receive.

The info guide emphasizes the need for clear and consistent communication with respect to mental health apprehension situations. As such, police officers, hospital staff and community care providers identified several strategies for reducing wait times for police accompanied visits to the ED including:

• Building strong relationships between police services and hospitals; • Providing cross-sectoral training for police services and hospital staff about mental health-

related apprehensions; • Calling ahead to an ED when a police officer is en route with a person experiencing a mental

health crisis; • Establishing clear lines of communication upon arrival at the ED; • Using a mental health screener form to communicate information about the circumstances, and

observations about the person in crisis; • Arranging a quiet room for police accompanied visitors to the ED; • Having adequate staff support to manage mental health crisis situations in the ED; • Designating a liaison in the ED to work directly with police officers when they arrive with a

person in crisis; • Establishing a written agreement between police detachments and hospitals that sets out

procedures, expectations, and respects patient rights; • Conducting routine monitoring and evaluation of the protocol in place, and making changes as

necessary, and • Ensuring patient centred care.



Peer Support in the ED: Value, Opportunities and Challenges Frank Fournier, Community Support Worker, St. Michael’s Hospital The Community Support Worker role at St. Michael’s Hospital is part of the hospital’s broader equity strategy. The position was created by the Homeless and Under-housed Community Advisory Panel at St. Michael’s Hospital as part of the ED team to provide support to vulnerable individuals in the hospital’s emergency department system. Critical to the support worker role is their “street lived experience,” which provides the worker with a peer perspective on the patient’s experience. The worker identifies and addresses the patient’s non-medical needs, often related to the social determinants of health, and provides peer support to increase the patient’s level of comfort during their time in the ED. In this role, the Community Support Worker orients vulnerable patients to the ED and to the hospital. They work closely with the ED team to advocate for patient and provide non-clinical and non-directive supports. The worker also facilitates clear communication at the patient’s point of entry and discharge, refers them to community resources and ensures they arrive for scheduled follow-up appointments to facilitate continuous care. The Worker assists with transportation and may accompany individuals to their next destination, builds rapport with people, ensures that patients have food, clothing, shelter, and educational materials such as information on harm reduction or community resources. In addition, the Community Support Worker also oversees the Needle Exchange Program. This peer-based role adds significant value to the ED team. The role helps to maximize valuable ED and health system resources by identifying and address non-medical needs so that medical staff can focus on medical needs. The worker also tries to ensure that patients remain until they are assessed by medical staff and return for follow up. Patients may experience distress, fear, worry, or cognitive challenges at the ED. In these situations, the support worker can act as a navigator around the ED and hospital. When patients are accompanied by the police, the support worker can help create a more positive experience by interacting with the individual, listening to them, providing food and water and providing support to prevent anxiety from escalating. Although this role has proven to be essential, the program is not without challenges. There is the need for more workers to ensure 24/7 availability. There is also a need for more peer support workers with shared lived experience of a range of socio-demographic characteristics, such as racialization. There is need for greater support and recognition of peers in the ED. In addition, it would be beneficial to establish standards for peer support work to inform training, compensation, and evaluation. For racialized populations, the Community Support Worker role can be particularly beneficial. Shared lived experience of both racialization and mental health issues can facilitate open communication and provide understanding of community dynamics. The worker can support triage and assessment, as assumptions about vulnerable populations can at times impact on patient experience and quality of service delivery. Finally, peer workers ensure there is clear communication among hospital staff, the patient, and their family.



Mental Health Shared Care Models: A Response to ED Usage and Racialized Women Notisha Massaquoi, Executive Director, Women’s Health in Women’s Hands Community Health Centre Women’s Health in Women’s Hands Community Health Centre (WHIWH CHC) provides primary health care to racialized women from Black, Caribbean, African, Latin American, and South Asian communities in Metropolitan Toronto and surrounding municipalities. Among the top reasons for visits to WHIWH CHC are:

• Depression • Health promotion and preventative medicine • Psychological symptoms or concerns • Poverty or financial problems • Hypertension • Assault or other harmful event • Post-traumatic stress disorder

Of the clients of WHIWH CHC, 35.4% initially come in to address mental health-related concerns, 6% are addressing serious mental health concerns, and 10% experience co-morbidities such as HIV and diabetes together. Racialized women with mental health issues are six times more likely to have diabetes, and 62% of new HIV infections are attributed to African and Caribbean women. For these reasons, it is increasingly important to offer MH&A services in primary health care settings to address the needs of these women and work with their communities to help them achieve optimal mental health. There are many service challenges linked to the social determinants of health that hinder the development and delivery of MH&A services in primary health care settings. These challenges are not specific to racialized populations, but are mitigated by race. These factors are:

• Poverty • Immigration status • Lack of access to mental health services • Discrimination – particularly racism and sexism • Cultural stigma • Social isolation • Lack of access to information • Unstable living environment • Mistrust of the mental health system

In 2011, WHIWH CHC conducted a study titled Every Woman Matters: Increasing Access to Primary Health Care for Racialized Women. The three-year study followed 250 women belonging to four populations — African, Caribbean, South Asian, and Latin American — to identify the enablers and barriers to accessing primary health care. The study found:

• The average number of visits to a health care provider was 10.5 per year, with 45.1% of visits linked to care for chronic health conditions;

• 7.4% went to the hospital ED for primary health care compared to 3.7% who went to walk-in clinics.

http://www.whiwh.com/every-woman-matters

http://www.whiwh.com/every-woman-matters



The main reasons women gave for not being able to access primary and preventative health care were:

• Primary health care services were too far; • Services were closed when they needed them; • Physicians did not accept new clients; • They had inconsistent housing; • They didn’t have OHIP coverage.

These factors increased the risk of unnecessary ED usage. The study’s findings also revealed the importance of providing culturally appropriate mental health services, and the need to address the factors that caused women to use the ED, resulting in significant costs to the health care system. For this reason, WHIWH CHC partnered with Women’s College Hospital to create the Shared Care Psychiatry Model. In this model, a psychiatry resident from Women’s College Hospital works jointly with primary care physicians at WHIWH CHC to provide bi-weekly psychiatric services. After three years of this partnership, WHIWH CHC took the idea further by adding a new face to the model, teaming up with the Centre for Addiction and Mental Health (CAMH) to provide additional services:

• Psychiatric consultations at WHIWH CHC for five hours per week; • Phone consultations for WHIWH CHC primary care providers, as needed; • Team-based case conferencing and education.

Statistics show the success of the Shared Care Psychiatry Model:

• In 2009, before the model was introduced, use of the ED among clients of WHIWH CHC for mental health-related reasons was 2.69% compared to the expected 1.3% based on provincial data for the population served by WHIWH CHC;

• Between 2009 and 2011, at the time of the partnership with Women’s College Hospital, ED use dropped to 1.19%;

• Between 2011 and 2012, with the CAMH psychiatrist onsite, ED use dropped to 0.68%. These numbers demonstrate that the model was a success and should be considered for use across the province, not only for psychiatry services but as a way to address the social determinants of health and increase access to the mental health system for racialized women or other marginalized communities. This Shared Care Model is discussed further as an innovative initiative in the Promising Practices section below.



Figure 2: Graphic recording of presentations



Keynote Address Camille Orridge, CEO, Toronto Central Local Health Integration Network (LHIN) Increasingly, policies and service delivery are based on or informed by evidence. Good-quality information and data are needed to inform policy development, monitor changes in service needs, and evaluate programs and services. But what exactly constitutes “good” data? There are information gaps about the socio-economic status of racialized populations in Ontario, which poses challenges for public policy development and health system planning. There are currently few sources for equity-related data collection, and the replacement of the mandatory long form census questionnaire will also reduce the availability of data. Currently, there are few health databases that do collect equity-related information (see tables below). Table 1: Examples of Common Health Related Databases and Collection of Equity Variables– Hospital, Community Services, and Others

Database Area Include socio-demographic variables

CIHI (Canadian Institute for Health Information) Discharge Abstract Database (DAD)

Acute Inpatient discharges No

CIHI National Ambulatory Care Reporting System (NACRS)

Emergency department and selected outpatient visits and day surgeries

Only Homeless

CIHI Ontario Mental Health Reporting System (OMHRS)

Adult inpatient mental health admissions

Few – Aboriginal, homeless but are optional

National Rehabilitation System (NRS) Inpatient rehabilitation No

Continuing Care Reporting System (CCRS) Complex continuing care No

LTC (Long-term care) database Long term care homes Few

Home Care Database (HCD) Homecare data Home care data (CCAC) Few

OHIP(Ontario Health Insurance Plan) Primary Care No

CCO iPort (Cancer Care Ontario) Wait time for ALC and priority surgeries and diagnostic test (MRI, CT)

No

RMR (Resource Matching and Referral) Transitions from different sectors across the healthcare

No



system (Acute, Rehab/CCC, LTC, CCAC, CSS)


Ontario Common Assessment of Need (OCAN)

Community mental health Yes, but just being adopted and many of the variables are optional

Drug and Addiction Information System (DATIS)

Substances abuse and problem gambling

Yes, but not in a consistent manner

Community Health Centre (CHC) Business Intelligence Reporting Tool (BIRT) Data Repository

CHC administrative and clinical data

Yes, but not consistent

interRAI-CHA (Resident Assessment Instrument - Common Health Assessment)

Assessment of CSS clients Few

CHRIS (Client Health Related Information System)

Client management system within the CCACs

Few, but some variables are optional

Canadian Community Health Survey (CCHS) National survey with information related to health status, health care utilization and health determinants

Yes – but limited sample for vulnerable groups e.g. new immigrants, homeless, Aboriginal

Vital Statistics – Ontario Registrar General Births and Deaths No

Cardiac Care Network (CCN) Selected cardiac procedures in Ontario

No

Cancer Care Ontario (CCO) Cancer prevalence, incidence and screening

No

Canadian Census Demographic and statistical information

Yes (2006), available at neighbourhood level; fewer variables in 2011 Census

National Household Survey (NHS) Social and economic data about the Canadian

Yes



population

Population Estimates (Statistics Canada) Annual estimates of the population by age and sex

No

Population Projections (Statistics Canada) Projections based on assumptions as to how the Canadian population will evolve in the future

No


Health Based Allocation Model (HBAM) Hospital and CCAC funding allocation model – calculates a share/portion of the overall funding envelope that health agencies will receive.

The only variable is income. Methodology for including the uninsured patient is being reviewed.

The lack of socio-economic data is a problem because it means that an equity lens is missing and we are missing the information we need to figure out which groups are more or less affected by current policies and services. For example, the Canadian Institute for Health Information (CIHI), a large national repository used by policy-makers, includes all hospital clinical and administrative data, but no socio-economic data. In addressing these issues, one key solution is to find ways to insert socio-economic data into the databases that decision-makers use. A partnership among the Toronto Central LHIN, Mount Sinai Hospital, St. Michael’s Hospital, CAMH, and Toronto Public Health developed eight questions that all health-related agencies and organizations should ask the individuals they serve. These questions are:

• What language do you feel most comfortable speaking in with your healthcare provider? • Were you born in Canada? (If no, what year did you arrive?) • Which of the following would best describe your racial or ethnic group? • Do you have any of the following disabilities? • What is your sex/gender? • What is your sexual orientation? • What was your total family income before taxes last year? • How many people does your income support?

Another Toronto Central LHIN initiative that integrates considerations of equity into health planning are Community Health Links. The Toronto Central LHIN experiences a rate higher than the provincial rate of repeat unplanned returns to the ED within 30 days for MH&A. Health Links are one initiative to try to



better understand and address ED use by marginalized populations, including those impacted by MH&A. This initiative fosters the growth of networks of health providers to identify and focus on the top 5% of service users, often those with chronic diseases and mental health issues. For its Health Links initiative, Toronto Central LHIN identified nine sub-regions. Two sub-regions, South Toronto and Mid-East Toronto, prioritized a focus on MH&A due to its significant role in their regions’ repeat ED visits. It is equally important to promote equity-based approaches to service delivery and cultural competency training for all staff and volunteers. For example, the Toronto Central LHIN has funded the Ontario Federation of Indian Friendship Centres to run successful cultural competency programs for individuals in leadership positions at health and social service agencies.

Figure 3: Graphic recording of keynote address



Participant Discussion During the Think Tank, participants were engaged in facilitated discussion. Participants were divided into small groups to identify challenges and solutions related to many different issues that impact on how and why racialized individuals with MH&A issues use the ED. Issues considered included the broader social determinants of health and role of non-health stakeholders; the provincial health system; hospital–community collaboration; and ED dynamics themselves. The discussions led to more questions, but also sharing of knowledge and promising practices.

Figure 4: Graphic recording of the think tank report back from group discussions

I. Looking beyond the health sector Due to the social determinants of health, it is important to look beyond the health sector when exploring how, why and when racialized PWLE use the ED. There are also various supports that can be leveraged to address and improve the situation. Racism and stigma are often the reasons why people from racialized populations don’t seek help in the early stages of their MH&A issue, so they end up going to the ED once the problem becomes more severe. While systemic issues such as racism and stigma can be difficult to address, their impacts or effects can be reduced through a range of different initiatives. A number of community and social service supports can be leveraged to help prevent avoidable ED visits for racialized population. Some examples include:

• Arts-based programming such as the Creative Works Studio at St. Michael’s hospital, which supports recovery by combining mental health supports, primary care, visual arts and vocational supports

• Addressing the social determinants of health, such as housing, within mental health • Initiatives that address racism within health • Improvements to socio-demographic data collection • Strategies that address the lack of access to primary health care for marginalized populations • Increased support for ethno-racial serving agencies to collaborate with the health system

There are promising practices for promoting collaboration and coordination between the broader community and social services sector and the health system, such as:



• Local Immigration Partnerships (LIPs) or community partnership that develops and implements local settlement strategies and coordinates service delivery to newcomers while promoting innovation and efficient use of resources.

• Toronto-based Parkdale Community Health Centre, which formed a partnership with a local community-based organization, St. Christopher House, to better serve the Roma community

• Ottawa-based Substance Use Prevention for Somali Youth and Parents, a partnership between Canadian Friends of Somalia, CAMH, and Rideauwood Addiction and Family Services.

II. Provincial health system Provincial policy, programs and health system planning play an upstream and downstream role in the use of EDs by racialized populations for MH&A reasons. At the overall health system level:

• There is a need for better ways to collect and use socio-demographic data to ensure that policy planning considers the needs of different populations. For example, there need to be more accessible formats for data collection, such as the use of standardized questions, which also can be used for hospital planning purposes.

• Data that is collected needs to be rolled up to inform health system planning and policy development.

o The Toronto Central LHIN Tri-Hospital and Public Health Socio-Demographic Data Collection Pilot Project is an important promising practice

At the LHIN level:

• Health system planning may benefit from initiatives such as Community Health Links, use of Health Equity Impact Assessment, and peer support navigators

• Equity-related information sharing between different levels and organizations could enhance services for marginalized communities

o For example, the College of Physicians and Surgeons of Ontario asks physicians what languages they speak, but this information is not searchable

At the Health Service Provider level:

• Training on equity-based approaches to providing services to racialized and other marginalized communities o For example, are there intake questions that may not be interpreted consistently due to

language differences? o Focus on an enhanced ability to hear and empathize o Ensure access barriers are decreased including language, transportation

• Explore a systems approach for mass buying of telephone translation services o E.g. translation software/ laptops using “Vicky” software is currently being tested in

Mississauga Halton



• Ensure there is clear signage in the ED that explains what to do upon arrival and when waiting

• Explore opportunities to increase open access to Family Health Teams to decrease ED use, rather than appointment-based services only

• Let people in the ED know approximately how long they might have to wait.

A number of stakeholders must be part of planning and priority setting to ensure improved outcomes for racialized individuals with MH&A issues including the community mental health sector, physicians, the justice sector, PWLE and family members, settlement agencies, faith-based organizations, researchers/evaluators/academics, and all levels of government, including the federal, provincial, LHIN, and municipal levels. Lack of collaboration and communication, isolated decision-making, and lack of infrastructure in smaller agencies are issues that continue to pose challenges for stakeholder engagement.

Current system drivers that can be leveraged to improve services and supports for racialized PWLE include:

• Quality improvement o Including looking at client pathways and flow and other processes, and Quality

Improvement Plans (QIPs) • Ontario’s Comprehensive MH&A Strategy

o Years 4-10 of the strategy will focus on adults • Health Links at the LHIN level • Health indicators and outcomes.

III. Hospital and community collaboration Participants identified that a number of key issues impact on hospital and community collaboration

within the mental health and/or addictions system:

• Policing services are not always at the table in terms of planning and decision-making, but play such a key role

• Staff across the community, hospital and policing sector need better education and training about working with MH&A issues and racialized communities

• Sustainability is often challenging for community agencies and community-based initiatives • There is often an imbalance in resources, capacity and power between larger and smaller

organizations • Involvement of family members and consumers is uneven • Need for more consistent monitoring and evaluation as well as documenting of promising

practices



There are promising practices for hospital-community collaborations that address emergency

department use for people living with mental health and addictions issues, and specifically for racialized

communities, such as:

• The Mental Health Commission of Canada’s At Home/Chez Soi project based on a housing first model

• ED diversion initiatives such as Toronto Central LHIN’s CATCH ED (see promising practice document)

• Adult pre-charge diversion • Mobile crisis teams • Human Services and Justice Collaborating Committee collaborations at the provincial, regional

and local levels • Peer training support providing by Ontario Peer Development Initiative

The following is needed to improve collaboration and coordination between first responders, hospitals

and community to address policing and ED issues:

• Commitment from police and hospital ED staff to work together to identify challenges and develop solutions

o Local champions are needed to support this work • In Hamilton, a promising practice has been developed that includes a process for a transfer of

person from police custody to hospital (using a special form); this process has also established stronger relationships between police and hospital

• There is also a process in Hamilton when an individual’s custody is transferred from police to the hospital that includes the use of a form that clarifies each party’s responsibilities.

• Monitoring and evaluation of new processes or protocols is needed • It would be helpful to develop a process map process to track what happens when someone

comes to the ED • Local solutions are needed that are consistent with the workplace culture and local context • Measure the admission rate of clients brought by police to the ED • Crisis Intervention Training for police and use of Police Crisis Teams can help to keep people out

of the ED • Stronger and direct linkages between hospital services and community services, with ideally a

“warm transfer” o Follow-up is important as is a continuum of care, especially for clients that may return to

the ED • Formalized MOUs between hospitals and community agencies can facilitate fast tracking for

police • Peer support workers in the ED can play an important role with admission and discharge • Consistent data collection at the ED would help with needs assessment, monitoring and

evaluation • Effective, consistent and available language interpretation services needed



The following may assist in promoting more effective discharge planning between hospitals and

community-level supports:

• Staff from community agencies attend hospital rounds once a week • Support from agencies to connect with patients and assist with day passes, and increase

awareness of community-based services • Follow up to prevent return to ED • After patient visit in ED, provide copy of discharge to primary care providers; ensure a social

worker is part of discharge • Ensure that frequent ED visitors are given priority for community-based services • Create system navigators in the ED to help with a discharge plan • Intensive short term case management • Peer support services

IV. Emergency Department dynamics Dynamics within hospital emergency departments themselves contribute to the experiences of racialized populations with MH&A issues, such as the effectiveness of patient/staff communication, degree of access to and collaboration with community services, and tracking of individual pathways to and beyond the ED. It was identified that many contributing factors can play a role in improving services and continuity of care for racialized or other marginalized populations:

• Leadership within and across the institution that is responsible, direct, and accountable, with the capacity and resources to encourage change and prioritize equity and the needs of marginalized populations;

• Support and incentives for staff to attend education and training sessions about service delivery for racialized populations and mental health- and addictions-related services.

o It would be helpful for PWLE to share first-hand experiences and challenges faced in the ED during the training sessions to increase awareness and promote dialogue;

• Ensure that a multi-language interpreter system is available at all times of the time of day, and that staff use plain language in speaking with patients.

It is also important to prioritize the collection of socio-demographic data at the hospital ED. High quality data depends on the information provided by individuals. Attention to be paid to the time, place and approach used when collecting data. If an appropriate time is selected, and reasons are provided about why data is being collected, people may be more likely to disclose information. There are some promising practices, protocols, procedures and/or other innovations that can improve

the quality of ED services for racialized or other marginalized populations, such as:

• Community care paramedics that work specifically with people who call emergency services multiple times

• Providing the option to bring a person in crisis directly to a hospital rather than an ED. o This can be problematic because at times admittance will not happen without medical

clearance



• Clear guidelines for inter-agency collaboration between hospitals, paramedics and police that indicate roles and responsibilities

• The wrap around model • Local, provincial and regional Human Services and Justice Coordinating Committees

Promising Practices Promising practices for ED diversion currently underway are laying the ground work for future action. Such promising practices include the Shared Care Model, the Coordinated Access to Care from Hospital Emergency Departments (CATCH-ED) pilot project, the Hong Fook Connecting Health Nurse Practitioner-Led Clinic, and Using Peer Support in Emergency Departments.

Shared Care Model

How does a community health centre meet the health care needs of racialized women from diverse backgrounds? If you ask Notisha Massaquoi, Executive Director of Women’s Health in Women’s Hands (WHIWH), it’s by playing a balancing act. The trick is to have a strong mandate and establish the right partnerships, while also remaining flexible to your clients’ changing needs. To read this Promising Practice click here.

CATCH-ED Pilot Project

The Coordinated Access to Care from Hospital Emergency Departments (CATCH-ED) pilot project was designed to reduce visits to the ED and improve access to care for people with mental health and addiction needs (MHA) who use EDs frequently.

The project is a partnership among six hospitals, three community mental health agencies, four community health centres, and one peer outreach service, sponsored by the Mental Health and Addictions Acute Care Alliance and supported by the Toronto Central LHIN.

CATCH-ED makes it easier for clients to access the services and supports they need by connecting them while they’re in the ED. The program gives them priority access to primary care, mental health






and addictions counseling, peer support, and transitional case management (12-16 weeks of service) at six hospital sites. To read the full Promising Practice, click here.

Hong Fook Connecting Health Nurse Practitioner-Led Clinic

For individuals who are doubly marginalized as racialized individuals and individuals with mental health issues, increasing access to quality primary care plays a significant role in improving health outcomes and reducing visits to the Emergency Department. The HF Connecting Health Nurse Practitioner – Led Clinic is a promising practice that aims to use a collaborative, holistic care model of service provision to increase access to primary health care for a range of marginalized communities, including newcomers and racialized populations. To read the full promising practice, click here.

Using Peer Support in Emergency Departments

The use of peer support in the emergency department (ED) is an emerging practice. In this promising practice, two scenarios are shared. One is the inner city hospital with the dense and diverse populations it serves, and its use of a Community Support Worker. The second is the future establishment of peer navigators in the Central Local health Integration Network (LHIN) at two sites – one in the city, and another serving a broader suburban area. Each offers some lessons and implications for their respective use by racialized people with mental health issues. To read the full promising practice, click here.








Concluding Remarks The COI’s March 2013 Think Tank event assisted in promoting knowledge exchange and new knowledge creation about how, why and when racialized populations turn to the ED for MH&A needs. In particular, a number of factors were explored:

• The social determinants of health, that include the issues of racism and mental health stigma, and make up the overarching, broad level factors and play a role upstream;

• Provincial health policy and system planning that inform the context for service delivery, availability and accessibility;

• Local collaboration between hospital, police, and community organizations; and,

• The dynamics at the hospital ED itself.

The work of the COI has helped to strategically frame key issues, as well as identify and highlight Ontario-based evidence and innovative practices that can be adapted in other communities across Ontario. As we move forward to better understand and take action in this issue area, stakeholders are encouraged to continue building on this dialogue.

“I attended the Think Tank event that was held a few days ago. Thank you for bringing so many wonderful people together. It was a fabulous experience and true opportunity to explore knowledge exchange”. Think tank participant, April 2013



References i One element of the research undertaken for this project was intensive consultations with people with lived experience of mental health issues and racialization, and community-based mental health service providers. The consultations were conducted by COI partners and a researcher from Women’s Health in Women’s Hands Community Health Centre in February 2013. ii Schizophrenia Society of Ontario (2008). Reducing Emergency Room Wait Times for People in Psychiatric Distress: Recommendations from the Schizophrenia Society of Ontario. Retrieved December 10, 2012 http://www.schizophrenia.on.ca/images/stories/sso_er_paper_final_oct_20_2008.pdf; Addictions Ontario, Canadian Mental Health Association, Ontario and CAMH. Addressing Emergency Department Wait Times and Enhancing Access to Community Mental Health & Addiction Services and Supports (2008). http://www.ontario.cmha.ca/admin_ver2/maps/emergency_department_wait_times_submission_20080722.pdf iii Coristine, R. W., Hartford, K., Vingilis, E & White, D. (2007). Mental health triage in the ER: a qualitative study. Journal of Evaluation in Clinical Practice, 13(2), 303-309. doi: 10.1111/j.1365-2753.2006.00759.x iv CMHA Ontario. Rural and Northern Community Issues in Mental Health. September 2009. http://www.ontario.cmha.ca/backgrounders.asp?cID=289773. v Newton, A. S., Rosychuk, R. J., Dong, K., Curran, J., Slomp, M. et al. (2012). Emergency health care use and follow-up among sociodemographic groups of children who visit emergency departments for mental health crises. Canadian Medical Association Journal, 184 (12): 665-674. Doi: 10.1503/cmaj.111697. vi Schizophrenia Society of Ontario (2008). Reducing Emergency Room Wait Times for People in Psychiatric Distress: Recommendations from the Schizophrenia Society of Ontario. Retrieved December 10, 2012 http://www.schizophrenia.on.ca/images/stories/sso_er_paper_final_oct_20_2008.pdf; Addictions Ontario, Canadian Mental Health Association, Ontario and CAMH. Addressing Emergency Department Wait Times and Enhancing Access to Community Mental Health & Addiction Services and Supports (2008). vii Archie, S et al. (2010). Ethnic diversity and pathways to care for a first episode of psychosis in Ontario. Schizophrenia Bulletin 36 (4): 688-701. viii CMHA Ontario. “Emergency Room Wait Times.” http://www.ontario.cmha.ca/policy_and_research.asp?cID=218226 ix Mental Health Commission of Canada (2009). Improving mental health services for immigrant, refugee, ethno-cultural, and racialized groups. http://www.mentalhealthcommission.ca/SiteCollectionDocuments/Key_Documents/en/2010/Issues_Options_FINAL_English%2012Nov09.pdf x Mental Health Commission of Canada. 2011. xi Mental Health Act. (1990). (Accessed from the Internet, February 1, 2013.) http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90m07_e.htm xii Provincial Human Services and Justice Coordinating Committee. (2011). Police & Mental Health: A Critical Review of Police/Mental Health Collaborations in Ontario. (Accessed from the Internet, February 1, 2013.) http://www.hsjcc.on.ca/Uploads/PHSJCC_Police-MH_Final_Report_January_31_2011.pdf

http://www.schizophrenia.on.ca/images/stories/sso_er_paper_final_oct_20_2008.pdf

http://www.ontario.cmha.ca/admin_ver2/maps/emergency_department_wait_times_submission_20080722.pdf

http://www.ontario.cmha.ca/admin_ver2/maps/emergency_department_wait_times_submission_20080722.pdf

http://www.ontario.cmha.ca/backgrounders.asp?cID=289773

http://search.proquest.com.ezproxy.library.yorku.ca/indexinglinkhandler/sng/au/Newton,+Amanda+S,+PhD/$N?accountid=15182

http://search.proquest.com.ezproxy.library.yorku.ca/indexinglinkhandler/sng/au/Newton,+Amanda+S,+PhD/$N?accountid=15182

http://search.proquest.com.ezproxy.library.yorku.ca/indexinglinkhandler/sng/au/Dong,+Kathryn/$N?accountid=15182

http://search.proquest.com.ezproxy.library.yorku.ca/indexinglinkhandler/sng/au/Curran,+Janet/$N?accountid=15182

http://search.proquest.com.ezproxy.library.yorku.ca/indexinglinkhandler/sng/au/Slomp,+Mel/$N?accountid=15182

http://www.schizophrenia.on.ca/images/stories/sso_er_paper_final_oct_20_2008.pdf

http://www.ontario.cmha.ca/policy_and_research.asp?cID=218226

http://www.mentalhealthcommission.ca/SiteCollectionDocuments/Key_Documents/en/2010/Issues_Options_FINAL_English%2012Nov09.pdf

http://www.mentalhealthcommission.ca/SiteCollectionDocuments/Key_Documents/en/2010/Issues_Options_FINAL_English%2012Nov09.pdf

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90m07_e.htm

http://www.hsjcc.on.ca/Uploads/PHSJCC_Police-MH_Final_Report_January_31_2011.pdf