[homeles_ot-l] Fwd: [New post] What Works: Reflections on Rural Mental Health Service Delivery

[Bill Dare]

Hello All,
This article by Gary Glover, Sharbot Lake Family Health team helps us
 reflect on our practice, rural or not!
Cheers, Bill Dare



[image: Site logo image] Bill Dare posted: "By Gary Glover Mental Health
Counsellor Sharbot Lake Family Health Team  I have been challenged to
reflect on my front-line observations of what works and the barriers to
effective provision of mental health and addictions services from my
perspective " Social & Health Practice Ottawa
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What
Works: Reflections on Rural Mental Health Service Delivery
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Bill Dare

May 16

*By* *Gary Glover
<http://www.sharbotlakefht.com/?page_id=1395#:~:text=Gary%20uses%20that%20education%20and,and%20other%20problematic%20coping%20behaviours.>
Mental Health Counsellor Sharbot Lake Family Health Team *

I have been challenged to reflect on my front-line observations of what
works and the barriers to effective provision of mental health and
addictions services from my perspective currently working as a mental
health counsellor in a small rural Family Health Team. I previously worked
for several years for an urban non-profit adult Mental Health and
Addictions agency. At that agency I worked out of the urban central office
for a time doing strictly intakes and then for a time doing my own intakes
and then providing counselling. From there I worked in a number of the
small-town satellite offices doing counselling and my own intakes as well
as developing a “drop in/same day” program and then moved on to several
years as the concurrent disorders counsellor in the rural and remote
catchment area of that agency, including two years working at the OPP
sponsored “Situation Table” developed to address imminent risk situations
and respond to emergent mental health and addictions issues. Prior to that
I worked for several years delivering a mandated domestic abuse program.
Before entering the social services field, I farmed for 30 years and worked
in various blue-collar jobs to support my farming habit. This is the lens
that informs this reflection.

Working two days a week for the family health team is easily the most
effective provision of mental health services I have ever experienced. This
is a personal musing on what makes that so and what might make it even
better. One of the key ingredients is the multi-disciplinary team approach.
As a social worker trained in the “structural approach”, I tend to view
mental health and addictions issues as coping behaviours rather than
illness or genetic programming, so my approach is less about “diagnose and
treat” than the approach of the medical clinicians I work with, but working
with doctors and nurse practitioners and occupational therapists and
dieticians and mindfulness practitioners, and caring front office and back
office staff provides a wholistic and client (patient in their terms)
centered approach, which allows trust building and engagement on whatever
level the person is able to engage at. An additional strength of course is
the fact that the staff are embedded in the community to a large degree and
know the history and context for almost everyone who accesses the services,
often going back generations.

This highlights another critical factor which is what could be called the
“culture” of the team. Ours was largely created and maintained by the
attitude of the founding Doctor who developed the team in response to what
he saw as community need and effective response to those needs. He has been
in this practice for over 50 years and takes great and justifiable pride in
accepting as a patient anyone who lives in “his” community. This raises
obvious problems with workload and capacity for all of us (and particularly
for him). This is not the way things are done anymore and finding anyone to
help him move into retirement is an ongoing issue.

Despite the problems this creates, it seems to me that it highlights what
is the most important in terms of “What Works?”, which is summed up in my
mind as “Inclusion”. This is evidenced in every aspect of the team culture
and service delivery, from the willingness to accept new patients, to the
provision of an urgent care clinic on Saturdays for the seasonal and
resident population, to the wholistic approach that includes mindfulness
and nutrition and physical activation, to the physician coming and spending
an hour with me talking to a suicidal client, to the front desk staff
knocking on my door and asking me if I can talk to someone who is really
distressed, to the Doc telling me “it’s easier to put out a campfire than a
forest fire”, and “no-one gets better on their own” when I ask if it’s ok
to provide counselling to a non-patient who is related to a patient.

This is in total congruence with modern neuroscience and countless studies
which show the primary effect of any mental health counselling has less to
do with the “franchise” modality than the actual relationship of
trust/safety and non-judgmental acceptance of the whole person.

If we then look at barriers to inclusion or even name it as “exclusionary
criteria” which prevents building relationships of safety/trust and
development of self-awareness and effective skills for maintaining good
mental (and physical) health, what do we see?
At the local level, it comes down to limited access to human resources in
terms of time and scope of practice. In terms of mental health and
addictions service delivery, there are services I cannot provide within my
two days a week or with the training and skills I have. I cannot provide
effective child mental health services, marriage and family counselling,
intensive trauma or crisis work, casework services, intensive personality
behaviour skills development, psychiatric diagnosis, medication assessment
and review, intensive support with addictions issues and other specialized
services.

In order to address these client needs, our lead physician instituted a
weekly mental health rounds which includes external providers of these
services. Most of these external providers come from urban based agencies,
including hospital-based services. Pre-covid, the rounds were held in
person and were very collaborative and collegial, working within the
inclusive culture of the FHT. Client needs would be discussed and
coordinated plans formulated in a timely and responsive manner and adjusted
as the need arose. It worked extremely well. There was what we think of as
“warm hand offs”, where clients would be introduced to another provider by
someone that they had an existing level of trust with. There was the
minimal paperwork required to maintain continuity and ensure accountability.

Since covid, the rounds have changed to virtual meetings. While this has
simplified the ability for different agencies to attend and reduces time
lost to travel, which can be better spent seeing patients, the lack of
direct face to face meetings makes it harder for participants to engage as
effectively in a collaborative way. An outcome of this has been a change to
more formal processes between agencies where the warm hand off from agency
to agency has shifted to a more paper and non-healthcare provider
process-based system that has resulted in delays for patients to receive
the care that they need. Specific issues include:

• new and restrictive definition of “circle of care” which precludes use of
any client identifier information for rounds discussion with some of the
larger urban based agencies.

• insistence that all referrals must first go to a central wait list for
intake assessment (resulting in a 4to 8-week delay before care is
delivered). This system also does not allow for reference to geography or
skills of a receiving healthcare provider and does not utilize the
referring providers knowledge of the care needs of the patient.

• requirement that all residential treatment for addiction requires GAINs
assessment. I was trained to administer the GAINs assessment and found it
to be a shaming and disempowering experience for clients that triggered
lots of trauma dissociation and served no therapeutic purpose.

• paperwork requirements on top of intake requiring extensive ongoing
documentation. I was told in my final days with an urban based agency that
the expectation was to spend sixty percent of my time on paperwork and
forty percent of my time providing services to clients. Is this good use of
scarce mental health human resources in a time of high patient need levels?

• strict policies that remove patients from the care system: three missed
calls and you’re out. Cell service in rural areas is spotty at best and
poverty prevents access to reliable communication and travel. In a typical
day I will have a cancellation due to weather, illness, travel issues,
phone issues, anxiety, family emergency, etc., etc. By definition, I am
dealing with people whose lives are in some disarray and sometimes that
means that a session with me is not their top priority. Accepting this has
the positive feature of allowing me to respond quickly to requests for
contact and at least check in with the person.

• limited number of sessions. It is unrealistic to think that every
client’s needs can be met in a limited number of sessions. With every
client at the FHT, I am able to tell them that I want to be there for them
when and if they need me and get out of the way when they are living their
life. Mental health is not a defined treatment regimen such as antibiotics
that are done in ten days. The nature of patient mental health needs
requires an element of flexibility in appointments needed: some will need
less - some will need more. The system has become less responsive to the
needs of the patients in this aspect.

• rejection of referrals based on geographic service delivery boundaries.
We are located close to the boundaries of two health “areas” (used to be
called LHINs) and our people may have an address in one service “area” and
actually live in the other area. They also access all types of services
across these artificial boundaries. For instance, I deal with clients that
receive hospital care in at least 10 different hospitals in two different
health “areas”. (I don’t even know what to call them anymore). As Ontario
Health Teams evolve in their mandate to provide more seamless care across
the system, this needs to be explored and patient access to care,
especially mental health care where residency can change frequently needs
to be approached from an inclusive rather than exclusive viewpoint.

• varying eligibility criteria for service provision and rejection of
referrals based on those criteria. For instance, one service requires three
hospitalizations before service can be provided, another service requires
psychiatric diagnosis, another service has decided that trauma has nothing
to do with mental health or addictions issues, other services would require
re-location to an urban center to access (intensive casework such as ACT).
This approach is exclusionary rather than collaborative and reliant on the
judgement of the primary care providers who know the patients the best.

There are also the exclusionary criteria applied for mental health services
when people present to emergency wards at hospitals. It takes a lot for
someone with a mental health issue to go to a public hospital. To be sent
home without a plan for effective follow-up after being screened for
suicidality (typically after a lengthy delay) deepens a sense of despair
and hopelessness for so many people. It reminds me of the one client who
presented to six different hospitals and was refused help at all of them
until she went into the parking lot at the last one and slashed her wrists.
She was smart about it… transverse superficial cuts but she realized that
was what it would take to get the help she needed.

It is frustrating because these exclusionary criteria make it difficult for
competent and caring clinicians to do their job and provide the necessary
care to patients. In some ways this can be seen as a contrast between urban
and rural ways of doing things. I remember reviewing the literature on
differences between urban and rural social work delivery when I was at
university and the key difference was that in a rural/remote environment
with limited resources, people relied on themselves and a network of other
personally known and trusted providers to stretch their scope of practice
to get the job done. In in urban work, patient volume tends to result in a
more impersonal system of resource use and clinicians have to feed the
algorithm and it spits out the result (eventually… maybe). While the goal
may be efficiency it results in data heavy inefficiency, especially in the
rural environment where the data on hand is often already sufficient for
the purpose.

I recently participated in a research study looking at the experience of
mental health counsellors working in mostly rural or otherwise marginalized
populations. The common experience is definitely that most of our people
are unable to get through the maze of exclusionary criteria to access any
of the specialized programs and it’s “just easier” and quicker in the end
to deal with it ourselves. I’m hoping this is just a flaw in the system
that can largely be attributed to urban (volume-based) systems not being
attuned to rural culture but certainly many of my clients see it as a
design feature and take it as further proof of their marginalization and
invisibility.

I don’t think that the FHT is the only model for effective service
delivery, and indeed, without the inclusive culture of our team, it could
be just as ineffective as any other part of the system.

Another effective model is the “Situation table” which I had the good
fortune to work with a few years ago. This was initiated out of a
realization by some local OPP officers that a huge percentage of their
calls were for mental health and addictions issues and that this is outside
their mandate but as one officer explained to me, “We’re the only ones that
can’t say no”. When the call comes in, they are required to attend.

This collaborative table was attended by most of the social service
agencies in the county including school board reps, mental health and
addictions, social services, victim services, probation, child welfare,
etc. Anyone could bring a “situation” to the table and describe it using
non identifying information. It was then assessed for risk and if the
threshold for imminent risk was met, identifying information would be given
and the agencies would check to see if they had involvement or should have
involvement depending on their criteria for service delivery. Whoever felt
that the situation was included in their criteria would get together,
formulate, and carry out an action plan immediately. In the first year I
believe that myself (as the concurrent disorder worker) and the probation
officer who sat at the table responded to something like sixty percent of
the situations because ours were the only criteria inclusive enough. This
eventually levelled out as other agencies began to see how effective this
type of response was and enabled their staff to respond. I don’t recall the
exact numbers but there was a remarkable drop in police calls and emerg.
presentations for the folks who were provided service through this effort.
The dual successes of this approach were that the patients got the right
kind of support to serve their needs and the load on the judiciary system
was reduced by diverting people that didn’t need to enter a judicial
process.

Again, the success of this endeavour came down to the cooperative culture
created by the coordinator of the program and the leadership of a couple of
the OPP officers. Reports back from other situation tables where this
inclusive approach was not taken did not tend to have the same positive
results.

These are models that I have seen work. I believe that is largely due to
their inclusive, adaptive, and timely response.

In order to illustrate what all this means in a real-life situation; it has
been suggested that I present a fictional situation to illustrate what
works and what doesn’t.

*Situation #1*
So, our receptionist knocks on my door and tells me she has a long time
(2nd generation) patient on the line who is really upset and asks if I can
speak to them. The lead physician in our clinic was her parent’s doctor and
actually delivered her and has been her doctor all her life, other than a
few years when she was out west. The client I was booked to speak to has
just called to say that she has a really bad headache so we have
rescheduled for 3 weeks from now, with the understanding that she will call
in the meantime and leave me a message for my “stand by list”, if things
get bad. We’ve discussed before that she could go to the hospital but on
three previous occasions when she did this, she was sent home without any
treatment after a lengthy wait in ER.

So, I am able to pick up the phone and “have a chat”. Quick song and dance
about limits to confidentiality and the story emerges of a woman who has
worked all her life in various blue-collar jobs and been through a number
of unsatisfactory relationships. She has three kids with two different
fathers. Two of them live independently and one is still at home and going
to high school. She has used alcohol and marijuana since she was in her
teens. A year ago, she met a man, and they developed what she describes as
the healthiest relationship she has ever been in. Her kids all like him and
he treats her with kindness and respect. They got married three weeks ago
and went to the Dominican for their honeymoon. She had reduced her drinking
and cannabis consumption to minimal levels in this new relationship but
drank heavily in the resort and ended up physically assaulting her husband,
who was subsequently hospitalized with non-life-threatening injuries.

They have returned to Canada, and he has moved out to live with his sister.
She is terrified that she has destroyed this relationship and determined to
end the control that alcohol has had on her life. Her children are furious
with her, and her entire life is out of control.
She asks me for immediate referral to an addictions counsellor. I tell her
I can do that and fill out the paperwork.

She asks when she will hear from them, and I tell her it will be about
three or four weeks. She tells me that she won’t be here anymore. It’s now
or never. We talk some more and I tell her I will call in a personal favour
and call a worker I know that can maybe get her hooked up with the AA
meetings today. I call this worker and she tells me that she will call the
woman today and relay the information but it’s really important that her
agency doesn’t ever hear that she did this, or she might lose her job,
because this client lives outside of her catchment area.

I call the woman back when I get a chance later in the day and my friend
has called the woman and she is going to a meeting in a neighbouring town
tonight.

I send in the referral and continue to check in with this client each week.
She finds a sponsor in AA and reports to me that she is able to maintain
sobriety and is working to rebuild her relationships.

Six weeks later she tells me that she got a call from the intake for
addictions services and thought she should go through the process but
became angry with the questions and told them she didn’t need their help
anymore.

Occasionally she calls me to discuss some of the incidents of childhood and
relationship sexual assault in her life that she is beginning to recognize
she was self-medicating with alcohol to cope with. I would like to refer
her for intensive trauma therapy, but the publicly funded system does not
provide this and she doesn’t have the money for enrolment in a fee for
service program.

*Situation #2*
A 32-year-old male is referred by the Nurse Practitioner for mental health
counselling. His family has been rostered with the clinic for 45 years and
live on a backroad about 20 minutes away. They live in this county, but
their mailing address is through a post office in the neighbouring county.
This man is also rostered with the clinic but has been living and working
in the city for years. Recently he was in an accident which resulted in a
brain injury and severe body trauma. He has recovered mobility but still
suffers chronic pain which appears in different parts of his body and has
proven difficult to diagnose or treat. His relationship in the city broke
down and he has moved back with his family but there is constant conflict
with his father. He managed to buy a lot just outside the village and a
mobile home to put on the lot with his savings and the insurance money but
had run out of money before he was able to do the municipally required
upgrades to septic and hydro. He is eligible for some grant money and would
also receive some money if he was able to do his taxes, but the brain
injury keeps him from organizing his paperwork and he gets frustrated and
reactive, and this alienates his family further.

We agree that it would be good to get a caseworker to help him sort through
the paperwork and move towards getting into his home. I fill out a referral
and fax it in. I ask the caseworker at the next mental health rounds if she
has received or even seen the referral. I cannot refer to this client by
name, only first name and last initial. His is a common name in the area.
This caseworker (who is excellent!) is only able to attend our mental
health rounds once a month and once a month her agency sends an intake
worker. I ask the intake worker the next time she is there. I keep asking
for 3 months, first the caseworker, then the intake worker (oh, except she
doesn’t show up at rounds a couple of times).

Finally, we discover that the referral was sent to the mental health
services in the next county, because the postal address was in that county.
When I call that agency, I am told that they will not provide casework
services because the property he is trying to move into is not in their
county, and in fact his residence is not in their county.

I resend the referral to the original agency explaining all the confusion.
They put him on the wait list for intake. Six weeks later they attempt to
call to do an intake but are unable to connect. I know that the cell
service is bad at their place and his parents also make it a point to not
answer any call with an unknown number and call to urge him to call them.
He does that but becomes angry with the questions and hangs up on them.

I have lost touch with this client. I saw his sister at the grocery store,
and she said he went back to the city, but they have lost touch with him
and are afraid he’s at the shelter and “probably using drugs” in her words.

These fictional scenarios are unfortunately based on real life situations.
It doesn’t have to be this way and some of the veteran clinicians in our
team assure me that it didn’t use to be this bad when we had collaborative
and timely client centered mental health rounds with external agencies.
They tell me, “They took something that worked… and broke it”.
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