Visions Journal

A Systems Approach to Accountability

Catharine Hume

Reprinted from "Seniors' Mental Health" issue of Visions Journal, 2002, No. 15, pp.41-43

In 1999/2000 as part of a mental health system review conducted in what was then the North Okanagan Health Region (NOHR), CMHA BC Division completed a Regional Seniors’ Mental Health System Progress Report.

CMHA BC and the NOHR heard from over 200 respondents, including seniors who had received mental health services, family members of seniors receiving mental health services, mental health service providers, family doctors and a wide range of respondents external to the formal mental health system, including people from Continuing Care, Home Support, the Hospice Society, the Caregivers’ Association, and the Alzheimer’s Society, among others. Based on the information gathered, local Progress Report steering committees identified strengths of the regional seniors’ mental health system and areas for improvement.

System Strengths

Three areas of the seniors’ mental health system were identified as working particularly well in the North Okanagan. These three areas were the Geriatric Assessment Team, frontline mental health personnel, and support groups and companionship. The quotes that follow illustrate some of the key strengths identified.

• “In this last year we have been able to utilize a visiting psychiatrist service for our seniors (which is working well).” – Revelstoke Hospital

• “ [There were V]ery caring and supportive people (staff).” – family/caregiver (Vernon)

• “I have received help from various sources in the Shuswap but my group has helped me the most.” – senior (Salmon Arm)

The ability to get out for activities and companionship as well as attending information sessions and support groups were repeatedly identified by respondents as strengths of the system. This finding highlights the importance of bringing seniors together for support and mutual aid thereby reducing the isolation experienced by many.

Areas for Improvement

In addition to the strengths, the following three key areas for improvement were identified: increasing access to mental health supports for seniors, strengthening the integration of the seniors’ mental health system within the larger seniors support system and the community at large, and improving both the provision of information to seniors and caregivers and their involvement in decision-making.

Access

In the area of access, the following four key themes were identified: lack of knowledge of seniors’ mental health services among seniors and the general public, poor early identification of mental health issues among seniors, internalized barriers to accessing services among seniors, and limited seniors’ mental health resources particularly in outlying and remote areas of the region.

The area most identified as needing increased attention was the area of outreach and education with the goal of raising awareness about the supports and services available to seniors with mental health difficulties in the region.

• “I had trouble finding information ... felt like I had to fight to get anything.” – family/caregiver (Enderby)

• “The first bout I didn’t know where to turn to. Now I do.” – senior (Salmon Arm)

In terms of early detection, the findings suggested that mental health supports only become available at the point of crisis.

• “Problems go unnoticed or not reported until it becomes a crisis.” – crisis line (Vernon)

• “I believe that mental illness in the elderly often goes undetected. Therefore it is difficult to say they get the help they need.” – family doctor (Revelstoke)

A number of possible responses to improve early identification were suggested, including increasing general awareness of the early signs of mental health difficulties among seniors. Another barrier to effective early identification identified was seniors’ own internalized barriers to asking for help.

Increasing access to local and regional mental health services for people living outside the core service areas was also identified for improvement. While the Geriatric Assessment Team was identified as a key strength of the Vernon seniors’ mental health system, concerns were expressed regarding its accessibility to outlying areas. In addition, in Revelstoke at that time, very few respondents experienced the presence of a mental health system for seniors at all due to a lack of human and financial resources.

• “90% of resources are centred in Vernon. [This] makes access difficult for many.” – “external” (Armstrong)

• “We have no mental health services for seniors.” – “external” (Revelstoke)

Integration

The area of system-community integration, that is to say, the extent to which the mental health system for seniors works with, and responds to, external groups and the community as a whole, was also frequently identified by respondents as an area for improvement.

Within this area, the following three key themes emerged: the lack of role clarity between and among seniors’ mental health services, continuing care and community groups and organizations working with seniors, particularly with respect to the lack of clarity about criteria for involvement in specific services; the need to strengthen the involvement of family doctors in the seniors’ mental health system; and the lack of effective care coordination when multiple services are involved in a senior’s life.

• “The reality is that mental health and physical concerns are difficult to separate, so the artificial jurisdictional separation sometimes causes coordination problems.” – family doctor (Salmon Arm)

• “As a professional dealing with seniors, I need direction and I need someone sitting at the table with us weekly. We don’t have that.” – “external” (Revelstoke)

• “Fragmented, unclear communication regarding what services are available when and where.” – caregiver (Salmon Arm)

• “Stronger networking between the clergy and other mental health professionals (is needed).” – religious leader (Revelstoke)

Information and Involvement

Finally, in the area of providing seniors and caregivers with relevant and timely mental health and medication information, and meaningfully involving them in care decisions, two themes emerged. Firstly, the provision of information from the mental health system to seniors and caregivers tends to be passive; that is to say the onus is often on the senior or caregiver to ask for information and/or clarification rather than it being provided as a matter of course and in a way that is easily understood.

The second theme in this section was the finding that seniors are generally not involved in decision-making. A significant number of quotes from service providers within and beyond the mental health system suggest that some assume that seniors lack the competence and/or motivation to be meaningfully involved, either through the provision of information or direct involvement in decision-making. Quotes from seniors and family members, however, generally suggested that more information and involvement is needed.

There were a number of system-level findings that were common to both the adult and senior mental health system Progress Reports in the North Okanagan. Areas for improvement common to both systems included the need to:

While these findings are specific to the North Okanagan, it is likely that these broad areas for improvement are common to many local and regional adult and senior mental health systems.

Since the Progress Report was completed in 2000, a number of recommendations have been implemented in an attempt to improve local and regional mental health services. Involving seniors, their families and key external groups in accountability exercises such as the Progress Report has proven to be an effective way to create local momentum for change, as well as a concrete way to demonstrate the value of incorporating people’s direct experiences into mental health service reform efforts.

• “You have to ask the right questions.” – family/caregiver (Vernon)

• “There is a need for less medical jargon and more simple, down-to-earth information.” – religious leader (Vernon)

• “This information (re: the illness or medications) is usually given while the individual is still in crisis, during the early stages of medication, and the information is not retained or understood.” – residential facility (Vernon)

  • increase public awareness of existing mental health resources

  • strengthen early identification capabilities

  • ensure better access to core regional and communitybased services for people from outlying areas

  • create coordinated networks of services and supports

  • provide clear and helpful information to people with mental illness and their families.