PEEL REGION COMMITTEE FOR PERSON WITH A DUAL DIAGNOSIS REPORT ON SERVICE GAPS, MAY 2005

Submitted by the Peel Region Committee for Persons with a Dual Diagnosis

August 31, 2000

Contents

1. Introduction: the history of this document
2. Background information on the Peel Region Committee for Persons with a Dual Diagnosis
3. A perceptual snapshot of Peel Region
4. Identified needs of persons with a dual diagnosis in Peel
5. System design
6. Developing the system
7. Compliance with Dual Diagnosis Guidelines
8. Membership list of the Peel Region Committee for Persons with a Dual Diagnosis
9. Service Statistics

Section 1:

Introduction

Since the summer of 1997, communities across the province of Ontario have been actively engaged in the process of planning how to better meet the needs of persons with a developmental disability and mental health issues. These individuals, commonly referred to as persons with a dual diagnosis, have long been under served. This is due, in part, to 2 main factors.

Firstly, dual diagnosis is complex. The skills and knowledge required to provide appropriate services have only been developed within the last 10 years. The dissemination of this expertise is in its initial stages in Ontario. Therefore, it has been very difficult for persons with a dual diagnosis to receive effective comprehensive supports when staff at all levels have limited dual diagnosis education and training.

Secondly, the supports required by these individuals are delivered in Ontario by 2 different bureaucratic jurisdictions, the Ministry of Community, Family and Children's Services and the Ministry of Health. Unfortunately, these 2 Ministries have had totally separate geographical districts, budgets, planning processes, regulations, philosophies, and service delivery structures. While best practice in dual diagnosis requires cross sectoral planning and coordination, reality saw the 2 Ministries acting independently of each other, leaving persons with a dual diagnosis caught between them.

Fortunately, in the mid 1990's, the provincial government recognized the plight of persons with a dual diagnosis. The Ministry of Community, Family and Children's Services and the Ministry of Health jointly released the document entitled "Policy Guideline: the Provision of Services for Persons with a Dual Diagnosis" in July, 1997. In brief, the document confirmed that both Ministries were responsible for serving persons with a dual diagnosis, outlining the specific responsibilities of each.

The next step was to put the Policy Guideline into practice. In June, 1998, the 2 Ministries jointly released a companion document entitled "Dual Diagnosis Policy Guidelines Implementation Workplan". The Workplan described expected outcomes, target dates, and responsibility centres.

Some of these outcomes at both program and individual levels were the logical responsibility of service providers as well as the local District Health Councils and Regional Offices of the Ministry of Community, Family and Children's Services. Therefore, either local dual diagnosis committees were created to assist with planning or, as in the case of Peel Region, the existing dual diagnosis committees were recruited to develop the plan.

Therefore, the Peel Region Plan has been produced by the Peel Region Committee for Persons with a Dual Diagnosis, with the assistance of the Halton-Peel District Health Council and the Central West Regional Office of the Ministry of Community, Family and Children's Services.

Section 2:

Background Information on The Peel Region Committee for Persons with a Dual Diagnosis

The Peel Region Committee for Persons with a Dual Diagnosis has been in existence since 1990.

From its inception, our Committee has been cross sectoral, with representatives from both developmental and mental health services. (Please see Section 8 for a list of Committee members) Our focus has been on the systemic level, with an emphasis on developing cross sector partnerships.

Throughout the years, we have carried out a variety of functions:

• provision of several dual diagnosis training events for staff from both sectors
• consultation to staff regarding specific clients with a dual diagnosis
• identification of service needs through 2 surveys of service providers and through focus groups with both family members and service providers
• systemic advocacy through participation in planning processes such as Mental Health Reform and Making Services Work for People
• design of the ideal system
• submission of proposals for staff development and for a Dual Diagnosis Facilitator (unfortunately neither were funded)

A by-product of our long term existence has been the nurturing of countless informal cross sectoral collaborations and consultations. Recently, we have recognized the need for a more formalized coordination of the human service system in Peel Region to better serve and support persons with a dual diagnosis. Therefore, we certainly agree that now is the appropriate time to develop a structured system.

Thus, the Peel Region Committee for Persons with a Dual Diagnosis was pleased to assume the responsibility of producing the Dual Diagnosis Plan and System Design for Peel Region.

We believe that this Plan builds upon the already existing strengths in Peel Region, while identifying issues. Most importantly, the Plan includes specific recommendations for dealing with these issues and provides our Committee with a blueprint for its work over the next several years.

Section 3:

A Perceptual Snapshot of Peel Region

Peel Region is in the "905" area bordering the City of Toronto on the west. As of the date of this report, March 2000, Peel Region is the second largest municipality in Ontario.

There are many factors about our Region which have impacted on the development of this document:

• A large and rapidly growing population - currently, there are approximately 900,000 residents of Peel. The Planning Department of the Regional government has forecasted that the population will reach 1,206,900 by the year 2011 and 1,327,900 by the year 2021.
• a culturally diverse population - approximately 40% of Peel's residents are non Canadian born. Furthermore, approximately 25% of Peel residents have identified that they speak a language other than English or French at home. Therefore, human services must be provided in a manner that is both accessible to a multicultural population and culturally sensitive.
• a mix of urban and rural communities - Peel Region consists of the city of Mississauga, the city of Brampton, and the town of Caledon. Mississauga is a large urban centre of approximately 585,000 people in the south of Peel Region. North of Mississauga is Brampton, a city of 285,000 which has a urban core surrounded by farmland. Caledon, with a population of 46,000, is in the rural north of the Region, geographically spread out with small villages dotting a relatively unpopulated countryside.
• limited transportation - one key concern for the residents of Peel is the fact that public transportation is limited. It is difficult for people to conveniently travel from the north to the south of the Region, and just as difficult to travel east to west in some areas. Travel to Toronto is very time consuming from most of the Region. Therefore, it is critical that services be provided "close to home" so that they are realistically accessible to both clients and families.
• chronic under funding of human services in Peel - Peel Region receives per capita funding for its health and social services which lags far behind the average for the province of Ontario. As our population soars, we fall even further behind. Therefore, the citizens of Peel Region are faced with extremely limited resources to meet a growing demand. This issue impacts on persons with a dual diagnosis who require services from 2 significantly underfunded systems.

For the planning purposes, it has been important to determine the number of individuals with a dual diagnosis living in Peel Region. Commonly accepted practice has been to estimate that approximately 1% of the population could be identified as having a developmental disability and approximately 30% of those persons would have a dual diagnosis.

Therefore, in Peel, we can estimate that 9,000 people have a developmental disability and about 2,700 would have a dual diagnosis.

It is clear that we are dealing with a significant number of individuals with a dual diagnosis in a geographic area experiencing rapid growth, considerable diversity, and critical under funding!

Section 4:

Identified Needs of Persons with a Dual Diagnosis in Peel Region

For several years, the Peel Region Committee for Persons with a Dual Diagnosis has been identifying the needs of persons with a dual diagnosis. This has been done through focus groups as well as the consultation process related to specific individuals.

For the purposes of this plan, it was decided to hold a community consultation meeting to ascertain up to date information regarding needs. This meeting was held in September, 1999. Participants included staff from several service sectors who spent the day discussing service needs in Peel Region.

The results of this meeting indicated that the following were considered to be service priorities for Peel Region:

• education/training of service providers
• housing
• family support(information, respite, recreation)
• meaningful day activities
• community awareness
• strengthening existing programmes
• improved access/empowerment
• clarification re the jurisdictions of different Ministries
• partnerships

Some of these priorities such as residential services require large amounts of new funding to deal with waiting list backlogs. However, others such as education and partnerships, could be accomplished through the development of a better coordinated system, bolstered by relatively minor amounts of financial support.

This information regarding priorities was very helpful and was utilized by our Committee when we conducted our planning of the system design.

Section 5:

Peel Region Dual Diagnosis System Design

When designing the dual diagnosis system for Peel Region, our Committee had several key goals:

• to build upon the cross sectoral coordination and good will which we already have in Peel Region
• to utilize the strengths of the Peel Region Committee for Persons with a Dual Diagnosis which has a long history and represents considerable expertise
• to develop creative ways to improve service delivery that are low cost, or no cost, thus maximizing existing resources
• to recognize services/supports that are needed which will realistically require new funding
• to identify new partners who could potentially enhance the dual diagnosis system through the extension of their existing services

The System is represented in a diagram on page 11. The following is a description of this diagram which explains in some detail what the diagram represents.

Level One: Joint Planning and Funding

Superimposed over the local system is Joint Planning and Funding between the Ministry of Health and the Ministry of Community, Family and Children's Services at provincial and local levels. It is crucial to recognize that several of the issues related to access and coordination of the 2 service systems require cross sectoral commitment at the highest level of the system.

Level Two: The Peel Region Committee for Persons with a Dual Diagnosis

The Peel Region Committee for Persons with a Dual Diagnosis

Our Committee overlooks the entire system with generalized functions: education/training(in conjunction with Halton as is appropriate); consultation to service providers and consumers, particularly with regards to best practices, general recommendations, and brain storming regarding individual clients; and advocacy on a systems level. To fulfill these functions more effectively, our Committee should link in a more formal way with other existing planning/advisory bodies in Peel Region regarding services that pertain to dual diagnosis.

Consumers/Families:

Consumers and families are the ultimate purpose for the system and their needs should drive what happens. The Committee and Consumers/Families relate informally, with the Committee providing support re systemic issues. Input from consumers and families will be obtained as needed through focus groups, surveys, etc. as our Committee has previously done. There is no plan to change the Committee format to include consumers or families at this time.

Level Three: Referrals

This box does not represent a specific entity or organization but rather the function of referral as the entrance point into the system. It is important to understand that anyone could be the source of referrals. Therefore, in the box we could place the labels families, professionals, and consumers.

Level Four: Information/Web Site/Intake/Protocols/Dual Diagnosis Resource Contact /Tracking

This box represents the supportive functions for the system. Information would be available to service providers and/or families. This could happen through an existing information line(such as Coordinated Info Peel), a web site, or consultation with others. Some people may just need information and require no further services.

However, formal intake would also take place at this level. Service protocols would be established to ensure that there was coordination of the intake function so that clients could get the service they need quickly and without continual repetition of the intake processing. As well, a mechanism would be developed to "track" persons with a dual diagnosis. This would be done to ensure that people are not falling between the cracks and to identify service gaps. All ethical and legal requirements related to confidentiality would be strictly adhered to in this process. This information could be used to identify clients with high priority need when services became available. Also, the information would be of great assistance when planning for service expansion or creation if any new funding were allocated to Peel Region.

The "dual diagnosis resource contact" concept is crucial to this System. Basically, each agency that supports persons with a dual diagnosis would designate a "resource contact person re dual diagnosis". This person would be responsible for being knowledgeable about how to network in the system, e.g. who to call for an assessment for a client. The dual diagnosis resource contact would not be an "expert in dual diagnosis" with regards to clinical information, but with regards to networking. Other staff in the same agency could contact the dual diagnosis resource person regarding their clients. As well, external agencies would use this resource contact person as a liaison.

The involvement and support of agencies' intake workers is integral to the success of the tracking and resource contact processes. Joint education for intake workers will be critical, especially with regards to services offered by Coordinated Info Peel, the web site, and the dual diagnosis resource contact process. As well, since intake workers are already extremely busy, the new processes should be designed in a streamlined manner to minimize the amount of "new work" added to agency staff.

Level Five: Assessments

Assessments of different kinds by either system occur at this level. Given the complexity of dual diagnosis, multidisciplinary assessments are best practice. As well, the term assessment in this context is broadly defined and incorporates a variety of disciplines. Therefore, psychiatric, social work, psychological, residential, vocational, and several other types of evaluations would be included. This requires the coordinated involvement of several agencies.

Level Six: Continuum of Services

This represents the continuum of services. It includes both major systems as well as other jurisdictions such as housing or education.

Level Seven: Mobile Crisis/Case Resolution

Mobile crisis and case resolution are supportive functions which act, in a sense, as a foundation for the system as a whole. Therefore, they are placed at the bottom of the system design diagram to represent this supportive role, not because they are the last services accessed. In fact, mobile crisis and case resolution fulfill specific short term functions and can refer into the system at any level.

It is anticipated that the dual diagnosis system will coordinate with the children's mental health sector with regards to "transition aged youth" in the 16 to 18 year old range. This is particularly relevant in light of the recent initiatives with respect to mobile crisis response in the children's mental health system. The two systems should make every effort to ensure that there is seamless support for these young people. One way of doing this is to include representatives from both systems on any planning or advisory bodies related to the news services.

Outside any Level but Relating to the System as a Whole: Case Management

The case managers from each system are placed outside the direct service organizations, receiving referrals from any source, and making referrals to any point in the system. Case managers are not necessary and referrals into the system can occur without a case manager.

In Summary

Level Four is key to the functioning of this system. It represents an addition to the existing system, with crucial supports to both professionals and consumers/families. It is important to stress that the supports represented at this Level can be put into place with relatively minor amounts of funding. They build on the strengths of the current system by providing:

• the availability of coordinated information
• various consultation mechanisms
• supports to education, training, and dissemination of best practice
• linkages between agencies within and across sectors through the dual diagnosis resource contact mechanism
• identification of gaps in services
• tracking of individuals to ensure that people are not "lost" and that priorities are identified with regards to individual client needs

Section 6:

Developing The System

Developing a comprehensive dual diagnosis system requires the creation of a workplan which describes what actions are required, who will be responsible for these actions, and when these actions should be completed.

The Peel Region system design indicates that there are several levels of service delivery to be considered. Specifically, there are specialized regional services, specialized district services, and community support services.

The following 2 pages are the workplans for the creation of the Peel Region dual diagnosis system.

The workplan is comprised of 2 charts. The first describes the regional and district levels while the second focuses on the community support level.

Section 7:

Compliance With Dual Diagnosis Guidelines

Two of the categories of Performance Measures and Outcomes pertain to local dual diagnosis committees. These are both under "Cross Sector Partnerships will Exist" and refer to the Program Level and the Individual Level.

The following is a summary of the measures undertaken in Peel Region to comply with the Performance Measures and Outcomes under these categories. It is important to state that some of the outcomes will not be identical to those stated in the original Guidelines. This is due to the fact that outcomes should be individualized for each community and thus the outcomes stated below are tailored to the needs of Peel Region.

Cross Sector Partnerships will Exist at the Program Level:

Cross Sector Dual Diagnosis Committees will exist:

The Peel Region Committee for Persons with a Dual Diagnosis, which is cross sectoral, has been in existence since 1990.

Common "Assessment"/Intake Tools:

It is crucial to recognize the fact that the mental health and developmental services systems have been engaged in developing their own assessment/intake tools.

The developmental services sector has established common assessment/intake formats as per the requirements of Making Services Work for People. Some of the mental health providers in Peel Region have worked together to develop a common assessment/intake format. This has not been adopted by all the mental health providers.

The most efficient method of ensuring coordinated assessment/intake for persons with a dual diagnosis would be to work with the 2 processes that have been so painstakingly developed, rather than trying to introduce a 3rd process specific to dual diagnosis.

Actions required to achieve compliance:

1. The mental health sector develop a common assessment/intake tool which will be used by all mental health service providers.
2. Each sector add specific questions regarding dual diagnosis to their already existing formats. For example, the Making Services Work for People format could have a small number of questions designed to investigate if the individual is dually diagnosed - "Do you receive services from a mental health programmes?"

Coordinated Access Points:

The developmental services sector in Peel Region has established a process in which there are multiple access points but all these points utilize the same assessment/intake tool. The mental health sector does not yet have a coordinated access system. As per the previous item, the most efficient method of coordinated access would be to utilize common tools within the access systems that are developed by each sector.

As well, Peel Region is exploring the possibility of inserting a specific dual diagnosis information subdirectory into the existing Making Services Work for People coordinated information system which is Coordinated Info Peel, a phone service operated by the Peel Child Care Committee. This would play a significant role in coordinating access. The current Directory of Dual Diagnosis Services for Persons Living in Peel Region, published by the Peel Region Committee, would be incorporated into this.

Actions required to achieve compliance:

1. Mental health service providers develop a coordinated access system.
2. A dual diagnosis subdirectory be added to Coordinated Info Peel.

Dissemination of Best Practices/Joint Staff Training:

These 2 outcomes are linked since effective staff training would disseminate up to date information regarding best practices in the field. The Peel Region Committee for Persons with a Dual Diagnosis has conducted a survey to determine local staff training needs. It has struck a joint subcommittee with Halton Region to explore potential joint training ventures. This will be conducted utilizing, in part, the dual diagnosis training curriculum which is being produced by the Habilitative Mental Health Resource Network, the Ontario Chapter of NADD. Furthermore, a volunteer is currently researching best practices for the Peel Committee.

As well, our Committee has approached Coordinated Info Peel with respect to the potential of creating a dual diagnosis web site for Peel Region. This site would provide a training calendar, link to sources of training materials, and list up to date resources, including the best practices information compiled by our volunteer. Actions required to achieve compliance:

1. A Peel Region Dual Diagnosis Web Site be developed, in conjunction with Coordinated Info Peel.
2. Halton and Peel Regions work together to deliver coordinated staff training where appropriate.
3. The best practices information be added to the Web Site.

Cross Sector Partnerships will Exist at the Individual Level:

Flexible Admission Criteria:

It has been our experience that flexible admission criteria already exist in Peel Region. The main barrier to service access, as identified by service providers on several occasions, is lack of knowledge and expertise in dual diagnosis. This would be addressed by the Dissemination of Best Practices/ Joint Staff Training process as discussed above.

Cross Sector Case Management Buddy System/Telephone Support Services:

Given the nature of Peel Region, with its relatively small number of services and case managers, it has been decided that the most effective way to address these issues would be to have 1 agency take the lead role with each specific client, thus becoming the primary case manager. This case manager would consult as required with: the Peel Region Committee for Persons with a Dual Diagnosis, other service providers through the web site and by phone, and staff at Coordinated Info Peel. The case manager would be chosen from the service system which would be the most logical for the client, based upon his/her needs.

Actions required to achieve compliance:

1. The system of primary case manager, with access to multiple sources of consultation, be utilized in Peel Region.

Multidisciplinary Specialized Teams:

With the extremely limited resources in Peel Region, and the lack of specialized dual diagnosis supports, it is practical to make optimum use of what is available. Therefore, an team would be developed for each client that is individualized, based on the service needs that are identified by the client and/or family.

Actions required to achieve compliance:

1. The system of individualized teams be utilized in Peel Region

Section 8:

Peel Region Committee for Persons with a Dual Diagnosis: Membership as of January, 2009

Section 9:

Service Statistics