Towards Recovery: The Mental Health & Addictions Action Plan for NL NLHHN Conference

1. Towards Recovery Towards Recovery: The Mental Health & Addictions Action Plan for NL NLHHN Conference April 26, 2018

2. How we think learning, knowledge, flexibility, innovation, creativity How we feel coping style, mood, emotions, subjective wellbeing How we behave (relationships with others) listening, communicating, co operating, empathy, tolerance Mental well being: Meaning and purpose sense of coherence, values, goals, spirituality, politics, beliefs With good mental health and well-being we can manage emotions (and behavior), handle stress, build relationships, have better health outcomes and lead productive and fulfilling lives. Mental Well Being

3. Two Continua Model: Mental Health and Mental illness

4. Physical Environment Income and Social Status Education Genetics/Biology Employment and Working Conditions Social Environments Social Support Networks Gender Culture Personal Health Practices and Coping Skills Health Services Personal Health Practices and Coping Skills Social Determinants of Health

5. Meta Analysis of comparative odds of decreased mortality Source: Holt-Lundstad et al 2010

6. Adults who experienced 4 or more categories of adverse childhood exposure compared to those who had experienced none had: 7.4 fold increase for alcoholism 10.3 fold increase for drug abuse 4.6 fold increase for depression 12.0 fold increase in suicide attempts 2.2 fold increase in smoking 2.2 fold increase poor self-rated health 3.2 fold increase in > 50 sexual intercourse partners 2.5 fold increase in sexually transmitted infection Childhood Adverse Experiences

7. And also… 2.2 fold increase in ischemic heart disease 1.9 fold increase cancer, 3.9 fold increase in chronic lung disease 1.6 fold increase in skeletal fractures, 2.4 fold increase in liver disease. Results

8. What keeps some people with mental illness flourishing? Risk Factors are not predictive factors due to protective factors (Bell, 2012) Resiliency & Protective Factors

9. Parental resilience Social Connections Knowledge of Parenting and Child Development Concrete support in times of need Social and emotional competence of children Protective Factors for Families

10. Social and Emotional Competence • The ability to: • accurately recognize one’s emotions and thoughts and their influence on behavior • regulate one’s emotions, thoughts, and behaviors effectively in different situations • take the perspective of and empathize with others • establish and maintain healthy and rewarding relationships • make constructive and respectful choices about personal behavior and social interactions

11. Mental Health in NL • 73.6% report perceiving excellent/very good mental health • 6.8% with diagnosis of Mood disorder: depression, mania, bipolar, dysthymia • Suicide rate (2012): 9.2 /100,000 overall but 3X higher in Labrador • 10.6% have had contact with a MH professional • 31.3 % of all mental illness /addictions hospitalizations in NL are at Waterford (Psychiatric) Hospital in St. John’s • 29.1% of total days in hospital for MH/A reasons were Alternate Level of Care • Total MH/A Expenditures for 4 RHAs: $128.6 M (5.7% of all RHA Exp.)

12. Provincial Volume • 21,000 referrals to MH/A counselling services yearly • 12,000 crisis calls yearly to the crisis line. • 3000 admissions to inpatient mental health and addictions services yearly • Top reason for admission in all RHAs is depression • 15% of all mental health and addictions hospitalizations in Newfoundland and Labrador are for treatment of concurrent mental health and addictions conditions. • 15% were involuntary admissions under the Mental Health Care and Treatment Act • On over 500 occasions last year someone in NL was detained for up to 72 hours under the MHCTA

13. What is the MH/A System? Comprised of: • Individuals and Families • Primary health care providers (family physicians, pharmacists, community health nurses) • 4 Regional Health Authorities • Community agencies: Choices for Youth, Stella’s Circle, Community Mental Health Initiative, U-Turn CHANNAL, EDFNL, CMHA, SSNL, Turnings…and more • Private practitioners (psychologists, psychiatrists, social workers, counselors)

14. Police, Correctional Settings, Legal Aid, MH/A staff in youth and adult correctional settings Indigenous Partners Schools, school counselors, ed psychologists, University Counseling Center Housing support services Income support services Womens’ Groups; Youth and seniors groups Transition Houses Employers Immigrant, refugee and distinct ethnocultural groups Groups/agencies for persons with disabilities Other community agencies (e.g., Association for Deaf, John Howard Society, Seniors Resource Center, Native Friendship Centers) National organizations-Mental Health Commission of Canada; Canadian Center for Substance Abuse and 0ther provinces/territories and countries Who We Collaborate With

15. Provincial Treatment Centres • The Recovery Centre -inpatient withdrawal management services-age 16 and over • Humberwood Treatment Centre –adult addictions • The Hope Valley Youth Treatment Centre – specialized addictions treatment services for youth age 12-18 • The Tuckamore Centre-specialized treatment for youth with complex mental health needs age 12-18 • Waterford Hospital- age 18 and over

16. All-Party Committee (APC) • All-Party Committee for Mental Health was formed by HoA in January 2015 to review the system and make recommendations for improvement. • 69 stakeholder groups participated • 70 presentations from individuals/groups • 11 sessions with experts • 9 Roundtable sessions with 292 participants • About 120 online submissions • Met with RHA senior leadership in each region

17. All-Party Committee Report Themes Need for improved mental health promotion and mental illness and addiction prevention Better access to more services; Better quality of care; Need for improved policy and programming; and, Need for strengthened community supports.

18. Promotion/Prevention (11 recs) Provide all new/young families with access to programs New school health and wellness framework Regional interdisciplinary teams for schools Review the roles of guidance counselors, instructional resource teachers and educational psychologists Post secondary promotion/prevention/early intervention programs Community coalitions to promote wellness/prevent suicide Eliminate stigma/discrimination Work together better Housing First Amend Residential Tenancies Act E Mental health for prevention/early intervention

19. Access to Services (12 recs) Replace Waterford with beds and services closer to home Reduce wait lists Implement stepped care and a range of services throughout the province Access to services via technology Health services in prisons to be responsibility of HCS Increase counseling services for inmates Replace HMP Review criteria for services for developmental disabilities, including ASD Primary health care access to specialized services Provide online information about services Conduct review of neuroleptic meds and meds for ADHD Advocate for better health insurance programs

20. Quality of Care (9 recs) Transition to recovery focused, person centered system Support Choosing Wisely guidelines Education for health & correctional staff Regulatory bodies to mandate MH/A training PHIA Review include needs of family members Standards and guidelines on including families/caregivers Information for families with primary care providers Increase # of NPs and physicians in addictions medicine

21. Policy & Programming (16 recs) Adopt harm reduction as a foundational approach Support sustained land-based programs 4-6 bed mental health unit in Labrador Recruit 2 psychiatrists for Labrador Regular psychiatrist visits to coastal communities in Labrador Education/training in mental health needs of seniors & LGBTQ2S Standards, policies & programs for gender-based needs Continue to support the opioid action plan Increase spending to 9% in 5 years Develop comprehensive inclusion policy Service standards for youth age 16-25 Action plans for alcohol abuse & suicide prevention Government adopt a health in all policies approach

22. Community Supports RHAs and Community Agencies work more closely together - Strengthen existing partnerships - Expect consultation and sharing of non confidential information to meet needs of population Develop adequate multi year funding models for community agencies

23. Recommendations that change how we do business Provide all young families with access to parenting programs that build protective factors; Replace Waterford with combination of beds and community services; using a stepped-care approach, offer a range of services throughout the province; Transition to recovery focused, person centered care; Adopt a harm reduction approach Provide access to evidence based services via technology; and, Assign responsibility for provision of health services in prisons to HCS system to improve health services for inmates.

24. Government’s Response Towards Recovery: The Mental Health and Addictions Action Plan for NL Policy direction to guide a provincial mental health and addictions system; Timeframes for substantial completion of each recommendation; guiding principles; and, Governance model.

25. Policy Direction for the Next 5 Years Policy Pillars: • Promotion, prevention and early intervention; • Focusing on the person; • Improving service access, collaboration and continuity of care; and, • Including all people everywhere.

26. 54 Recommendations Short-term Medium-term Long-term

27. “No More Us and Them” (Bartram & Mulvale, 2016)

28. Governance 8 project teams Implementation team executive committee mental health & addictions advisory council recovery council

29. Governance & Performance Monitoring Implementation Team

30. Health in Schools • Lead: Brad Clarke, EECD • Working Groups: SEL advisory group, curriculum working group and professional learning working group • Goals: 1 APC rec • Develop K-8 SEL curriculum • Select student and teacher resources • Create professional learning plan and resources • Monitor & evaluate both PL and SEL curriculum

31. Health in Correctional Settings • Lead: Heather Yetman, JPS • Goals: 3 APC recs • Increase access to counselling services for inmates • Assign responsibility for provision of health services and the assoc. funding to HCS • Prioritize completion of new facility to replace HMP

32. Inclusion Team • Lead: Dean Gambin, HCS • Working Groups: Recovery, Education and Anti-Discrimination • Goals: 11 APC recs • Transition to recovery focused, person-centered care • Provide education and training on MH/A topics • Eliminate Stigma and discrimination

33. Provincial Services • Lead: Monica Bull, HCS • Goals: 7 APC recs • Development of One Provincial Program • Complete Program Evaluation • Legislation Issues • Family and Caregivers Issues • Psychiatric Prescribing • Gender-Based Needs

34. Promotion/Prevention • Lead: Michelle Healey, CSSD • Working Groups: 6 • Goals: 4 APC recs • Supports for all Young/New Families • Community Coalitions • E-Mental Health • Provincial Action Plan for Alcohol Abuse • Provincial Action Plan for Suicide Prevention • Supports for Mental Wellness

35. Wait Time Reduction • Lead: Kim Grant, Eastern Health • Goals: 2 APC recs • Develop a wait time reduction plan • Provide online information about MH/A services and how to navigate them • Develop provincial referral and intake tools and processes, recognizing regional differences • Develop a standardized methodology for collecting and reporting wait times, including psychiatry wait times, across the 4 RHAs

36. Service Redesign • Lead: Colleen Simms, HCS • Working Groups: 3 • Goals: 11 APC recs • Plan for Waterford Redesign project and oversee its implementation. • Plan for integrated service delivery models for child/youth and emerging adults and oversee its implementation. • Plan for redesigned addictions treatment services, including a new provincial opioid dependence treatment model and oversee its implementation.

37. Rec #12: Towards Recovery Action Plan “The Waterford Hospital must be replaced as an urgent priority. While it is recognized that some type of infrastructure and in-patient services are needed, having them all located in one psychiatric hospital is not the answer. The Provincial Government must investigate options for replacing the existing hospital with in-patient services as well as more services provided in community and closer to home. These in-patient and community services should be identified in a plan within the first year of this report’s release. Services delivered at the Waterford Hospital must continue until new service options are in place.”

38. Waterford Redesign • hospital-based and community-based services throughout the province

39. Community-based MHA Services Focus of a Redesigned MHA System Ensure a robust system of community-based programs, services and beds across the four RHAs Services provided closer to home Balances in-patient and community-based MHA programs and services Integrated service delivery models Stepped Care

40. Stepped-Care Approach

42. Redesigned Community Treatment • focused on harm reduction & recovery; & infused with peer support • crisis response, acute and long term treatment • housing, home support, assisted employment • family services • psychological therapies and E mental health options throughout • integrated community system that, while unique to each region, is provincial in nature

43. Community-based MHA Services Overview of Community-based Services Assertive Community Treatment (ACT) and Flexible ACT Provincial Warm Line / Crisis Line Mobile Crisis Response Teams Community Crisis Beds Single-Session Walk-In Clinics Day Treatment Program Supportive Housing Psychological Therapies Access to support after hours and weekends

44. MHA Facility Bed Projections Community bed counts to be confirmed in future planning Additional 6 mental health hospital based beds for HVGB

45. Opioid Action Plan • Safe Prescribing Course • Provincial Pharmacy Network • Prescription Monitoring Legislation • Naloxone Take Home Kits • Rapid Access to Suboxone

47. Working Together

48. Questions/Comments