1. Chapter 4 Ministry of Health and Long-Term Care
Section
4.06 Community Mental
Health
Follow-up on VFM Section 3.06, 2008 Annual Report
In our 2008 Annual Report, we identified the fol-
Background lowing key issues:
• The Ministry was not yet close to achieving
its target of spending 60% of mental-health
The Ministry of Health and Long-Term Care (Min-
funding on community-based services. In the
istry) provides transfer payments to 14 Local Health
2006/07 fiscal year, the Ministry spent about
Integration Networks (LHINs) that, in turn, in the
$39 on community-based services for every
2009/2010 fiscal year funded and oversaw about
$61 it spent on institutional services.
325 (330 in 2007/08) community-based providers
of mental-health services. In the 2009/10 fiscal • Notwithstanding the significant investments
in community care that had been made,
year, funding to community mental-health services
the LHINs and service providers we visited
and programs in Ontario was about $683 million
acknowledged that many people with serious
($647 million in 2007/08).
mental illness in the community were still
At the time of our 2008 audit, studies showed
not receiving an appropriate level of care.
Chapter 4 • Follow-up Section 4.06
that one in five Ontarians would experience a
Of those people in hospitals, many could be
mental illness in some form and to some degree in
discharged into the community if the neces-
their lifetime; about 2.5% of the province’s popula-
sary community mental-health services were
tion aged 16 years and over would be categorized
available.
as having been seriously mentally ill for some time.
Mental-health policy in Ontario has been moving • There were lengthy wait times for community
mental-health services, ranging from a min-
from institutional care in psychiatric hospitals to
imum of eight weeks to a year or more, and
community-based care in the most appropriate,
about 180 days on average.
most effective, and least restrictive setting. Our
audit found that, while progress had been made in • Formal co-ordination and collaboration
among stakeholders, including community
reducing the number of mentally ill people in insti-
mental-health service providers, relevant
tutions, the Ministry, working with the LHINs and
ministries, and LHINs, was often lacking.
its community-based partners, still had significant
work to do to enable people with serious mental ill- • The Ministry transferred responsibility for
delivery of community mental-health services
ness to live fulfilling lives in their local community.
to the LHINs on April 1, 2007, but the LHINs
329

2. 330 2010 Annual Report of the Office of the Auditor General of Ontario
still faced challenges in assuming responsibil- ing most of our recommendations. Several will take
ity for effectively overseeing and co-ordinating a few years to implement given that a long-term
community-based services. strategy has not yet been completed and the infor-
• Community mental-health service providers mation needed to ensure equitable funding and
indicated that they were significantly chal- track success in meeting objectives and perform-
lenged in their ability to maintain service ance commitments was not yet being collected from
levels and qualified staff, given an average community agencies. The status of the action taken
annual base-funding increase of 1.5% over on each recommendation at the time of our follow-
the few years prior to our 2007/08 fiscal year up was as follows.
audit.
• Funding of community mental-health services
Mental-HealtH StRategy
was based on past funding levels rather than
on actual needs. Historical-based funding Recommendation 1
resulted in significant differences in regional To better ensure that Ontario’s strategy of serving
average per capita funding, ranging from a people with serious mental illness in the community
high of $115 to a low of $19. rather than in an institutional setting is implemented
• There was a critical shortage of supportive effectively, the Local Health Integration Networks
housing units in some regions, with wait times (LHINs), in consultation with the Ministry of Health
ranging from one to six years. Housing units and Long-Term Care, should provide the community
were unevenly distributed, ranging from 20 capacity and resources needed to serve people with
units per 100,000 people in one LHIN to 273 serious mental illness being discharged from institu-
units per 100,000 people in another. While tional settings.
some regions had shortages, others had sig-
Status
nificant vacancy rates, which were as high as
In October 2008, the Ministry established an Advis-
26% in the Greater Toronto Area.
ory Group on Mental Health and Addictions to
• The Ministry and LHINs did not have suf-
provide advice on:
ficient information to be able to assess the
adequacy of community-based care that • a new 10-year strategy for mental health and
addictions focusing on people with serious
Chapter 4 • Follow-up Section 4.06
people with serious mental illness were
mental illness, complex problematic substance
actually receiving.
use, and problem-gambling issues as well as
We made a number of recommendations for
on people with less serious problems; and
improvement and received commitments from
the Ministry that it would take action to address • provincial priorities, actions, and expected
results.
our concerns. On February 18, 2009, the Standing
The Ministry released a strategy progress report
Committee on Public Accounts held a hearing on
in March 2009 as well as a strategy discussion
these recommendations and the Ministry’s plans to
paper in July 2009. Other affected ministries (such
address them.
as Community and Social Services; Children and
Youth Services; Education, Training, Colleges and
Universities; and Municipal Affairs and Housing)
Status of Recommendations and external organizations are also helping to iden-
tify priorities for the strategy. The Ministry expects
its 10-year Mental Health and Addictions Strategy
According to information provided to us by the
to be released in December 2010.
Ministry, some progress has been made in address-

3. Community Mental Health 331
The Ministry also informed us that LHINs are (OCAN), which is based on the Camberwell Assess-
exploring the expanded use of the new multi- ment of Need being used in other jurisdictions to
sectoral service accountability agreements with track client data and assess the health and social
community mental-health organizations to further needs of people with mental illness. The OCAN tool
refine performance measures to ensure that resour- enables knowledge transfer by allowing service
ces are appropriately deployed based on needs. providers to share standardized client assessment
These agreements came into effect on April 1, 2009. information, thus reducing repetitive information-
gathering and improving the flow of data through
the system.
aCCeSS to SeRviCeS
At the time of our initial audit, the tool was
Recommendation 2 being piloted in 16 community mental-health
To help ensure that people with serious mental ill- organizations across the province. The Ministry
ness have consistent, equitable, and timely access to advised us that the pilot was successfully com-
community-based services that are appropriate to pleted. These 16 organizations continued to use the
their level of need, the Ministry of Health and Long- tool and shared their expertise with others begin-
Term Care should: ning to use the tool.
• improve provincial co-ordination with the Local The Ministry targets March 31, 2012, for OCAN
Health Integration Networks (LHINs) and other to be fully implemented across more than 300
ministries that are involved in serving people community mental-health organizations. Once
with mental illness; and implemented across the sector, the tool is expected
• provide support to the LHINs—particularly in to produce high-quality data that support both
terms of knowledge transfer and data avail- the provision of mental-health care to clients and
ability—that would enable them to effectively informed decision-making at the organization,
co-ordinate and oversee service providers as LHIN, and Ministry levels.
intended. The Ministry reiterated that it is the responsibil-
The Local Health Integration Networks should: ity of the LHINs to co-ordinate and integrate local
• work with service providers to improve the reli- health services to serve client needs. The Ministry
ability of wait-list and wait-time information; is working with them on community mental-health
Chapter 4 • Follow-up Section 4.06
• collect and analyze wait-lists and wait times program issues such as improving wait times and
and use such information in determining the availability of services.
need for and prioritizing specific types and levels Meanwhile, the Ministry also informed us that
of service; and LHINs have been identifying their populations
• provide the necessary assistance to enhance in need and are working with local providers to
co-ordination and collaboration among health- develop approaches to ensure that people with ser-
service providers. ious mental illness receive appropriate services.
Status
The two-year multi-sectoral service accountability Funding
agreements between the LHINs and the community
Recommendation 3
organizations implemented during the 2009/10
To ensure that people with similar needs are able to
fiscal year include financial and statistical reporting
receive a similar level of community supports and ser-
requirements.
vices, the Ministry of Health and Long-Term Care and
In our 2008 Annual Report, we identified a new
the Local Health Integration Networks should collect
tool, the Ontario Common Assessment of Need
complete data and adequate cost estimates to review

4. 332 2010 Annual Report of the Office of the Auditor General of Ontario
regional variations in population characteristics, of housing units needed; the areas with serious
needs, and health risks so that funding provided is shortages of housing; the levels of unmet needs,
commensurate with the demand for and value of the occupancy, and vacancy; and the adequacy and
services to be provided. appropriateness of care provided to housing
clients; and
Status
The Ministry informed us that it is still in the • ensure one-time capital funding is being spent in
a timely and prudent manner.
process of compiling financial and program per-
formance data that could be used to facilitate an Status
evidence-based allocation methodology for the The Ministry advised us that it is continuing to
community mental-health sector. In spring 2009, it improve data collection in regard to housing needs.
received a four-year evaluation report on the impact It further indicated that it will over the next few
of new funding. The Ministry has been working years refine, as required, and make more effective
closely with the LHINs and service providers to the existing housing allocation methodology based
develop a framework for new funding investments on the current portfolio and population. The Min-
in the community mental-health sector. Ultimately, istry further indicated that it is currently working
the Ministry expects to: with the Ministry of Municipal Affairs and Housing
• provide evidence-based allocation of funding on a two-year, $16-million capital grant program
for community mental health; and for the repair and regeneration of eligible social
• develop strategies to address funding inequi- housing projects.
ties across different regions so that clients The Ministry also informed us that it has initi-
with similar mental-health issues receive ated accountability agreements and reporting
appropriate levels of treatment services wher- mechanisms to monitor the implementation of one-
ever they live in Ontario. time capital grants and ensure prudent and timely
However, at the time of our follow-up, the spending.
Ministry advised us that new funding methodolo-
gies for the mental-health sector had not been
PRogRaM StandaRdS
developed because it lacked consistent data from
this sector. The Ministry further indicated that it Recommendation 5
Chapter 4 • Follow-up Section 4.06
has conveyed to addiction and mental-health agen- To ensure that service providers are delivering
cies the need for the collection of consistent and comprehensive, consistent, and high-quality services
complete clinical diagnostic and financial data sets in a cost-effective manner across the province, the
in order to develop a reliable funding methodology. Ministry of Health and Long-Term Care and the Local
Health Integration Networks should:
HouSing • improve data-collection mechanisms and
reporting requirements to obtain relevant,
Recommendation 4 accurate, and consistent information across the
To ensure that adequate supportive housing is avail- province for performance-monitoring purposes;
able to provide people with serious mental illness and
with appropriate, equitable, and consistent care, the • establish provincial standards, performance
Ministry of Health and Long-Term Care and the Local benchmarks, and outcome measures for at least
Health Integration Networks should: the more critical programs against which the
• improve data-collection mechanisms and system quality and costs of services can be evaluated.
monitoring to determine the number and type

5. Community Mental Health 333
Status • report periodically to the public on the perform-
The Ministry advised us that it is working to ance indicators for the community mental-
improve data collection from mental-health agen- health sector.
cies and has formed an advisory committee that
Status
reviews all account codes and their definitions for
The Ministry informed us that a steering committee
appropriateness and applicability to the sector. The
consisting of ministry and LHIN representatives is
multi-sectoral service accountability agreements
developing performance indicators, including those
between LHINs and community mental-health
related to mental health. These indicators are to
organizations require the organizations to meet
become part of the next accountability agreement
established financial and statistical reporting cri-
now under development between the LHINs and
teria. The Ministry also informed us that ongoing
the mental-health service providers.
data quality feedback and education was being
At the end of the 2009/10 fiscal year, the
offered to this sector.
Ministry told us that 91% of all community mental-
The Ministry further advised us that early psych-
health and addiction organizations met reporting
osis intervention standards have been developed
requirements for financial and statistical data.
but not yet released. All agencies funded to provide
According to the Ministry, new financial and human
early psychosis intervention programs will be
resources/payroll systems have been implemented
expected to adhere to these new standards.
for some organizations to simplify the processes for
The Ministry informed us that it also has
setting up and maintaining account information
conducted a review of short-term crisis beds that
and for tracking data, and to streamline the process
is to help develop standards to address this need.
for submitting data to the Ministry.
These standards are expected to be finalized by
The first two-year, multi-sectoral service
March 2012.
accountability agreements include provisions for
regular review of health-service providers, provi-
PeRFoRManCe MeaSuReMent and sions to meet reporting requirements, and penalties
RePoRting in the case of non-compliance.
The Ministry indicated that it would consider
Recommendation 6
the public reporting of performance indicators for
Chapter 4 • Follow-up Section 4.06
To better enable it to assess whether the service
the community mental-health sector.
providers are delivering services in a consistent, equit-
able, and cost-effective manner, the Ministry of Health
and Long-Term Care should: MonitoRing and aCCountaBility
• complete implementation of its comprehensive
Recommendation 7
set of performance indicators and select targets
To ensure that all partners in the community
or benchmarks that will enable the Ministry and
mental-health sector—the Ministry, the Local Health
Local Health Integration Networks to properly
Integration Networks (LHINs), and the service provid-
assess the performance of service providers;
ers—are accountable to Ontarians for the effective-
• improve information systems to enable them to
ness and quality of services, the Ministry should:
collect complete, accurate, and useful data on
which to base management decisions and to help • develop compliance mechanisms to monitor the
LHINs’ accomplishment of their stated priorities
determine if services provided are effective and
and provide feedback to the LHINs for improve-
represent value for money spent; and
ment of their operations; and

6. 334 2010 Annual Report of the Office of the Auditor General of Ontario
• review settlement packages on a timely basis to ment packages up to and including those from the
ensure that funding is being spent in accordance 2006/07 fiscal year. This substantially meets its
with ministry guidelines and that significant commitment made at the time of our initial audit to
funding surpluses are being recovered from clear this old backlog by March 31, 2009.
service providers. As well, the Ministry had completed 85% of the
The Local Health Integration Networks should: 2007/08 fiscal year settlements and the remain-
• develop guidelines together with the Ministry ing 15% was under review. All settlements with
on monitoring service providers that include material balances were expected to be completed
requirements to monitor significant third-party by August 31, 2010.
contracts and to ensure that community mental- In addition to working toward the elimination of
health funding is being well spent. the settlement backlog, the Ministry also informed
us at the time of our follow-up that it had com-
Status
pleted 30% of the 2008/09 fiscal year settlements.
According to the Ministry, LHINs are required to
In February 2009, the Ministry and the LHINs
provide it with an annual progress update on their
developed draft audit and review guidelines for
identified priorities. The Ministry informed us that
hospitals that provide mental-health services.
its staff review and analyze this information and
According to the Ministry, similar audit and review
provide the LHINs with an opportunity to explain
guidelines are currently under development for
any variances and revise their targets and imple-
community agencies.
mentation as necessary.
The Ministry informed us that as of May 31,
2010, it had reviewed 98% of the backlog of settle-
Chapter 4 • Follow-up Section 4.06