Investigating Access to Mental Health and Addiction Care in Calgary
by John Podstawka - BRIGHT University of Calgary Chapter
Published July 4, 2020, last updated July 4, 2020, 7:29 p.m.
BRIGHT Research Report - University of Calgary Chapter
Calgary, Alberta, Canada - February 2020
Table of Contents
- Social Barriers
- Infrastructure Barriers
- Collaborations to Address Barriers
- Improving Addiction and Mental Health Care
Substance misuse, substance disorders, and mental illnesses are widespread and debilitating conditions that also consume large portions of healthcare resources globally. In Canada alone, the total healthcare spending during the 2013 fiscal year for addiction and mental health programs and resources was estimated to reach $6.75 billion(CAD) of which $4.02 billion (59.6%) was used for supporting hospital inpatient services(1,2). Due to complexities and differences with how the different provinces support, structure, and report community mental health and addiction services and programs, we lack a comprehensive picture of the mental health and addiction care system in Canada(3).
The difficulties in characterizing community substance abuse and mental health services may be due to their typical separation from the traditional healthcare system(4). Services and programs for treating substance misuse disorders in particular were typically not viewed as the responsibility of the healthcare system, as substance abuse was long considered a criminal or social issue(4). However, while the high co-occurrence rate of substance abuse and mental health and its co-morbidities and outcomes are well-characterized, the continued separation and lack of support for community resources for substance abuse and mental health leads to hurdles in successful patient care(4).
The opioid crisis in Canada, caused by illegal drug trade and prescription opioids, has had a disturbing impact on Canadians across all socioeconomic groups(5). In 2016, Canada saw 16 Canadians hospitalized per day as a direct result of opioid-related overdoses(5). Alberta in particular had one of the highest recorded opioid-related death rates in the country (14.4 per 100,000 population) alongside British Columbia, Yukon, and the Northwest Territories(5).
During the midst of this opioid crisis, Alberta Health Services (AHS) published the 2017-2020 Health Plan & Business Plan(6). The AHS Health Plan & Business Plan functions as a public accountability document which highlights strategies to improve delivery of quality health services(6). Specifically, GOAL 1: PART 4, targets the improvement of access to community addiction and mental health services for adults, children and families during this timeframe(6). However, there is no information regarding what aspects of accessibility to community addiction and mental health services are being improved, nor mention of a specific timeline during which improvements would be occurring(6).
With a focus on Calgary AB as a case study, this paper will take a closer look at the addiction care and mental health services, the barriers to care for the patrons of these establishments, how these establishments are tackling these barriers, and how AHS has supported and collaborated with these establishments. In this present study, we identified both social and infrastructural barriers affecting access to care, characterized collaborations taking place to address overcome these harmful obstacles, and gained novel insight on actionable solutions community mental health and addiction care establishments want to implement to improve access to care.
In exploratory and pioneering investigations, qualitative surveys are a descriptive research method which allows the researcher to generate novel insights and explore the participants’ perceptions surrounding the topic of interest. Such methods are useful for achieving greater understanding of the participants, and their values, attitudes, and outlook beyond what would be allowed in a quantitative survey alone. Qualitative surveys were the method of choice, as this method allowed the participants to respond creatively in an organic manner to open-ended questions, and approach the prompts based on their needs. As such, a qualitative survey was administered in order to explore the overall view of the roles of the participant organizations in mental health and addiction care, the nature of their collaborations with other organizations and AHS, barriers of access of their patrons to their organization, and the organization’s perspective of what could be done to improve access to mental health and addiction care in Calgary.
Study organizations were identified for recruitment via online listing for addiction care and mental health services in Calgary. Study participants from the Calgary area were contacted by email, then recruited in-person. Each participant of the study was informed of the BRIGHT parent organization, The BRIGHT University of Calgary Chapter, and the purpose of the study. We fielded any questions or concerns the participants had prior to the completion of the survey. Of the 14 organizations recruited for the study, we received responses and completed surveys from 3 addiction care and mental health services establishments.
With respect to data handling, the identities and program names were removed from the survey forms once completed, and the results were transcribed for assessment in order to ensure confidentiality. Informed consent was verbally obtained from all individual participant organization representatives included in the study. The survey results were then subsequently collectively assessed for trends and patterns in order to identify key themes in providing addiction care and mental health services in Calgary.
The 3 survey participants represented a broad variety of expertise regarding addiction and mental health care in Calgary. The first establishment (organization A) directly helps patrons and clients in managing mental health issues and substance abuse problems. The second establishment (organization B) is a charitable organization which broadly funds other services which target aspects surrounding mental health, addiction, poverty, emotional learning, traumatic experiences. This second organization in particular extended their responses to include the perspectives of service establishments which receive their charitable donations. The third organization (organization C) plays a central role in providing frameworks for families and other organizations in actively tackling or learning more about mental health or substance abuse issues.
The four chief social barriers hindering access to these mental health and addiction care establishments included (1) cultural and social stigma from the community, (2) cultural and social stigma from healthcare providers, (3) poverty, and (4) lack of a social support network. All the participants highlighted that the impact of community stigma was emphasized by a lack of understanding of the complexity and trauma that the patient has experienced. When discussed further, organization A described that this phenomenon was the result of the community members making a character judgement of moral failure, demonstrating a need for increased community education and awareness surrounding mental health and addiction.
Stigma experienced in healthcare establishments when seeking mental health support was another chief complaint. Healthcare stigma was reported to be a frequent grievance where patrons often found themselves looked down upon in similar manner to the way they experienced stigma in the community. Organization B highlighted that once their patrons entered a traditional healthcare establishment as patients to address mental health issues, they felt unwelcome, discriminated against, and reluctant to go back for further treatment, painting a picture of institutional bias or implicit discrimination of mental health patients.
Poverty was mentioned by the participant organizations as a complex social barrier to access which serves to enhance stigma experienced by the patrons. Not only was poverty emphasised as a key determinant in hygiene and obtaining apparel which impacts first impressions and influences stigma, it also impacted the ability for the patrons to access tools needed to re-integrate into the community. The participating establishments noted that clients often complained about the lack of resources and support for both affordable mental health therapies, and for learning and job opportunities which would help them become self-sufficient.
Social support emerged as a multifaceted barrier which the mental health and addiction care establishments highlighted. The impact of social isolation would vary from client to client and present in different ways. For some patrons, the lack of social support meant difficulties finding help with childcare, while for others it meant having a lack of meaningful community activities, and an inability to learn social norms. Organization B highlighted an increased emphasis on the need for developing support which involves patients’ families in a “whole family” treatment model to address this issue when able or appropriate. Needless to say, this is a complex barrier which can only truly be addressed on a client-to-client basis.
In addition to social barriers, key infrastructure barriers were identified, including (1) hours of access, (2) adequate transport, and (3) resource needs for complex patrons. Limited hours of access was emphasised as a major barrier to the patrons of these organizations accessing the resources they need. Organization C noted that many community mental health and addiction care organizations operate during standard business hours (approximately 9AM-5PM) which limits the ability for patrons to seek help if they are working, or limits their options in a crisis situation. As access hours vary from agency-to-agency, infrastructural redundancies were broadly reported to be put in place to attempt to address this issue.
Adequate transport to access mental health and addiction care was a salient barrier, highlighted by all participant organizations. As most addiction and mental health care establishments are located centrally in the downtown area of Calgary, patrons who do not have flexible transport have serious difficulties accessing these establishments. Concentrating the resources within the downtown area impacts patrons who live far away, those who are not able to drive or use public transit, and patrons who simply do not like the downtown area.
The last cited major and potentially most difficult infrastructural barrier to address is the lack of resources for complex patrons. While many mental health and addiction care organizations are relatively new and still building up their position as care providers, once they find support to operate, it may be difficult to maintain. This was particularly highlighted by organization A which mentioned instances where funding establishments and donors were sometimes reluctant to provide ongoing support once they learned how much resources complex clients consumed. Here, the participating mental health and addiction care establishments broadly addressed the need to educate the community on how the short-term investment of resources in these clients would help Calgary and the province save resources in the long-term.
Collaborations to Address Barriers
Highlighting efforts to overcome the discussed barriers, the surveyed mental health and addiction care establishments of Calgary expounded on their collaborations to improved access to the care they provide. All of the participating establishments described partnerships with family and children serving agencies. As poverty and substance abuse directly impacts key aspects of child and adolescent development, and poses societal and financial stress for the family, services which work to address these problems can cause a break in inter-generational cycles of underprivileged families(7).
Broadly, the interviewed mental health and addiction care establishments collaborated and partnered with affordable housing agencies and food services to address basic necessities. Additionally, these establishments are allied with shelters and acute care services for those suffering from adversities due to substance abuse and mental health problems. Lastly, therapy and counselling services were described as important partners in addressing the complex needs and problems related to tackling mental health and addiction in Calgary.
To follow-up and investigate the impact of GOAL 1: PART 4 of the AHS 2017-2020 Health Plan & Business Plan in improving access to addiction and mental health care, we prompted the establishments to discuss their collaborations with AHS. Prior to the survey being conducted, none of the establishments had any knowledge of AHS’s commitment to their causes in the 2017-2020 Health Plan and Business Plan. Despite this, all organizations were able to speak fondly of their partnership with AHS and spoke highly of AHS’s knowledge and professionalism in the treatment of their patrons and support of their establishments, with organization C in particular stating that the establishment they collaborate best with was AHS clinics. However, broadly speaking, all organizations stated they wished AHS would increase their efforts in prevention, in order to avoid situations where their patron’s need medical treatment in the first place.
Improving Addiction and Mental Health Care
Better-quality communication and support were cited to be key areas of focus to improve access to mental health care and addiction care in Calgary. All interviewed establishments either described a need for more placements of mental health support staff in all healthcare clinics, or increased access to therapy, counselling, and mental health professionals. Increasing funding for resources and staff, particularly for complex clients was stated to be an important way to improve the quality of care.
In order to improve the collaboration surrounding mental health care and addiction care issues, a chief complaint was the perceived barriers surrounding information sharing. The participating organizations all desired to improve the continuum of care for the patrons who interacted with the healthcare system in order to better manage the individuals in an informed case-to-case basis and provide better family support. In order to begin a sense of integration between the different mental health and addiction care establishments, the participating organizations proposed a harmonization of their services with AHS. Increased information sharing from AHS with these community mental health and addiction care establishments was cited as a potential way to improve case management to more effectively to treat these patients for their own unique struggles.
While balancing equitable care being received by their patrons, the organizations cited the need for a comprehensive and descriptive list of mental health and addiction care resources for patients upon discharge from AHS hospitals, supplemented with a database listing the same resources. While also an effective way to minimize the amount of patients who become lost seeking for aid, this would allow organizations to recognize each other’s role in patient care, challenge each other to ensure a standard of care, and increase gatherings and communication of like-minded organizations to bring local care providers together to improve community level prevention, diversion, and treatment available to Calgarians.
The results of this study provided insight into the factors affecting addiction and mental health care in Calgary. Understanding the barriers to access to treatment and care is essential to helping patients and patrons overcome them. Similar to a study where the barriers to access in substance abuse care were investigated in urban and rural areas, we found that complex societal and infrastructural hurdles prevented effective treatment of patrons in mental health and addiction care establishments in Calgary(8). While confronting the societal friction of cultural and social stigma from community members and healthcare providers, the challenges posed by poverty, and a despondent social support network, these clients face the additional challenge of trying to get care from organizations that do not receive enough funding, are in locations where clients cannot access the services, or even have at operating hours that are accessible for these clients in the first place. Through the lens of local community organizations striving to provide addiction and mental health care to those need it, a mission to provide informed, sensitive, and compassionate care which is adequately supported and funded is of utmost importance to bring the patrons and their families back on their feet.
Community collaborations were highlighted as an effective way to minimize the impact of the barriers on patrons seeking care. Previous studies have demonstrated that collaborative care models where primary care and community care establishments and services are integrated are cost-efficient strategies for improving health outcomes(9,10). With partnerships addressing issues of basic needs, food services, and affordable housing, along with shelters and acute care resources, community organizations are forming alliances to improve mental health and addiction care services. Although AHS was mentioned to be a strong collaborator in the field of addiction and mental health care, the participating establishments cited that AHS is positioned but has not acted to become a leader in the prevention of these problems, and that the AHS could play an increased role in facilitating collaboration between community addiction and mental health resources, and primary care services.
Finally, resources were described as an overarching limitation in the quality of mental health and addiction care being provided to organization patrons. Due to the daunting task of treating complex patients, some organizations reported difficulty maintaining funding and resources. Increased community level learning and collaborations was reported as a way to challenge the stigma and misconceptions surrounding mental health and addiction care, thereby playing a role in addressing the difficulties in funding. A broader understanding of these issues by the community will lead to successful prevention and treatment strategies in Calgary.
Due to the small sample size and the qualitative findings of this study, the results must be carefully interpreted. This study was intended to have up to 14 participants, but organization non-responsiveness was broadly an issue which impeded communication. A few organizations also cited a lack of expertise to answer the questionnaire, a lack of relevant organization data to answer the questionnaire, and the organizational inability to meet the deadlines to finish the survey for our study. Additionally, due to the nature of qualitative data analysis, there is an intrinsic potential for bias in the interpretation process. Lastly, universality of the results and interpretations cannot be assumed and must be proven through further investigation and larger studies.
Qualitative survey data proved to be an effective way to paint a picture of the addiction and mental healthcare landscape in Calgary. These methods allowed us to explore the hurdles surrounding receiving relevant care, how Calgary community organizations are overcoming these barriers, and what they look to accomplish in the future in collaboration with AHS and other community services.
The results revealed that a recommendation to improve the access to and quality of mental health and addiction care in Calgary would be to create a map and database of resources for patients which is supported by AHS. Not only would this help patients efficiently find community resources to match the care they need, this would improve inter-organization communication and highlight gaps in resources and funding in community care. Support from AHS in harmonizing information sharing and handling with community organizations would further improve case handling and aid in providing equitable and appropriate care.
Collectively, this study provided an important first step in investigating the landscape of addiction and mental health care in Calgary. Future studies surrounding how a collaborative care model and the implementation of an easily navigable map and database of addiction and mental health community care establishments would impact harm reduction in the Calgary setting would be an important next step in investigating how preventative treatments improve patient outcomes.
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