Access to mental health care and

performance measurement: emerging

developments in Ontario

Paul Kurdyak MD PhD

Medical Director, Performance Improvement, CAMH

Lead, Mental Health and Addictions Program, ICES

Financial Disclosure

I am funded by the following grants:

• the Ontario Ministry of Health and Long-Term Care Health

Health System Research Program Award

• Ontario Mental Health Foundation

• CIHR

I receive salary support from the Medical Psychiatry

Alliance, a collaborative health partnership of the

University of Toronto, the Centre for Addiction and

Mental Health, the Hospital for Sick Children, Trillium

Health Partners, the Ontario Ministry of Health and

Long-Term Care and an anonymous donor.

Learning Objectives

1. To understand the role of performance

measurement to monitor the health care system.

2. To learn about the use of administrative health data

for performance measurement.

3. To learn about new and emerging opportunities to

apply performance measurement to mental health

system delivery.

Key Assumption

We need to be able to measure performance to

determine whether services are delivered effectively

and equitably

Access to Psychiatrists in Vancouver

6/230 Goldner et al., 2011; Can J Psychiatry; 56:474-80

Paul Kurdyak; Confidential – Do Not Distribute

Ontario Regional Psychiatrist Supply

0

10

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60

70

Psychia

tris

ts/1

00,0

00

Paul Kurdyak; Confidential – Do Not Distribute

Avg total and new patients/year

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50

100

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450

500

Toronto Champlain Southwest Southeast Hamilton Low Supply

Pati

en

ts p

er

Fu

ll-T

ime P

sych

iatr

ist Avg # Patients

Avg # New Patients

Paul Kurdyak; Confidential – Do Not Distribute

Understanding the Distribution by Visit

Frequency

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70

Toronto Champlain Southwest Southeast Hamilton Low Supply

Pe

rce

nt

of

Fu

ll-T

ime

Ps

yc

hia

tris

ts < 4 Visits/Year 4 to 16 Visits/Year > 16 Visits/Year

• Patients in >16 visits/year more likely in highest neighbourhood income quintile

and almost never had a prior psychiatric hospitalization

What we are doing now

Looking at ALL ON psychiatrists (not just “full-time”)

Evaluating psychiatrist characteristics

Evaluating practice patterns over time

Psychiatrist Characteristics - 2012

Characteristics N %

Total 2,049 100

Female 810 39.5

Age

<30 7 0.3

31 To 40 308 15

41 to 50 402 19.6

51 to 60 600 29.3

>60 732 35.7

Medical School

Canadian 1253 61.2

International 605 29.5

US 35 1.7

UK, Australia, NZ 128 6.2

Practices <100 by Years Since Graduation

0

5

10

15

20

25

30

35

40

45

50

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Pe

rce

nt

0 to 15

16 to 30

>31

<100 Outpatients Per Year

<40 Outpatients Per Year

% Female Psychiatrists Over Time

0

5

10

15

20

25

30

35

40

45

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Paul Kurdyak; Confidential – Do Not Distribute

<15 Male

<15 Female

16-30 Male

16-30 Female

>30 Male

>30 Female

0

50

100

150

200

250

300

350

Male Female Male Female Male Female

<15 16-30 >30

Nu

mb

er

of

ou

tpa

tie

ns

t/ye

ar

Percentage of Ontario Psychiatrists by

Years since Med School Graduation

and Sex

Supply, Psychiatrist Age and Region

Moving Forward

Incentives introduced in September 2011

Qualitative Study – Why do psychiatrists adopt

different practice patterns?

Costs of Mental Health Care Services among

High Cost Users in Ontario

Claire de Olivera, Joyce Cheng*, Walter

Wodchis, Jurgen Rehm, and Paul

Kurdyak

Health Affairs, Jan., 2016

Background

High cost users • In general, 5% of high cost users account for 75% of health care

spending (Wodchis et al., CMAJ 2016)

• NO data on mental health-specific high cost users

• Policy implications

Objective: • estimate and examine costs of care among MH HCUs from the

perspective of the Ontario Ministry of Health and Long-term Care (MOHLTC)

Results

Descriptive Characteristics

MH HCUs accounted for 4% of total MH HCUs BUT accounted for 6% of total HC costs

MH HCU mean age – 46 (compared to 64 for non-MH HCUs)

0

5

10

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25

30

35

Low High

Pe

rce

nt

MH HCUs

non-MH HCUs

Average costs (total and by resource) for mental health-related and non-mental health-related for mental health high cost users in 2012

Key points

MH HCUs are young, low income

Most health care costs related to hospitalizations (frequent and long LOS)

MH HCUs cost 50% more per capita than non-MH HCUs

• A real opportunity to improve quality AND reduce costs

Frequent Use of Emergency Departments for

Mental Health and Addictions

Karen Urbanoski PhD, Joyce Cheng MSc,

Paul Kurdyak MD PhD

Objective

To examine the characteristics and service use

patterns of individuals who frequently use Emergency

Departments for addictions vs. mental health care in

the TC LHIN

Cohort Creation

Types of substance use at index visit

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Substance use

disorders

Alcohol Opiates Cocaine Multiple Other

Pe

rce

nt

1+ visit

2+ visits

3+ visits

4+ visits

5+ visits

Past Year Service Utilization

0

5

10

15

20

25

0 visits 1+ visits 2+ visits 3+ visits 4+ visits 5+ visits

Cu

mu

lative

Me

an

Vis

its

Psychiatrist Visits

Primary Care Visits

ED visits

Number of addictions related visits

Addiction-Related ED Visits and Follow-Up

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10

20

30

40

50

60

0 visits 1+ visits 2+ visits 3+ visits 4+ visits 5+ visits

Pe

rce

nt

Se

en

Po

st-

ED

D/C

Addiction-Related ED Visits

Primary Care

Psychiatrist

Summary

Substance-related presentations form the majority of

MHA frequent ED users

The majority of substance use is ETOH

As proportion of substance-related ED visits

increases, psychiatrist involvement in year prior to

and 30-days following ED visits decreases

Child and Youth Mental Health – ED Visit Rates

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

2006 2007 2008 2009 2010 2011

Rate

per

1,0

00 p

op

ula

tio

n

Overall

Substance abuse

Schizophrenia

Anxiety

Mood and affective

Other childhood disorders

Child and Youth Mental Health – MD Visit Rates

0

50

100

150

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350

400

450

2006 2007 2008 2009 2010 2011

Rate

per

1,0

00 p

op

ula

tio

n

Family Physician

Psychiatrist

Paediatrician

Overall

Is diagnosis enough?

What do we need to know about a patient at CAMH

to determine type AND intensity of treatment?

Functional Impairment - WHODAS

Developed by WHO to measure health status and

disability

Recommended by DSMV to replace GAF

Covers multiple domains of functioning:

• Cognition – understanding & communicating

• Mobility– moving & getting around

• Self-care– hygiene, dressing, eating & staying alone

• Getting along– interacting with other people

• Life activities– domestic responsibilities, leisure, work &

school

• Participation– joining in community activities

WHODAS

Two versions – 36-item and 12-item

12-item version captures 86% of variance captured

by 36-item version (and MUCH shorter)

WHODAS has been modified to capture health status

and disability in children (WHODAS-Child)

Is Diagnosis Enough?

Functional Impairment

Diagnosis is necessary to direct an individual to

TYPE of treatment (e.g., depression and anxiety lead

to antidepressants and/or CBT)

Diagnosis does not necessarily lead to INTENSITY of

treatment (admit/ACT/Case Mgmt/brief crisis

mgmt/primary care involvement only)

WHODAS is a valid way to capture function and may

be useful in determining INTENSITY of function

What’s happening in the province?

36

Mental Health & Addictions Performance Indicators for Ontario

37

THANK YOU!