The two most pressing problems in Canada’s mental health system are insufficient mental health beds and a lack of services for homeless people with serious mental illness. Quebec is the only province that has clearly articulated, effective, evidence-based policies to deal with these.
The rest of Canada should adopt those policies.
Canada has insufficent mental health beds – 30/100,000 population; the 29th lowest number of beds of 35 similar countries. Experts have concluded that many problems develop such as increased suicide risk, homelessness and “ boarding “ of psychiatric patients in ER’s if the bed count is less than 50-60/100,000.
Boarding refers to patients in emergency rooms waiting days to be admitted, often taking up half the beds and deteriorating. This is a major cause of crowding, compromised care, stress and burn out.
Mentally ill homeless people get admitted to mental health wards, sometimes as involuntary patients. They may be discharged to a homeless shelter. The shelters don’t have the capacity to care for seriously mentally ill residents. Homeless people with serious mental health problems don’t have the wherewithal to get to appointments or have their prescription filled or take medicine reliably. So, they often end up back in the hospital in a repeat cycle.
The linchpin of Quebec’s mental health system enabling it to deal effectively with these problems is Intensive Home Treatment ( IHT ). IHT programs provide patients in a mental health crisis all the services in their own homes that a hospital provides; psychiatric hospitalization at home.
About a third of patients can be treated at home instead of in hospital, and of those admitted, 40 % can be discharged early to an IHT program.“ Home” can include a relative or friend’s home, a crisis residence, women’s shelter, homeless shelter or group home etc.
Programs consist of a mental health team, mainly nurses, plus social workers, occupational therapists, and one or two psychiatrists.
Team members make home visits, daily or more frequently at first. There is 24/7 clinical coverage.
The team works closely with the patient’s supports who often help with the treatment. Usually, but not always, these are family members and can include room mates, friends, neighbours and others. In shelters, the staff and other social agencies provide support.
A hallmark of IHT is its focus on the stresses and social problems that contributed to the patient’s break down. Much easier done in the home than on a hospital ward.
Practical help is provided with often basic problems: getting the house in shape, childcare, helping with unpaid bills that have piled up, landlord problems, and social benefit problems. And in the context of homelessness, help with obtaining identification, applying for social assistance, applying for citizenship, and entering stable housing.
Treatment includes medication, counselling, home-based detox, anything that a hospital would provide. Treatment usually lasts up to six weeks until the patient is ready to be transferred to another program for follow up, such as a mental health clinic. In homeless shelters treatment typically lasts 8-12 weeks.
In 2000, Britain’s National Health Service launched a plan for 335 IHT teams throughout the country – a revolutionary change in the management of mental health crises. ( N.B.The British term for IHT – Crisis Resolution Home Treatment – CRHT).
Since then, one country after another has been developing IHT programs influenced by the CRHT model; twelve countries so far. Eg. Germany has 62 programs with plans for 400.
In Canada, BC has three IHT programs which are called Acute Home Based Treatment and which may include an addiction trained GP on the team. Ontario has one – the Hazelglen program that I founded in 1989.
In October 2023, the Quebec government became the first to announce plans for a province wide roll out of IHT.
IHT can reduce boarding in ER’s in three ways. Patients in the ER can be referred to IHT instead of being admitted. Patients in a crisis can bypass the ER altogether and go straight to IHT. Early discharge of patients on the psychiatric ward will free up beds for the ER patients that need them.
IHT can make up for the shortfall in mental health beds if combined with sufficient supervised residences and day hospitals, according to a 2002 study in Montreal. A floor ratio of 18 beds per 100,000 appeared adequate for the area .
There has been controversial demand for mentally ill homeless people to be admitted involuntarily which would require more beds. Hospital care would barely scratch the surface of their many complex social problems. Just because a patient refuses to go to hospital does not mean they cannot be engaged in treatment outside a hospital. Often, the homeless mentally ill think treatment in hospital does not meet their needs. IHT can reduce the need for involuntary admission. IHT programs can treat homeless patients if they are in a suitable shelter such as Quebec’s PRISM ( Project Reaffiliation Itinerance Sante Mentale [ Homelessness Mental Health Reaffiliation Project].
IHT is an integral part of the PRISM program which treats patients with severe mental illnesses such as schizophrenia, schizoaffective disorder, major depression with psychotic symptoms and bipolar disorder often with comorbid substance use disorder. The program admits individuals who are currently homeless or at imminent risk of homelessness ( e.g., after eviction, hospital discharge, or prison release).
An IHT team treat clients in PRISM facilities located at different shelters in Montreal. People typically stay for 8-12 weeks. Each facility has eight to 16 beds and is located within a dedicated shelter dormitory that offers some privacy, big lockers, and a lounge with sofas and computers. Unlike other shelter users, clients are free to come and go as they please.
Clients have continuous access to the PRISM team throughout their stay. Crisis intervention outside regular working hours is provided in conjunction with shelter staff and a city-wide mental emergency mobile team. The goal is to get clients well enough so they can be established in permanent housing and receive ongoing psychiatric care.
PRISM can be conceived as psychiatric hospitalization in the community; as the ‘home’ in IHT.
PRISM involves ongoing partnerships with major nonprofit organizations that deliver Housing First services such as Old Brewery Mission and Welcome Hall Mission.
A 2013-2019 chart review showed 63% clients were housed when discharged ; 52% in permanent housing and 11% in temporary settings. 21% were not housed and 16% were transferred to hospital or rehabilitation services. A 2018-2019 study followed 43 clients who completed the program of which 77% were discharged to housing.
The cost of each episode of care is $ 5-7000. The subsequent cost of being housed and receiving care for a year is $25,000. Contrast that with the costs incurred by homelessness for a year- $75,000 from repeated ambulance trips to hospital, police calls, tying up the justice system with petty issues and prison.
There are now four PRISM programs in Montreal, and one in Quebec City. Expansion to Val-d’or and Sherbrook is planned and the government is open to funding more programs.
I see no reason why Quebec’s innovative mental health programs cannot be implemented nation wide , using the following resources: Brief Intensive Home Treatment Team Plan; Video presentation by psychiatrist Marianne Genest ( in French ) ; the CORE fidelity scale; Home Treatment Accreditation Scheme ( HTAS) ; CORE BOOKLET; www.intensivehometreatment.com; PRISM.