Briefing note; November 2023
(The Ecological Model of Community Mental Health Care accompanies this briefing note).
Background
Community mental health (CMH) is a critical complement to hospital-based care. Research shows that hospital-based provision alone cannot offer sufficient access to a local population seeking mental healthcare or provide substantial follow-up care (Thornicroft et al., 2016). A “balanced care model” involving both healthcare systems and community-based care as complementary services is a better solution (Thornicroft et al, 2016).
Ideally, CMH addresses needs in more expansive and accessible ways than a traditional healthcare model (ie a medical system). It promotes wide networks of supports and services that increase capacity. It can reduce wait times and increase access by coordinating care, as well as reducing costs to the healthcare system overall (Moroz et al., 2020). Some mental health interventions may also be better suited for community care provision than within the healthcare system, such as residential care or peer support, for example (Thornicroft et al, 2016). Some research indicates increased patient satisfaction with CMH than those received in the formal healthcare system (Stamboglis & Jacobs, 2020).
The delivery of CMH services and supports can be illustrated in different ways. The stepped care model, which depicts the levels of care intensity required by differing members of the population, will be described below. A companion brief examining community mental health through an ecological model, emphasizing the complex interplay of individual and population-level factors on mental health, can be read separately.
Report on community mental health services and a stepped care model of services and supports
A TaylorNewberry Consulting report, commissioned by the Canadian Mental Health Association (CMHA)-National in 2022 uses a “stepped care model” of support to categorize the community mental health services landscape. They relate how the de-institutionalization of psychiatric institutions in the 1950s-1970s created a need for mental health services delivered in the community. These services have evolved from early efforts such as day programs, outpatient services and housing considerations to include practices that are proactive and preventative, adopting a social determinant of health perspective, providing resources and services that address mental health upstream. (Newberry, 2023) This broader definition of health requires a broader scope of services. The Stepped Care model is a good fit for this.
The authors of the report state that stepped care is “an integrated approach to needs identification and service delivery that matches level of need to level of care, individually and in relation to a community”. (Newberry, 2023, p.5) The model consists of a pyramid: at the top, a smaller population requiring more specialized and intense services to meet more complex mental health and substance use needs resides. These indicated interventions are mostly provided by highly intensive mental health services and supports in the healthcare (medical) system. Descending, the middle levels comprise individuals who have mental health and substance use challenges that can be addressed by the healthcare system but also through community mental health care. These are called selective interventions. The bottom levels of the pyramid are universal initiatives of prevention and promotion. These are intended for the whole population and are called universal interventions. (Newberry, 2023)
Within this grid of service intensity, the Highly intensive services and supports include inpatient hospital treatment or long-term residential treatment at the top. These are followed by Specialized mental health services and supports for people with chronic and persistent mental health and substance use concerns. These include services and supports offered by Formal health and social systems, and Formal community-based services and supports. Farther down are Informal community supports such as peer networks like 12-step groups, CMHA Welcome Centres staffed by peers, OSI-CAN peer groups for first responders and public safety personnel. Lowest on the grid reside the Continuum of community-based services and supports which address concerns like housing and employment, as well as the Continuum of mental health promotion and prevention, like school-based education programs or psychological health and safety standards in the workplace.
The intent of the stepped care approach is to deliver the most effective interventions in the least resource intensive manner. The graduated options of stepped care allow for an apparent and appropriate match for the individual in need. This can only be done utilizing resources and supports from both the healthcare (medical) system and community mental health care – a balanced care model.
References
Moroz, N., Moroz, I., D’Angelo, M. (2020) Mental health services in Canada: Barriers and cost-effective solutions to increase access. Healthcare Management Forum, 33(6), 282-287.
Newberry, J. (2023). A Review of Community Mental Health and Addictions Definitions and Service Types. Literature review submitted to CMHA National in support of the development of a Core Services Framework for CMHA Federation. Taylor Newberry Consulting: Guelph, ON.
Stamboglis, N. & Jacobs, R. (2020). Factors associated with patient satisfaction of community mental health services: A multilevel approach. Community Mental Health Journal, 56,50–64. https://doi.org/10.1007/s10597-019-00449-x
Thornicroft, G., Deb, T., & Henderson, C. (2016). Community mental health care worldwide: Current status and further developments. World Psychiatry. 2016, 15, 276-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5032514/pdf/WPS-15-276.pdf