Tier 3 Divestment Report

What is it

It’s a report by the Tier 3 Provincial Working Group, an advisory group of four hospitals and four community agencies, convened by the Ministry of Health and Long-Term Care. The report makes recommendations about the transfer of outpatient programs from the former Provincial Psychiatric Hospitals to community agencies. The working group did not consult with health care workers or their unions. The report is available at: http://www.health.gov.on.ca/english/providers
/program/mentalhealth/mohtier3.html

There has been no indication to date from Health Minister George Smitherman as to whether the McGuinty government will or has accepted the report’s recommendations. We know, however, that at least two OPSEU employers (St. Joseph Health Care London and Northeast Mental Health Centre) have had discussions with community providers about the transfer of programs.

Definition of terms: Tier 1 divestment is the transfer of governance and operations of a Provincial Psychiatric Hospital (PPH) to a public hospital. Tier 2 is the transfer of beds and programs from the receiving hospital to another public hospital. Tier 3 is the transfer of outpatient (“non-bedded”) programs to a community agency. All but one of the PPHs, Mental Health Centre Penetanguishene, has been divested.

Who are the members of the Tier 3 Provincial Working Group

Royal Ottawa Health Care Group
North East Mental Health Centre
St Joseph’s Health Care Centre, Hamilton
St. Joseph’s Health Care, London
CMHA-Windsor-Essex
CMHA-Cochrane-Timiskaming
Causeway Work Centre, Ottawa
Adult Mental Health Services Haldimand-Norfolk

What OPSEU has said in response to the report

Our Oct. 5 press release http://www.opseu.org/news/Press2006/oct052006.htm said that funding, staffing and service quality guarantees must be in place before the downloading of mental health programs takes place.

OPSEU President Leah Casselman noted that the downloading will affect thousands of health care workers and people with serious mental illness. She pointed out that neither health care workers nor their unions were consulted. “We call on the government to immediately commit to negotiating a province-wide Human Resources Adjustment Plan to minimize service disruptions, ensure staff continuity and eliminate uncertainty for everyone involved.”

What the report says

Tier 2 and Tier 3 divestment can happen at the same time (p. 5)

“In terms of sequencing, Tier 1 divestment must happen before Tiers 2 and 3 can take place, but …Tier 2 divestment is not a mandatory requirement or a prerequisite to …Tier 3 transfer. Many Tier 2 receiving hospitals have not completed Tier 2 divestment, however the ministry is now preparing for Tier 3, which refers specifically to the transfer of non-bedded programs and services from Tier 1 and Tier 2 receiving hospitals to community mental health agencies, where appropriate. Non-bedded programs are mental health services that can be provided to individuals in their own environment … and do not require a medical stay.” (p. 5)

Examples of non-bedded services, p. 9

• “The list is not comprehensive or exhaustive. It represents examples of non-bedded mental health services …No recommendations have been made regarding governance … or their transfer.” (p. 9)
• Examples include: vocational employment, concurrent disorders, psycho-geriatric outreach, addictions, dual diagnosis, peer support, forensic outreach and psych-social rehabilitation. Go to the report for the full list.

Benefits of divestment, p. 11-12:

• Supports the provincial vision of mental health reform as an integrated and co-ordinated system of care.
•  Provision of outpatient programs “may be incongruent with the specialized care and short-term delivery of acute care in many hospitals.”
•  “Offers possibility of capacity-building in community mental health sector.”

Barriers to divestment, p. 13- 14:

• If operating dollars for community programs were frozen, could be a loss of future capacity and make hospitals responsible for care.
• Not all community providers can deliver services equally and may not deliver services in the same way hospitals can.
• Loss of diagnostic efficiency could result.
• Individuals may need to go to multiple sites for assessment and staff may need to travel to multiple sites to provide care.
• Could bring about a loss of accredited sites (and clients) for training purposes.
• Community agencies may not be able to manage long-term salary expectations or pay equity issues. An inability to recruit staff will have ramifications on the community’s ability to deliver programs effectively.
• Tier 3 transfers may also lead to agencies becoming unionized environments, which for some would represent a significant change.
• Community agencies have not received the same type or extent of stable funding as hospitals, resulting in concerns about taking on additional program responsibilities.

Guiding principles, p. 15 -20

• A philosophy of care focused on the individual's needs so he/she can reach his/her potential in the community.
• Achieving integration involves bringing together services providers and organizations across the continuum so services are complementary, co-ordinated, seamless, with continuity for individual. Adoption of a “zero exclusion policy”, can’t exclude individuals from a program.
• Flexibility: decisions regarding the transfer of services must balance evidence-based practices with local and individual needs.
• The system must respond to emerging needs and involve stakeholder engagement (clients, family, providers, police, not bargaining agents) in the service transfers in order to preserve and enhance continuity of care and service efficiency.
• All transfers to maintain and enhance existing service capacity and quality. “Tier 3 divestment is not an attempt to scale down organizations in an effort to make the mental health system more cost-efficient and accountable.” (p. 17)
• Protocols must be established to share information/records for uninterrupted continuity of care.
• Evaluation of program transfers is essential, with assessments from the individual and family, as well as any impacts on research and education of health providers.

Human resources (p.18-20)

• Full disclosure of the composition of human resources and labour environment (whether it’s union or non-union) by the sending and receiving organizations. Full disclosure will help receiving organizations make “fully informed decisions based on realistic expectations and an appreciation of the current situation. Applicable legislation and labour agreements will also guide Tier 3 transfers.” (p. 18)
• Program transfer is the preferred approach. “Consistency in relationship between the client and service providers is vital to maintain. When staff feel anxious about their job security then “client care has the potential to become inadvertently compromised. The objectives are to preserve existing capacity and build new capacity … this principle suggests that staff in sending organizations be encouraged to follow their work wherever possible while also apprised of their options (e.g. reassignement, severance, early retirement etc.) Program transfers would maintain program staff and preserve continuity of care and service.” (p.18-19)
• Regions involved in a Tier 3 transfer will develop a service transfer plan including “a labour adjustment strategy with a defined timeframe that minimizes disruptions … For a smooth transfer … the ideal is to aim for one move rather than multiple moves … a one-move principle requires a timeframe that reflects unionized environments and sequencing of labour-related steps such as employee decisions on rights and entitlements. (p. 19) The report fails to recommend that health care workers and their unions should be part of the development of the labour adjustment strategy through negotiations. The union believes this is a grave omission on the part of the working group.
• Tier 3 transfers will use a consistent approach to the funding methodology, including pre, post and transition transfer costs for sending and receiving organizations. The working group “also identified unique costs that could arise, such as severance payments. Costs associated with severance are not within the existing budgets of sending organizations and therefore need to be considered as extraordinary costs that merit unique consideration by the MOHLTC in the development of a uniform funding methodology.” (p. 20)

Process principles: (p. 20 – 22)

• Communications: Pro-active communication plans that are open, transparent and inclusive to ensure timely, consistent relations between all stakeholders to minimize uncertainty. (Bargaining agents are considered one of the stakeholders.)
• Planning: A Tier 3 divestment plan is to be developed, using a map or inventory of current services, considering population health needs, the guiding principles outlined earlier, and the interests of all parties, in order “to assess the benefits and implications of all viable options.” The plan will include a timeframe with “target implementation and completion dates, including the service plan development, stakeholder engagement, negotiation, determination of transfer, approvals, actual transfer and related human resources adjustments. “Ideally planning for divestment should be an uninterrupted process with an expeditious time limit (e.g. 12 months). (p. 20-21)
• Support from government ministries: “….a process will be in place to address and resolve issues associated with government policies, guidelines and practices that may inhibit integration. … Further discussion is required to determine a receptor site within the MOHLTC that could co-ordinate resolution of policy issues. For example, some policies may create barriers to integration (i.e. pay grids for Nurse Practitioners in Community Health Centres may differ from mental health and addiction pay rates.
• The MOHLTC may need to consider creating standardized guidelines for divested hospitals and receiving agencies, LHINS, and other stakeholders ....
•  …The Tier 3 Provincial Working Group expressed concern that community mental health programs have an ongoing need for base increases and adjustments in order to avoid program erosion …
•  …The working group also noted that wage harmonization between the hospital and community sectors was a longstanding issue. …While resolving the matter was beyond the capacity and mandate of the group, pay equity legislation will ideally guide and inform its future discussions. There is concern for the impact of program transfers on the wages of other employees from receiving organizations and thus, the organization’s overall fiscal situation. Furthermore, there is concern that a wage harmonization issue could negatively affect the interest of many community organizations to participate in program transfer discussions or the interest of staff to transfer with their program” (p. 21- 22)

Criteria (p. 22-24)

• “The working group agreed that all non-bedded programs are not the same. Since each community has its own needs and its own local spectrum of mental health services…the range of non-bedded programs in a given geographic region cannot be considered appropriate for divestment, collectively….criteria were developed to help determine the element that make programs eligible for Tier 3 transfer. Programs …do not have to meet every one of the following critiera. All of the criteria, however, must be considered …in order to decide the suitability … (p. 22)
• The criteria include: program remains intact, receiving agency demonstrates capacity, ability to achieve fidelity with program standards, preserves accessibility and brings services closer to home, wellness focused philosophy, reduces duplication, reduces pressure on hospital, Tier 3 transfer does not automatically mean a change in program or location, among others.

Tier 3 transfers don’t have to be directed by the LHINs (p. 25)

• “While LHINs may be ideal entities for initiating discussions about Tier 3 transfers, this statement does not suggest that all dialogue regarding Tier 3 divestment must start at the LHIN level. The impetus for discussing Tier 3 transfers can feasibly come from a number of different settings (e.g. hospitals, community agencies, local planning tables etc.) …The principles recommended in this report encourage discussion about divestment between local parties at the earliest stages of planning.” (p.25)

When are Tier 3 transfers going to happen?

The report doesn’t say. As noted earlier, however, we know that at least two OPSEU employers, St Joseph’s Health Care London and Northeast Mental Health Centre, have been in discussions with community providers. The St. Joseph’s discussions have been going on since 2004. We expect the first Tier 3 divestments in the province to happen in the Southwest.

As always, OPSEU is getting prepared by demanding through a variety of labour relations forums: full disclosure of employers' plans, enforcement of collective agreement rights and entitlements and provincially, calling for the negotiation of province-wide Human Resourcs Adjustment Plan to ensure:

1) the smooth and stable transition of staff from hospitals to community agencies and;

2) that protections/provisions are in place for non-direct care staff in the hospitals who will be affected by the transfer but won’t be going with the programs.

Prepared by OPSEU’s Campaigns Unit
October, 2006