Funding mental health care: Why community-based care matters

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When it comes to mental health care, or health care in general for that matter, a simple fact is that the sicker people get, the more it costs to treat them. Sicker people need more acute services, and they need to continue accessing those services for longer amounts of time. Acute care services are extremely expensive, far more so than community-based care. So why is it that far too many people aren’t able to access critical services in the community, leaving them without care until they reach the crisis stage?

Shortsightedness in funding

It seems to be a sad truth that health care comes down to dollars and cents. What matters is this year’s budget, so costs incurred right now tend to be seen as far more important than potential cost savings down the road. Whether it’s a public payor system trying to woo votes with balanced budgets or private insurance companies wanting to deliver good numbers to their shareholders, short-term matters.

Putting someone on a waitlist right now for community mental health services costs very little, but this doesn’t factor in the fact that this same person might completely fall apart a few months down the road. They might then have multiple emergency department visits, or an inpatient admission. That costs a lot, but it’s just a maybe, while the low cost of putting someone on a waitlist is an immediate certainty.

Something I’ve seen in the area where I live is the notion that service levels shouldn’t need to increase because more stable clients should be offloaded to their family physicians (never mind how hard it is to even find a family physician). The health authority had a tool for ranking each client’s level of need, and pushing for everyone beneath a certain score to be transferred out of community mental health services. The problem was, a lot of those clients were stable only because of the support they were receiving. When I was a nurse at a community mental health team, I had a client who was doing really well, but only because I was seeing her every day. Based on the health authority’s scoring tool, she should have been transferred to her family doctor. Had that happened, she probably would have been dead within a couple of months.

Funding of psychotherapy services

Psychotherapeutic services seem to be particular difficult to access due to the cost involved. Certainly where I am in Canada these services are available on a very limited basis through the publicly funded health care system. Let’s consider dialectical behavior therapy (DBT), the gold standard for treatment of borderline personality disorder (BPD). There are typically very long waits to access DBT, and because it’s a very intensive form of therapy, it may seem costly to offer. But perhaps no one thinks about the fact that those with untreated BPD often bounce from crisis to crisis as a result of their condition, leading to frequent emergency department visits, some of which lead to inpatient stays. Who’s saving money now?

Cost of acute vs. community care

What seems so obvious to me is that mental health care is best delivered with an early-intervention, community-based approach. If people are treated early in the course of their illness, they are more likely to respond to treatment and maintain greater functional ability. People who go chronically untreated or under-treated become more treatment-resistant. If these people don’t respond well enough to be treated on an acute inpatient ward, they may need to be transferred to a tertiary hospital, where stays aren’t measured in weeks but rather months or years. Early intervention certainly doesn’t guarantee someone won’t go down that road, but it significantly decrease the chances, and this is part of the reasoning behind proactive approaches like early psychosis intervention programs.

While community-focused approaches may seem more expensive at first, the potential ripple effect would likely be huge. There would be savings in acute care costs. Intervening early would likely keep more people working for longer, and that means taxes going into the government coffers. People who are more mentally well would be better able to participate in the economy in other ways as well by getting out and engaging in their communities (i.e. spending money).

Perhaps I’m living in a fantasy world that this makes sense to me, but the short-sighted approach of underfunding community mental health services just boggles my mind. We deserve to have care that’s not only effective but available. No one who is seriously ill should be languishing on a waitlist, or shuffled from service to service because no provider is willing to take them on as a patient. No one should be discharged from emergency, still suicidal, with instructions to call the crisis line until they can eventually get in to see a psychiatrist. Are these things really too much to ask?


Originally published at mentalhealthathome.org on December 17, 2018.