December 2008

Ministry of Health and Long-Term Care and Ministry of Community and Social Services

1. Purpose of the guideline

To provide a framework for the planning, coordination and delivery of community mental health and developmental services and supports that will promote better access to both sectors for persons 18 years and older with a dual diagnosis.

2. Context

In 1997 the Ministries of Community and Social Services (MCSS) and Health and Long-Term Care (MOHLTC) released a joint Guideline on dual diagnosis that updated earlier documents. The Guideline provided a definition of dual diagnosis and expectations for how the funded community service sectors of both Ministries would work together to provide supports to this population.

Since 1997 there have been many changes in the ministries and sectors as well as a growing understanding of the needs and challenges of adults with a dual diagnosis. As a result there is a need to update the 1997 Dual Diagnosis Guideline to reflect current structures and to restate the expectations for cooperative supports to this population. It is also the intention of the two ministries to review the Guideline on a regular basis.

3. Vision

Community mental health and developmental services for persons with a dual diagnosis and their families will be integrated, coordinated and operate responsively and proactively both within and across sectors.

4. Principles

Persons with a developmental disability may have mental health needs that require different types and intensity of service response from both the community mental health and developmental services systems. Interventions should be appropriate to address the individual’s circumstances and needs and should progress as required along the continuum from the least restrictive and least intrusive to the most specialized response.

Health, mental health and developmental services all have a role in the provision of services and supports to people with a dual diagnosis. The development of cross-sector linkages will serve to:

  • Strengthen community capacity to address the needs of those with a dual diagnosis through the provision of a coordinated, integrated and flexible service response;
  • Promote cross-sector planning to facilitate access to local services in the health, mental health and developmental services sectors;
  • Engage consumers, families/natural supportsfootnote 1 and service providers as partners in the planning and delivery of services.

Education and training initiatives will work to integrate and promote increased knowledge and skills regarding service provision for people with a dual diagnosis. These initiatives will be based on academic research where available and promote evidence-based practices.

5. Key assumptions

  • Dual diagnosis is a complex condition that often requires a multi-faceted service response from both the health and social services sectors. Effective cross-sector collaboration at all levels is essential to the provision of appropriate services.
  • Services for adults (age 18 and older) with a dual diagnosis are a responsibility shared by both ministries. While some responsibilities such as policy direction and planning are shared by both ministries, other responsibilities are distinct. Community-based mental health services and supports include: counselling and treatment, 24-hour crisis response including short-term crisis residential beds, Assertive Community Treatment Teams (ACTTs) and consumer/survivor/ family initiatives. Developmental services include: residential, community participation and respite supports, case management, and specialized community supports (refer to appendices 1 and 2 for lists of services).
  • System planning for transitional age youth (ages 16 and 17) with a dual diagnosis is a responsibility shared by both ministries to work with the Ministry of Children and Youth Services (MCYS) which has responsibility for developmental and mental health services for children and youth under age 18. Local system planning will also occur to facilitate the transition of youth to adult services.
  • Individuals should have access to a continuum of care that provides the most appropriate and least intrusive service possible, based on assessment of need. For some, this may mean support through general health care services such as primary care providers and general hospital services. For others with more complex needs, integrated cross-sector responses may be required. A segment of the population may require access to specialized services that integrate the expertise and knowledge of both the mental health and developmental services sectors.
  • Mental health and developmental services funded by the Ministry of Health and Long-Term Care and the Ministry of Community and Social Services are responsible for continuing to work collaboratively within and across sectors so that individuals who have a developmental disability and mental health needs receive the appropriate levels of service to respond to those needs and so that effective case resolution mechanisms are in place in communities.
  • It is an expectation of the Ministry of Health and Long-Term Care and the Ministry of Community and Social Services that this joint Guideline will be implemented across the province by the responsible parties.

6. Demographic/prevalence rates for dual diagnosis

While the Statistics Canada Participation and Activity Limitation Survey (PALS) sets the prevalence rate of people who have a developmental disability in Ontario as 0.7% other sources cite the rate as more appropriately expressed as being between 1 to 3% of the population. footnote 2 Using the prevalence rate of 1% and the Ministry of Finance 2005 Ontario population figure of 12,540,000 there are 125,400 persons with a developmental disability estimated to reside in Ontario.

The National Association for the Dually Diagnosed (NADD) estimates that 30% of the population with a developmental disability also has a mental health disorder. Other sources have suggested the prevalence of dual diagnosis may range as high as 38%. Using the NADD figure of 30%, it is estimated that there are approximately 37,620 individuals with a dual diagnosis in Ontario.

7. Defining the population to be served

7.1 Individuals with a dual diagnosis

The definition of the population for whom this Guideline applies remains the same as it was in the 1997 Guideline stated below:

Adults with a Dual Diagnosis’ are those persons 18 years of age and older with both a developmental disability and mental health needs.

This definition was acceptable in 1997 both to the developmental and mental health sectors as well as families and consumers because it was considered broader and more inclusive than previous definitions. It is unchanged in this Guideline.

7.2 Individuals with a developmental disability

The Ministry of Community and Social Services uses the definition of developmental disability described in the Developmental Services Act R.S.O. 1990, c. D.11 (DSA):

Developmental Disability’ means a condition of mental impairment, present or occurring during a person’s formative years, that is associated with limitations in adaptive behaviour.

The health system uses the definition of mental retardation contained in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) which is published by the American Psychiatric Association:

Mental Retardation’ – this disorder is characterized by significantly sub-average intellectual functioning (an IQ of 70 or below) with onset before age 18 years and concurrent deficits or impairments in adaptive functioning.

The DSM-IV-TR and DSA definitions are comparable in most aspects with the key distinction between the two being the explicit statement of required IQ level in the DSM-IV-TR definition.

7.3 Individuals with mental health needs

For the purposes of this Dual Diagnosis Guideline, “mental health needs” are defined as diagnosed mental illness or symptoms consistent with mental illness.

Individuals with serious mental illness

In 1999 the MOHLTC released Making It Happen: Implementation Plan for Mental Health Reform and Making It Happen: Operational Framework for the Delivery of Mental Health Services and Supports. These documents provided the framework to guide mental health reform in Ontario and stated that the priority population to be served by community mental health services and supports is people with a serious mental illness.

In 1999 the MOHLTC released Making It Happen: Implementation Plan for Mental Health Reform and Making It Happen: Operational Framework for the Delivery of Mental Health Services and Supports. These documents provided the framework to guide mental health reform in Ontario and stated that the priority population to be served by community mental health services and supports is people with a serious mental illness.

The documents describe three categories to identify individuals with a serious mental illness: disability, anticipated duration and/or current duration, and diagnosis. The critical dimension is the extent of disability and serious risk of harm to themselves or others, related to a diagnosable disorder.

  • Disability: lack of ability to perform basic living skills that interferes with or severely limits an individual’s capacity to function in one or more major life activities;
  • Duration: the acute and ongoing nature of the problems including intermittent episodes between which there are periods of full recovery, and
  • Diagnosis: including schizophrenia, mood disorders, organic brain disorders, paranoid psychosis or other psychoses, severe personality disorder, concurrent disorder and dual diagnosis.

The two “Making It Happen” documents define populations to be served according to their need for services: first-line, intensive and specialized:

  • First-line: prevention, assessment and treatment provided by front-line health care providers including general practitioners, mental health services, social services, hospital emergency services and hospital primary care clinics. Services include: information and referral, crisis telephone services, mobile crisis teams, safe beds, mental health counselling and emergency services in Schedule 1 hospitals;
  • Intensive: mental health assessment, treatment and support services which are provided in community or hospital settings and are focused on people with serious mental illness. Services include: intensive case management and housing supports, skill development, psychosocial rehabilitation programs, medication clinics, Schedule 1 inpatient and outpatient services;
  • Specialized: highly specialized mental health programs provided in community or hospital settings and which focus on serving people with serious mental illness who have complex, rare and unstable mental disorders. Services include: assertive community treatment teams, mobile outreach teams, residential treatment, specialized inpatient and outpatient services and forensic services.

Each level describes a flexible or variable combination of specific service functions that differ in terms of level of resource intensity, specialization, and/or service duration. For individuals with serious mental illness, “levels of need” serve as a guide to mental health resource utilization which must be applied in conjunction with sound clinical judgment. The services a client receives will usually be based on client choice and offered in accordance with the client’s functional needs.

Given that groups of clients share many common needs and will benefit from similar service approaches, people will receive most of their services from within a particular level but are not limited to accessing services from only within one level.

8. Provincial roles and functions

The Ministry of Health and Long-Term Care (MOHLTC) is responsible for stewardship of the provincial health system. It sets overall policy direction for health and mental health services. Until April 1, 2007, MOHLTC directly funded hospitals and other transfer payment agencies to provide adult mental health services. Effective April 1, 2007, the MOHLTC provides funding to Local Health Integration Network (LHIN). LHIN legislation enabled 14 LHINs across the province to become the planners and direct funders of community and inpatient mental health services. Most physicians are not included in the LHIN mandate.

The Ministry of Community and Social Services (MCSS) funds and has responsibility for setting the overall policy direction and planning guidelines for a broad range of social services for adults with a developmental disability and their families.

Together, through a coordinated interministerial approach and based on the knowledge, skills and expertise that currently exist in both sectors, MOHLTC and MCSS will:

  • Provide policy direction and develop corporate linkages that strengthen the range and capacity for a continuum of mental health and developmental services;
  • Coordinate planning and monitor the impact of changes on service access and availability at the provincial level;
  • Monitor and evaluate mechanisms for inter/intra-ministerial planning and coordination at a provincial level;
  • Encourage availability of appropriate training and education for service providers in both the developmental and mental health sectors.

9. Local roles and functions

Effective service responses at the local/regional level are the product of strong and meaningful linkages across the sectors. MOHLTC will continue to provide funding to Local Health Integration Networks (LHINs) and MCSS will continue to provide funding to Regional Offices for delivery of services at the community level by transfer payment agencies. Responsibility for planning, building capacity and linkages across both sectors will rest primarily with the following structures:

  • The Ministry of Health and Long-Term Care funded Local Health Integration Networks (LHINs) for mental health services and,
  • The Ministry of Community and Social Services Community Networks of Specialized Care (CNSCs) for developmental services with the support of the Ministry Regional Offices.

9.1. Local Health Integration Networks (LHINs)

Effective April 1, 2007 LHINs assumed planning and funding responsibilities for most community and hospital-based mental health services in their jurisdictions. LHIN Integrated Health Service Plans are consistent with the strategic planning directions for MOHLTC. The responsibilities of LHINs are to:

  • Support and facilitate the development of cross LHIN boundary and cross-sector planning at a LHIN level;
  • Facilitate integration of the local health system and develop strategies to integrate services;
  • Facilitate case resolution linkages, consistent with reforms in both sectors;
  • Develop a process with local communities to assess the mental health and other resources needed to serve persons with a dual diagnosis and establish cross-sector partnerships to implement effective solutions;
  • Plan and consult with the MCSS Community Networks of Specialized Care (CNSCs) so that persons with a dual diagnosis have access to a range of mental health services, consistent with the ministry’s mandate, that are responsive to individual needs, including clients who will be affected by institutional closures of either ministry.

9.2 Community Networks of Specialized Care (CNSC)

The Community Networks of Specialized Care funded by MCSS are partnerships of specialized Developmental Services and other community agencies, including LHIN funded mental health service providers and organizations, working together to improve and coordinate specialized services for people who have a developmental disability and mental health issues and/or challenging behaviour. The CNSCs were created with a mandate to build capacity and linkages across local planning groups in relation to serving persons with a dual diagnosis.

In their leadership role on behalf of service provision for persons with a dual diagnosis the four Networks (East/North/Central/West) will coordinate a Specialized Service System to:

  • Streamline access to specialized services:
    • break down barriers between the developmental services specialized and mental health service systems;
    • function at a local level and facilitate the development of protocols and agreements between service providers involved in serving people with a dual diagnosis;
    • expand partnerships and strengthen linkages with specialized mental health service providers such as LHIN funded Assertive Community Treatment Teams;
    • better coordinate scarce resources and improve the case resolution process for the most challenging individuals.
  • Enhance service delivery:
    • improve capacity of Network members to develop a broader range and increase the volume of services that both specialized and developmental services service providers can offer;
    • assess community needs and opportunities and provide advice to MCSS and LHINs about the allocation of resources to meet priorities and support restructuring in their communities.
  • Train and build capacity in the community:
    • develop relationships with the academic and research community;
    • improve access to research/best practices;
    • increase expertise in specialized services through professional development;
    • train general health and social service practitioners;
    • develop plans to recruit and retain more specialized professionals.
  • These actions will be undertaken in partnership with local dual diagnosis planning and/or advisory groups and LHINs with the support of the MCSS Regional Offices.

9.3 MCSS regional offices

In relation to the CNSCs, the regional offices will work with the Networks to:

  • Develop cross-sector linkages that strengthen the capacity for the planning and coordination of services and supports for persons with a dual diagnosis;
  • Help coordinate, support and build upon the existing continuum of services and supports in local communities, in partnership with institutional and community mental health and developmental service providers;
  • Address unmet service needs and pressures in local communities by identifying and prioritizing the gaps and barriers to access throughout the developmental services system based on individual needs;
  • Enable planning and coordination in local communities for persons with a dual diagnosis that is consistent with MCSS policy direction.

In addition, the regional offices will work with the LHINs with respect to initiatives in the mental health service sector related to:

  • MCSS Schedule 1 Facility closures and downsizing (e.g., Rideau and Huronia Regional Centres);
  • Development of appropriate community program strategies for inpatients of hospitals in order to support community living options for these individuals;
  • Participation in education and training initiatives within and across mental health and developmental services.

10. Next steps

Implementation of this Guideline at the local level will be the responsibility of the regional/local structures and service providers to work together to enhance the capacity across both sectors to serve this population. Specifically:

  • It is the expectation of both ministries that the LHINs and the appropriate local developmental services planning forum (Networks or other forums as defined by the local community) will link to define how the local system will implement this Guideline;
  • LHINs and Networks will take the appropriate steps to recognize and address the service needs for this population by building local cross-sectoral relationships and defining expectations for local service providers in both the health and social service sectors.

Ministry of Health and Long-Term Care, Mental Health and Addictions Unit Ministry of Community and Social Services, Developmental Services Branch December, 2008.

Appendix 1: Community mental health services for adults with a dual diagnosis

Case managementIncludes outreach, comprehensive individualized assessment and planning, service coordination and support, monitoring and evaluation of services provided to recipients, systems advocacy/resource coordination and Community Treatment Order (CTO) coordination.
Counselling and TreatmentCounselling, psychotherapy and other treatment services to individuals with serious mental illness in the community including tele-psychiatry.
Assertive Community Treatment Team (ACTT)Multi-disciplinary clinical teams provide treatment, rehabilitation and support services to clients with severe and persistent mental illness. They provide assertive outreach, individualized treatment, ongoing and continuous services, linkages to services and monitoring/evaluation.
ClubhousesMulti-service psychosocial rehabilitation based on the psychosocial rehabilitation principles, which includes assistance to further vocational and educational goals, secure housing and engage in social and recreational programs.
Early interventionSpecialized treatment and support services for individuals experiencing a first psychotic episode, and their families.
Diversion and court supportCourt support is provided in the courts to assist individuals and their families with the legal process, link to services and to assist the judiciary. Diversion is provided pre- or post-charge to link individuals to community or institutional mental health services.
Social rehabilitation/ recreationProvision and promotion of opportunities to develop interpersonal, social, and leadership skills, in order to interact fully in their communities as defined by themselves including assessment, counselling, planning, consultation with other service providers, coordination, advocacy, monitoring and evaluation.
Abuse servicesProvision of counselling, treatment services and support to women who have experienced an abusive act or who are in an abusive situation.
Crisis interventionActive treatment and support such as provision of safe beds, urgent psychological and/or medical attention offered as soon as possible after an individual has been identified as in acute distress. Includes: assessment and planning, crisis support/counselling, medical intervention, environmental interventions and crisis stabilization, review/follow-up referral.
Primary day/ night careFree-standing or attached units where treatment, counselling, rehabilitative/ social and recreational services are provided to recipients who attend for three to twelve hours on average.
Community service information and referralInformation and referral services over the telephone or in person.
Consumer/ Survivor InitiativesProvision of a range of consumer directed initiatives including self-help, peer support and drop-in centres based on the needs and interests of consumers/survivors in local areas.
Family InitiativesProvision of support and training to strengthen and maximize natural supports and existing community networking systems that are relevant to the consumer/family. Family groups participate in planning and evaluation of care delivery, as well as provision of services such as self-help, peer support and education.
Alternative BusinessesProvision of consumer operated businesses that offer full- or part-time employment at market rate or higher. They offer a combination of job development, job placement and supported education within the self-help context. They may also offer self-employment opportunities for consumers to earn income through independent contract work. Support and accommodation are provided on site to consumer employees.
Case managementIncludes service coordination, planning and support, monitoring, advocacy and resource coordination.
participation supports
Community participation supports provide opportunities for individuals who have a developmental disability to find more ways to participate in their communities, such as through social and recreational activities, work and volunteer activities.
specialized community supportsSpecialized resources include services such as behavioural assessment and counselling services, speech and language therapy; specialized training for professionals who work with individuals who have a dual diagnosis (e.g., psychiatrists, psychologists, social workers and behaviour therapists); services that provide urgent support for individuals whose needs exceed the capacity of their caregivers; community outreach such as training, consultation and counselling for caregivers (e.g., agency staff, family, community health professionals); residential arrangements where
individuals receive transitional or ongoing clinical supports from specialized professionals; research, professional development and training in best practice models of care, support and interventions.
Residential supportsProvision of housing supports to assist individuals to live independently in the community. Programs offered are Supported Independent Living, Group Home living situations, Family Home arrangements, and Individual Residential Model options.
Special Services at Home (SSAH)A directly operated MCSS respite program for children and adults who have a developmental disability and for children with a physical disability. The program provides annual funding directly to families so that they may purchase respite services and supports not already available in the community.
Ontario Disability Support Program (ODSP)

People with a developmental disability can apply to the Ontario Disability Support Program (ODSP) which is designed to meet the unique needs of people with disabilities who are in financial need, or who want and are able to work and need support. It is directly operated by the Ministry and the program has two components: Income Support; and Employment Supports.

Income support

Income Support provides financial assistance and other benefits to eligible people with disabilities and their families. This includes accommodation and basic living expenses, as well as prescription drugs and basic dental care.

Employment supports

The ODSP Employment Supports program works with community service providers to help people with disabilities prepare for and find jobs, keep a job and advance their career. The program can also help people with disabilities become self-employed.

Some examples of the supports that may be available include: Job coaching

  • on-the-job training
  • adaptive software and mobility devices Interpreter/intervenor services Transportation assistance
  • assistive devices and training to use them
  • tools and equipment
  • special clothing
  • specialized computer training
  • other items that may be needed for work.