This document discusses trends in Assertive Community Treatment (ACT) teams in Canada over the past 15 years. It provides an overview of the development of ACT teams across several Canadian provinces and highlights key outcomes such as significant reductions in hospital bed use and improvements in housing stability. It also reflects on evolving target populations, issues of fidelity to the ACT model, and considerations around measuring team effectiveness and ensuring appropriate resources and capacity.

1. TRENDS AND THEMES IN ACT
TEAM SERVICES IN CANADA….
…AND SOME SPECIFIC
REFLECTIONS ON EFFICIENCIES
AND CAPACITIES
C O L L O Q U E A N N I V E R S A I R E
D E S E Q U I P E S D E S U I V I I N T E N S I F
1 5 A N N E E S
I A N M U S G R A V E
S E R V I C E C H I E F / D I V I S I O N H E A D
A C T / T E R T I A R Y S E R V I C E S
V A N C O U V E R I S L A N D H E A L T H
A U T H O R I T Y
A P R I L 1 9 , 2 0 1 3

2. INTRODUCTION
celebrating the fifteen years of contribution of Quebec’s ACT teams, in enhancing the
freedom, hope, community tenure, autonomy and dignity of those with severe mental
illness
…felicitations!!
providing for both the clinical and personal recovery of tertiary level patients
advancing the cause of furthering excellence in existing teams services, over against
the literature and science of ACT and in the context of ensuring proper resources
advocating for the public policies and implementation of further ACT teams that build
continuously on the efforts of the last 15 years

3. DISCLOSURES
Longstanding passion and support for the work and efforts of my colleagues in
Quebec driving the desire of ACT implementation
Strong personal connections to Alain Lesage, Eric Latimer, Deborah Thompson
No censorship on the contents of this talk
Receiving no fees, compensation from pharmaceutical companies or any such source
Receiving an honorarium from the province of Quebec to contribute to the promotion
and consultation of ACT teams in Quebec

4. OUTLINE
The early years
 …..Ontario…Quebec…..
Provincial Infrastructures…Ontario, BC, Quebec
 fidelity, training, accreditation, evaluation
Evolution of Recovery Focus…
 clinical and personal recovery
Specialty teams and target populations
 “pressures” to admit everyone

5. OUTLINE CONT’D
Effectiveness Measurements
 Hospital data, housing data, qualitative data
Integration with
 Physical health care,
 Income assistance
 Criminal justice system
Housing First ACT (MHCC Study)
Efficiencies and Capacities….epidemiology, flowthrough
 Contacts, intake rates, population mix, finite capacities below initial expectations
 Discharge rates and Stepdown Services

6. Ontario
Quebec
British Columbia
Alberta…Calgary and Edmonton
Manitoba 2 Winnipeg, plus MHCC
PEI 1 modified
New Brunswick MHCC
Nova Scotia ?
Saskatchewan ?
NATIONAL IMPRESSIONS

7. ONTARIO
1989/90: Brockville Psychiatric Hospital …Hugh Lafave…Canada’s first ACT teams
Advocacy , early rollout
ACT Ontario: standards, (1995. 1997), training/workshops, accreditation, evaluation
Three phases of team rollout: early (new provincial funds) middle (longterm bed closures)
and late (federal health accord funds)
80 ACT teams…> 6000 patients, (many discharges…) …
double this quantity needed, with informed distribution required by proper expertise
No longer doing accreditation, site visit training, or evaluation measurements at a
provincial level…..decision to embrace “OCAN” the Camberwell recovery instrument
Loss of momentum in terms of new teams, and upholding current ones
Real danger of erosion of team funding, outcomes…

8. BRITISH COLUMBIA
Pre ACT 2003…..full ACT in 2007…Seven Oaks, Downtown Victoria ACT Teams
Provincial standards ….2007
Provincial evaluation framework….2007…ongoing efforts to see provincial data base
Provincial “ACTPAC” committee ….Ministry and ACT teams
12 teams…
Vancouver Island 7 teams, (needs 10 to 12)
Victoria (4), Nanaimo, Campbell River, Port Alberni
health authority level database, and vision for 2 more teams
Prince George, Vancouver (MHCC team, and 2 others), Fraser Health (Surrey)
More teams to come in Vancouver, Fraser Health
No teams in Interior Health (Kelowna, Kamloops)

9. QUEBEC ACT TEAMS
Strong historical legacy of attention to and understanding of high fidelity ACT
Douglas Hospital early advocacy….and original deinstitutionalization mandate
no provincial standards, no set global budgets, for many teams …teams without proper
staffing complement and thus compromised ability to rollout proper implementation
of teams at a provincial level
strong training, skills development emphasis for those teams that are implemented
no provincial level outcomes measurements infrastructure
hospital rates, housing status, recovery measurements, personal and
medical and social demographics
no doubt: lots of pressures to be doing more and more with little support and
recognition

10. ASSERTIVE COMMUNITY TREATMENT
An explicit target population to be served
 Long stays, heavy users of the system, homeless who are severely disabled and
high profile
An explicit service delivery model…
 Funded against standards of staffing, service articulation, epidemiology/capacity
targets
An explicit understanding of what to expect (over against “business as usual” or
against doing nothing)
Rigorous trials and history to support certain outcomes measurements that are worth
replicating

11. ASSERTIVE COMMUNITY TREATMENT
Community based service for the tertiary mental illness and addicted patients
Well defined structures and functions from a scientific literature framework
Funding and resources predicated against the prescribed structure
Explicit target population primarily mandated through service delivery needs rather than
diagnostic exclusions (“heavy users” of the secondary and tertiary system”)
Small caseloads served by a multidisciplinary team of hospital level staffing complements
Intensively able to serve clientele in their own homes, and community venues….up to
once or twice a day in significant numbers at any one time
Operating each day of the week, usually in a day/evening shift arrangement during the
week days and significant staffing on the weekends to cover off many daily service
obligations
Explicit outcome measurements replicated in many well constructed studies
Evolving model of care, in terms of target populations, service structures, related
measurements of outcome

12. CONCEPTUAL SCHEMA OF SERVICES TO
THOSE WITH SEVERE MENTAL ILLNESS
Tertiary Inpatient
Care (1-2%)
Assertive Community
Treatment Teams
(15-20%)
Intensive Case Management
Case Management (? 40-60%)
Collaborative Care: “Shared Care” Depression, Anxiety
Disorders and Psychotic Disorders (? 20 – 40%)
A P R - 1 3

13. TARGET POPULATIONS FOR ACT
1 The small but important minority of longstay inpatients leaving
institutional life for the community
 …let us always reach in with ACT to this longterm asylum group of patients!
2 The severe psychosis patient in acute care revolving door syndrome care
 …let us always “do our homework” and chase the high end users in our
acute care hospitals!
3 The growing trend and pressures of many disengaged homeless patients
of ACT level needs, a very mixed and complex group
 ..let us always do our share of chasing the high profile patients on our
streets!

14. ACCOUNTABILITY
Public funds….public disclosure…programmatic evaluations
Who is served?
 Target population...thorough understanding of our mandate
 Capacity/epidemiology projections (gap analysis)
 Numbers/descriptors/diagnoses/social contexts
How are they served?
 Modus operandi over against the known science
 Staffing, budget, empiric or published standards
 Measuring efficiencies and productivities
What difference does it make?
 Service impacts and changes…pre and post…randomized, controlled welcome!
 Regularly reported clinically meaningful presentations to all relevant stakeholders: internal and
external
 Each distinct category of service providing regularized, (?annual) presentation/rounds to
“higher ups” , collegial groups as well as local community of stakeholders

15. ACCOUNTABILITY….STANDARDS, BUDGET
ACT teams in Canada generally receive global autonomous/freestanding budget
allocations to carry out a specific mandate
Budgets may be integrated to a governance structure that situates ACT teams to the
local hospital and case management setting, and to other local ACT teams

16. MODEL FIDELITY AND EROSION OF BUDGETS
Budgets initially defined by standards
ideally global funding for full staff complement, psychiatrist alternate payment,
physical health care budget, rental subsidy budget (~ $1.2 – 1.4 M)
Partial funding arrangements often lead to false assumptions leading to false
conclusions
Budgets not protected by standards
Common staffing erosions
 Team leaders shared across multiple teams and/or related case management
services
 Less than dedicated psychiatrist time…(multiple psychiatrists “following their own”)
 Staff vacancies not being replaced, staff complements below full team funding …
 2 shift and weekend coverage gets thinned

17. SHIFTING TARGET POPULATIONS
Reflections of long term inpatient populations being served upon discharge
Newer generation of ACT clientele
 Revolving door syndrome general hospital patients
 Homeless patients…younger, higher street drug usage, more forensic/criminal justice system
involvement
 Brain injury, trauma/abuse, personality disorder
Specialty ACT teams with explicit subpopulations
 BPD, forensic, developmental delay, seniors
All ACT teams providing certain percentage inclusions of non “mainstream” populations
Basic limitations to ACT teams: no more than 10-20% of patients outside of initial mandate,
unless explicitly funded to target a set subpopulation
Responsibility of ACT to be credible players in service delivery needs of heavy users, and adapting
our model to fit patients who need our care, while ensuring the system addresses these
service needs with and without ACT level

18. SUBPOPULATION ACT TEAMS
Regional ACT teams deciding to target populations in specific ways
eg ottawa…BPD team…central intake…
or Kalamazoo teams sharing resources in specialized DBT manner of individual and
group work for this population
Specialized Teams
forensic ACT in urban areas big enough to have specialty eg toronto
developmental delay teams
…eg Brockville, Toronto
Specifically mandated teams
homeless ACT studies
eg MHCC Raincity study vancouver eastside, downtown teams in victoria, nanaimo

19. ACT ACCOUNTABILITY: EFFECTIVENESS AND EFFICIENCIES
Effectiveness: basic outcome measurements
 Hospitalization/ER, Housing status/changes, …and qualitative recovery
measurements (esp. vocational, educational)
 VIHA global ACT database
 Ministry ACT programmatic evaluation expectations
Efficiencies:
 contact measurements,
 informed understanding of factors affecting ultimate capacity per team
Ripple Effects in all of Mental Health Services
…witness VIHA’s new accountability framework…clear connection to ACT
publications of outcome measurements

20. EFFECTIVENESS…..COMMON MEASUREMENTS
Bed day utilization reductions in the ~ 70% range for heavy users (> 50 plus beddays in a
given year…Eric Latimer, McGill)
 Pre and post
ER reductions
 Pre and post
Housing status
Strong bias towards independent housing
 At time of admission, snapshots every 6 months
 Homelessness to housing…biases for market rent housing
 Progressive improvements in quality of housing
Clinical over against Cost effectiveness
 Clinical effectiveness has to be “affordable”
 The costs of the status quo (control group, pre vs post, cost avoidance measurements)

21. EFFECTIVENESS….QUALITY OF LIFE MEASUREMENTS
Service orientation towards clinical recovery leading to personal recovery
Literature development in general that the chronic psychotic patient should not be
forgotten in terms of being a person!
Vocational rehabilitation: IPS model mainstream in ACT philosophy
community development of vocational opportunities…(Queens, Kingston)
Family reconnections
Personal therapies….trauma, insight, DBT, CBT
Education, and individualized supports at schooling
Peer specialists in mental health services and in ACT work

22. ONTARIO: COMPARISON OF AVERAGE
HOSPITAL
BED DAY REDUCTION RESULTS
0
20
40
60
80
100
2001-02 70 27 17 16 14
2002-03 86 28 20 16 15
2003-04 77 26 23 16 16
2004-05 76 25 20 18 16
2005-06 71 27 22 19 17
1 Year
Pre-ACT
Year 1 Year 2 Year 3 Year 4

23. SEVEN OAKS ACT TEAM:
PRE AND POST ACUTE CARE BED UTILIZATION
(INCLUDES “RESPITE” AND EMP READMISSIONS)
194
303
19 22 19
0
50
100
150
200
250
300
350
Year 2 Year 1 Year 1 Year 2 Year 3
Pre-admission to ACT services Post-admission to ACT services
Number of days
n=35

24. SEVEN OAKS ACT TEAM:
PRE AND POST HOSPITAL COSTS & COST
AVOIDANCES
$2,206,750
$3,446,625
$216,125 $250,250 $216,125
$2,610,563 $2,576,438 $2,610,563
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
Year 2 Year 1 Year 1 Year 2 Year 3
Pre-admission to ACT services Post-admission to ACT services
Costs estimated using per diem of $325
n=35
Estimated cost avoidance
Estimated cost

25. PSYCHIATRIC ACUTE CARE BED DAYS BY TEAM
1 YEAR PRE AND 2 YEARS POST ACT ADMISSION
0
50
100
150
200
250
300
Pre Bed
DaysYr1
Post Bed
DaysYr1
Post Bed
DaysYr2
289
37
7
Numberofbeddays
Seven Oaks ACT N=9
(team N = 43)
0
200
400
600
800
1,000
1,200
1,400
Pre Bed
DaysYr1
Post Bed
DaysYr1
Post Bed
DaysYr2
1,228
352
113
Numberofbeddays
Pandora ACT N=28
(team N = 68)
0
100
200
300
400
500
Pre Bed
DaysYr1
Post Bed
DaysYr1
Post Bed
DaysYr2
469
42
11
Numberofbeddays
Downtown ACT N=16
(team N = 70)
91%
reduction
97.7%
reduction
EM3A, EM3B, EM4A, EM4B, PIC, KEN2, WAT2, 4STH-CD, 2SER, 2SWR, 1NWR, 1SWR, 2NER,
2NWR, PICJ, PIPJ, PSY-N, PIC
0
20
40
60
80
100
120
140
Pre Bed
DaysYr1
Post Bed
DaysYr1
Post Bed
DaysYr2
121
35
11
Numberofbeddays
VICOT
N=22
(team N = 67)
Reduction % is from 1 yr Pre ACT
97.6%
reduction
87.2%
reduction90.9% reduction
71.7% reduction
90.8%
reduction
71.3%
reduction

26. HOUSING TYPE SNAPSHOT - ADMISSION AND CURRENT (NOV. 2011)
0
5
10
15
20
25
30
35
17 18
0
10
14
5
8
13 1 1
5
32
18
13
0
Downtown ACT
Admission Current
N=73
0
5
10
15
20
25
9
22
3 2
6 5
11
3
0
4
2
0
22
11
20
2
Pandora ACT
Admission Current
N=61
0
5
10
15
20
25
30
12
27
2
4
2
6 8
32
4
0 2
12
26
17
1
VICOT
Admission Current
N = 64
0
5
10
15
20
25
30
1 2
0
7
26
0
4
1 2
0
5
0 0 0 1 0
12
5
17
3
Seven Oaks
Admission Current
N=43

27. ACT CAPACITY: POPULATION HEALTH
EPIDEMIOLOGY PERSPECTIVE
ACT teams serving a local general hospital heavy users population
Tertiary clientele
15 % of the seriously mentally ill
…… of which may be 1-2% in longer term hospital care
1 ACT Team for every 75-100,000 general population
….. Where 80% of patients are psychotic disorders
More ACT capacity required as the target population mandate expands
homeless and mental illness
forensic
developmental delay, cognitive impairment/brain injury
personality disordered hospitalphilic patients

28. CURRENT STATUS OF ACT SERVICES
Victoria
Downtown ACT
Pandora ACT
VICOT ACT
Seven Oaks ACT
Duncan
Nanaimo
Nanaimo ACT
Tofino
Courtenay

29. FUTURE PROJECTIONS OF ACT SERVICES
Victoria
Downtown ACT
Pandora ACT
VICOT ACT
Seven Oaks ACT
Victoria (5) ACT
Duncan
Nanaimo
Nanaimo ACT
Nanaimo(2) ACT
Campbell
River/Northern ACT
West Coast ACT
Tofino
Courtenay Courtenay/Comox ACT
Cowichan/Duncan ACT

30. FACTORS AFFECTING ACT INTAKE RATE, CAPACITY
AND DISCHARGE RATE
Staffing complement and staffing turnover, especially key roles such as team leader
or psychiatrist
“protection” of any “front line” staff member(s) from primary caseload
“developmental” stage and age of the team
Current number of patients on the team
Patient psychiatric and service needs acuities, “quadrant four” and homelessness
numbers
Frequency of face to face and indirect contact per patient
Potential for discharge: stepdown and other case management service availabilities
Commitment to clinical and then personal recovery
Travel times/distances for patient contacts

31. APPLICATION OF THEORY TO ACT CAPACITY REALITIES
Examining the theoretical construct of capacity limitation
what the standards dictate (staffing, and ratio definitions)
what the frequency of contact capabilities are of the staff
what the frequency of contact needs of the patients are
how those contacts may vary over time on a given team
how those contacts needs may vary as the target population changes
Examining the reality check of capacity limitation
implications of modifications to the standards

32. EFFICIENCIES…. WITHIN ACT
“intensive” tertiary home care translates into various components and measures of
efficiencies and capacity expectations:
Numbers of patients on the service
Numbers of staff on the service , staffing stability/turnover, one psychiatrist
Frequency of contact data (published reasonable assumptions of possible contacts
possible)
Staffing complement/gaps (published staffing standards)
Front line to patient ratio (published standards)
Numbers of “quadrant 1V” patients/labour intensity expectations
Centralized intake processes (between teams and with referral sources)
Respite care at Seven Oaks
Active “Stepdown” ACT discharges and flowthrough

33. 0
5
10
15
20
25
30
35
2 x day 1 x day 4-5 x week 2-3 x week 1 x week q 2 weeks q 3-4 weeks
3
34
4
16
3
0
1
5
27
5
25
5
3
2
5
12
5
22
9
4
0
9
13
7
3
1
0
4
0
1
0
8
20
0
4
#ofclients
# of face to face contacts
Face-to-face frequency of contact – Victoria ACT Teams
VICOT DACT PACT 7 O ACT Stepdown
Number of clients per team: VICOT=61 D/ACT=72 P/ACT=57 SO/ACT=37 Stepdown=33

34. EFFICIENCIES THROUGH EXTERNAL
PARTNERSHIP (1+1=…3)
Not all efficiencies are “internal” but can be realized by our key and strategic
partnerships
Witness the advent of collaborative care in our country and on our island, leveraging
efficiencies in how mental health systems create more leveraging of the care of
some individuals by positing the locus of care back into the primary care system,
and bringing psychiatric care into that system in a more efficient way than the
other way round
There are so many determinants of mental health that are outside of the mental
health system, where partnerships can be developed and formalized for a
synergistic “greater good”

35. ACT EFFICIENCIES….VICTORIA ACT
INTEGRATION WITH MINISTRY RESPONSIBLE
FOR INCOME ASSISTANCE
Strong partnership with income assistance
 Income assistance officer on site
 Direct day to day money management if required to maintain housing and
dignity…platform for skills teaching and autonomy
 treatment for addictions (ie budget for housing and food and essentials, not street
drugs and dealers)
 Often endorsed through Mental Health Act or the Courts (as a condition of freedom)
 Occasional use of public guardianship/trusteeships

36. ACT EFFICIENCIES…VICTORIA ACT INTEGRATION WITH
CRIMINAL JUSTICE SYSTEM
Strong partnership with Criminal Justice System
 Dedicated court (“Victoria Integrated Court”) system specific for ACT clientele
developed over last few years with judiciary, corrections, mental health (ACT) and
law enforcement
 Enhanced efficiencies, very little delay/holdovers
 Consensus building (crown, defence, probation, law enforcement, care givers) on
conditional community based ACT mediated sentencing and work services
 Community Sentence Orders and probation orders as a “court diversion” from
incarceration with specific court mandated attachment to specific ACT services

37. INTEGRATION WITH PHYSICAL HEALTH CARE
Clear evidence of increased morbidity and early mortality in the SMI
ACT clientele poorly served in traditional primary health care
Integrating primary care in ACT
 “reverse collaborative care”
 Addressing access to care for orphaned patients
 Addressing comprehensive primary care
 Injury, wound care
 Infectious diseases..Hep C, HIV
 Diabetic management
 Metabolic syndrome
 Cardiovascular risk factor mitigation…smoking, weight/diet, exercise, BP
 Cancer monitoring

38. ACT EFFICIENCIES…VICTORIA ACT INTEGRATION
WITH PRIMARY HEALTH CARE
Full time nurse practitioner serving our four teams
Integrated/on site services and at “Cool Aid”
Special emphasis on “orphaned patients” and those hard to engage
General practitioner also with our teams on site one half day per week
Nursing staff working closely with NP/GP and clinics wrt tough medical situations,
chronic disease management (eg IDDM, HIV, Hep C)

39. HOUSING FIRST ACT AND RENTAL SUBSIDIES
Increasing numbers of High high percentage homeless at time of
admission to ACT teams in BC
Very expensive rental context relative to income
Bias/Legacy of ACT empowering clients towards independent living
Clear evidence of clinical and cost effectiveness of living
independently for so many

40. HOUSING FIRST ACT AND RENTAL SUBSIDIES
Rental subsidies: “The smallest line in an ACT budget with the
greatest impact on outcomes”
$250 x 50 = $ 12,500 per month
$300 x 50 = $ 15,000 per month
CMHC market rent transparencies of amounts of subsidies for at
least half of clients in ACT
Housing position development of ….
 “ACT BC” , ACTPAC together with BC Housing

41. CAPACITY CHALLENGE 2013:
EVOLVING TARGET POPULATION (↑Q IV)
Ontario/BC
Standards
Capacity
Challenge
Solution?
Caseload 100 100 80
Number of frontline staff 10 10 10
Ratio of staff to patients 1:10 1:10 1:8
Average number of
patient contacts required
per week
2-3 5 5
Maximum number of
staff contacts per day
5 5 5
Number of contacts per
team per week (Mon-Fri)
250
=10 staff x (5 x 5 days)
250 250
Number of contacts per
team per weekend
20
=2 staff x (5 x 2 days)
20 20
Total number of team
contacts per week
270
=(250+20)
270 270
Total number of contacts
required per week
270
=100 patients x 2-3
contacts
500
=100 patients x 5
contacts
400
=80 patients x 5
contacts
CAPACITY DEFICIT 0 230 130

42. ACTUAL CAPACITY:
NEWER TEAM (e.g. <5 years)
Ontario
Standards
Capacity
Challenge
Solution?
Reality Check:
Actual Capacity
Caseload 100 100 80 54
Number of frontline staff 10 10 10 10
Ratio of staff to patients 1:10 1:10 1:8 1:5
Average number of
patient contacts required
per week
2-3 5 5 5
Maximum number of
staff contacts per day
5 5 5 5
Number of contacts per
team per week (Mon-Fri)
250
=10 staff x (5 x 5 days)
250 250 250
Number of contacts per
team per weekend
20
=2 staff x (5 x 2 days)
20 20 20
Total number of team
contacts per week
270
=(250+20)
270 270 270
Total number of contacts
required per week
270
=100 patients x 2-3
500
=100 patients x 5
400
=80 patients x 5
270
=54 patients x 5
CAPACITY DEFICIT 0 230 130 0

43. ACTUAL CAPACITY:
MATURE TEAM (e.g. 10+ years)
Ontario
Standards
Capacity
Challenge
Solution?
Reality Check:
Actual Capacity
Caseload 100 100 80 80
Number of frontline staff 10 10 10 10
Ratio of staff to patients 1:10 1:10 1:8 1:8
Average number of
patient contacts required
per week
2-3 5 5 3-4
Maximum number of
staff contacts per day
5 5 5 5
Number of contacts per
team per week
(Mon-Fri)
250
=10 staff x (5 x 5 days)
250 250 250
Number of contacts per
team per weekend
12
=2 staff x (5 x 2 days)
12 12 12
Total number of team
contacts per week
270
=(250+20)
270 270 270
Total number of contacts
required per week
270
=100 patients x 2-3
500
=100 patients x 5
400
=80 patients x 5
270
=80 patients x 3-4
CAPACITY DEFICIT 0 230 130 0

44. CONCLUSIONS
Capacity of ACT Teams probably not best conceptualized against a 1:10 ratio as the
only mantra to decide on capacity…..but rather formulated against target
population mandates, recovery emphases, many other staffing and service
delivery factors… much more likely 1:8 in capacity capping
Teams do well to measure and understand the factors affecting capacity:
staffing endowment, team stage and development
population served, geographic and catchment area context
intake rate,
proportions of Quadrant IV patients,
frequency of contact data
Stepdown team and overall discharge considerations

45. CONCLUSIONS
Mental Health Services do well to honour the mentally ill and addicted by taking
seriously the ACT model fidelity and accountabilities and efficiencies of their
services
ACT Teams are well known for robust service articulation and outcome measurement
ACT teams do well to have proper attention to:
1) thorough target population understanding and measurement
2) thorough service delivery model fidelity measurement
3) thorough outcome measurements of key determinants
4) thorough understanding of efficiencies and capacity measurements
(and all the factors affecting intake, census, and discharge rates )

46. QUESTIONS, COMMENTS, DISCUSSION
merci beaucoup!
ian.musgrave@viha.ca