The Next Decade of Service

 Relationship to Canada’s health system  Relationship to Ontario’s health system  Relationship to health system of the GTA  Relationship with Toronto Police Service  Where we work  How we work  How we’re doing  Where we’re going

SJHC

New York, N.Y. 8,175,133 Los Angeles, Calif. 3,792,621 Chicago, Ill. 2,695,598 Toronto, ON. 2,615,060 Houston, Tex. 2,099,451 Philadelphia, Pa. 1,526,006 Phoenix, Ariz. 1,445,632 San Antonio, Tex. 1,327,407 San Diego, Calif. 1,307,402 Dallas, Tex. 1,197,816 San Jose, Calif. 945,942

SJHC Statistics for Beds: 376 Admissions: 21,657 Births: 3,080 Ambulatory care visits : 272,689 Surgical Cases: 31,568 Diagnostic Imaging Procedures: 165,125 Emergency Department Visits : 93,741 Mental Health ED Visits : 7,248

26 bed Withdrawal Management Service offering residential, day and community services Addiction Medicine service with 13 family physicians 6 bed Child and Adolescent MH beds 6 bed Short Stay Unit 6 bed Psychiatric Intensive Care Unit 29 general adult psychiatric unit

Mobile Crisis Intervention Team Geriatric Mental Health Outreach Team Assertive Community Treatment Team Case Management Team Day Hospital Depot Clinic Shared Care Service Psychiatric Outpatient clinic (16 docs, RN, dietician) Recovery Support Program

SJHC

(works for us) socialized health care

The Ontario Health Insurance Plan is funded by taxes paid by the residents and businesses of Ontario and by transfer payments from the federal government. Every Ontario resident with his or her primary and permanent home in Ontario is entitled to access emergency and preventive medical care under OHIP free of charge. Ontario residents may go to any doctor practicing in the province any time they wish. It does not cover such areas as prescription drugs or dental care.

The 14 Local Health Integration Networks of Ontario plan, fund and coordinate services delivered in their region by: Hospitals Long-Term Care Homes Community Care Access Centre's (CCAC) Community Support Service Agencies Mental Health and Addiction Agencies Community Health Centre's (CHCs )

INTEGRATION INITIATIVES include a continuum of relationships that can exist between and among individual service providers, programs, organizations and systems of services Creating HEALTH EQUITY

HOSPITALPARTNER TPS DIVISIONS START-UP YEAR St. Michael’s Hospital51/522000/1 St. Joseph’s Health Centre 11/142005/6 The Scarborough Hospital 41/42/432006/7 Humber River Regional Hospital 12/312006/7

SJHC MCIT Catchment Area SMH MCIT Catchment Area Scarborough Hospital MCIT Catchment Area Humber River Regional Hospital MCIT Catchment Area

The team works in an area which is heavily populated by individuals suffering from a major mental illness: Proximity to a former provincial psychiatric hospital City by-laws that allow boarding homes A neighborhood with a large proportion of former mansion-like homes with the potential to be subdivided Becoming gentrified (which brings in even more drug traffic)

Visits/calls: 903 Number of individuals served: 594 Telephone Consultations: 324

MCIT TPS Chief + Board MCIT city-wide Inspector 14 Div. S. Sergeant 11 Div. S. Sergeant 11Div. PC 14 Div. PC SJHC RN SJHC Manager SJHC corporate objectives, policies + procedures MCIT LHIN Priorities Managing a team

40%

2000 Pre-MCIT 2007 Post-MCIT Source: St. Michael’s Hospital, 2007

 Communication – RN and PC, manager and staff sergeants  cc on everything  MOU  Quarterly meetings  Involved in each other’s hiring decisions  Keep in the forefront the other organization's mandate  Education

 Training  City-wide coverage /standardization  EMS

Driving police vehicles Firearms safety Use of force

Communication between EMS & MCIT. Avoid unnecessary transports to hospital. Stop transport of people threatening suicide by EMS prior to MCIT arrival.

52 year old female Borderline Personality Dissociative Identity Disorder Numerous overdoses Depression and anxiety Frequent user of the emergency services Hospital visits varied but could be as many as 3 per week

END OF ACT 1

The Frontline Nurse Perspective

“Bringing the Emergency Room to the person in Crisis”

Is the partnership between St Joseph’s Health Centre and Toronto Police Divisions 11/14 Utilizes the resources of 1 base hospitals and 2 local hospitals Care provided is flexible re: hospitals & jurisdictions Consists of a police officer in a modified uniform and a mental health nurse, combining the expertise of both professions to determine the best care/response to each situation Responds to 911 calls involving individuals who are in crisis, non-emergency calls Respond to location of individuals in crisis within our divisional boundaries Operates 7 days a week, 365 days a year, 10 hours per day based on statistical analysis ( hrs)

To de-escalate crisis and avoid unnecessary arrest and/or emergency room visits Provides short term support and stabilization in order to manage the crisis Provide referrals to services and resources available in the community Ensure continuity of care between the initial intervention and the involvement of follow up agencies Or simply EDP (Emotional Disturbed Person)

There is NO cookie cutter fix for those suffering from Mental Illness Symptoms of mental illness vary from mild to severe depending on the type of illness, the family and the socio-economic environment Severe impairments of thoughts & judgment - constituting a medical emergency Characterized by alternations in thinking,mood or behavior

We provide immediate on site response to people of all ages in our catchment area with urgent or emergent mental health This often includes addictions and/or homelessness issues

Dispatched (radio calls) Divisions / Supervisors MCIT Cell Hospitals / Doctors Community agencies Families In car Computer / volunteer

Responds to calls involving bizarre behavior, substance abuse and caring for people in crisis Mental crisis could include thoughts of suicide, distorted or psychotic thinking, anxiety, overwhelming depression, feeling unable to cope and out of control Cases of suicidal attempts/ideation and self harm Executes Forms 1, 2, 47 & 49 in conjunction with other teams in the Mental Health and Addiction programs

Persons intoxicated on drugs or alcohol Elopee Violent individuals or people with weapons Overdoses Barricaded EDP’s Individuals wanted on “Forms” who’s location is not known.

Perform a mental health assessment on site Conduct appropriate referrals to community agencies Provide telephone support and follow up visits Find appropriate shelter for the homeless Take client to hospital if deemed necessary Offer confidential, non- judgmental crisis support

Police : Use of Force Wheel Nurse : Non-violent Crisis Intervention Model

Assess the situation Attempt to stabilize and defuse the crisis Provide supportive counseling as needed Provide information and referrals, linkages to appropriate community services and support for ongoing treatment Transport individuals to the hospital emergency dept. if further psychiatric and/or medical treatment needed Follow up visit

Immediate response to people in crisis To quickly and safely de-escalate the situation Provide on site response to a crisis ensuring the best care Diversion from the emergency dept. Keep frontline workers free and available Provide referrals to services and resource in the community Teaching and educate clients, families, colleagues and community about crisis intervention and prevention Proactive approach to avoid unnecessary contact with the criminal justice system

PROS Utilizing RN’s Client centered care Close working relationship with Police Officers Ongoing education to PRU increases utilization of CIT CONS Accommodating 2 perspectives (i.e..: Medical vs. Police) Dealing with old school thinking Difficulty with EMS Police car (office on wheels)

Provides a range of crisis services on multiple levels Knowledge of medications & ability to give prescribed medications Assess treatment needed Establish a relationship & level of trust Cooperating with Dr’s, Psychiatrist & community agencies to execute the care needed for individual Protect the rights of the client by advocating on their behalf Networks with law enforcement to facilitate medical services for individuals who are at imminent risk of danger

Verbatim description as reported to CIT : “Complainant saying there is a male in the house and he doesn’t know him. Not talking to compliant. Male black, unknown age wearing black and white shirt. Compliant sounds EDP. Can’t give a description of male, has his pants over his head. Also reports seeing some kind of animal.” Police officer and Sergeant speaking to male. Admits to seeing the black male in police presence and unknown animals. Gun cabinet in room containing his hunting rifles. (properly/legally stored)

Many stressors. Had not slept x 4 days. Increased alcohol consumption since the death of his father. Denies any mental health history. Concerned for his mothers well being since his father death 1 year earlier. Marriage breakup. Chronic back pain x 2 yrs.. Fighting with city contractor re: faulty sidewalk repairs that caused his mother to fall. Fighting flu like symptoms. Taking excessive over the counter medication.

Substance abuse Financial burdens Relationship problems Legal problems Specific symptoms of mental illness Guarded in presence of police officer Feeling run down and generally unwell Psychiatric illnesses: None

Legal : fighting company that repaired the sidewalk Substance use : bottle vodka weekly x I 1 year Prescribed medications : None Mental status: Clean, well groomed, dressed appropriately for weather Down cast, worried looking Seeing unknown black male and unknown animal

Denies/No evidence of suicidal ideation. No past history of suicide attempts. Denies/No evidence of harm to self or others. Recommendations: No grounds for Mental Health Act apprehension. Encouraged male to attend the hospital with MCIT to be checked out medically.

The male was admitted to hospital. Officers on scene took the male’s guns due to safety issues regarding his hallucinations. Was not to be put in the police system as an “Emotionally Disturbed Person”. Follow up: PC Zawerbny had found out that the male had been put in the system as “EDP”. This meant the male would not get his guns back. A follow up visit was needed to find out his diagnosis.

Myocardial infarction Alcohol withdrawal The record of events was changed to show that no mental health issues existed and thus the male was able to get his firearms returned.

52 year old female Borderline Personality Dissociative Identity Disorder Numerous overdoses Depression and anxiety Frequent user of the emergency services Hospital visits varied but could be as many as 3 per week

END OF ACT 2

Nothing! Good Relationship With Police

Disease Dimensional Behavior Life Story

Disease Dimensional Behavior Life Story Treat Coach Interrupt “Rescript” (psychotherapy)

Disease Dimensional Behavior Life Story Treat Coach Interrupt “Rescript” (psychotherapy) Requires patient engagement

Disease Dimensional Behavior Life Story Schizophrenia Mild MR, Narcissistic Threatening, Assault “unsocialized” Requires patient engagement

 Consulting psychiatrist for every MCIT.  Liaison with Mental Health Courts

END OF ACT 3

The Police Officers Perspective

 Uniformed Officers – 5,629  Population Served – 2,855,085  Gross Operating Budget – 1,000,778,700  Largest urban police service in Canada.

Total calls received – 2,067, 938 Total calls dispatched – 921,722 Calls dispatched in 11 & 14 Divisions 97,171

City Wide  2009 – 16,976  ,513  2011 – 19, & 14 Division  2009 – 2785  2010 – 2970 

2009 – – – 665

“Police officers are concerned with immediate crisis response whereas the mental health system is slow, cumbersome and looks for longer term solutions. Whereas the motto of the medical profession might be “Above all, do no harm”, the public expectation of the police is more likely, ”Above all, do something! Dr. Dorothy Cotton, Feb 2005

 Less intimidating  More approachable  Shows understanding  Less noticeable to neighbors or bystanders.  Decreases Stigma

“Because my daddy did it and his daddy did it and his daddy before that did it.” Top 10 myths about mental illness – EDP’s are violent. “Combating stigma is a continual process. This seems to be especially true when the very culture of a system, like the criminal justice system, has incorporated many of the most extreme manifestations of stigma and discrimination.” Tom Lane, Director of Consumer Affairs, National Alliance on Mental Illness, USA

No Handcuffs reduces** - Stress - Anxiety - Shame -Embarrassment -Stigma  (** All risk factors have been assessed) Benefits Continuity of Care Trust Future contact

“When police respond to a person in a mental health crisis as they are trained to respond to a typical criminal emergency situation – with a show of force and authority – they may in fact escalate the crisis to a point of risking injury or death for police or the public, but most often for the person in mental health crisis. Canadian Mental Health Association British Columbia, 2005

Everyone in your organization needs EDP training. Organize training days. Organize or get involved with committees to study the success, failures and necessity of your CIT program. Most common phrases heard by CIT member at committee meeting: “ I did not know that” “ We’re glad you’re here to explain this” “Your obviously very passionate about your work”. Change old school thinking.

Uniform changes/alterations - (Decision pending) Vehicle changes/alterations – (Achieved in principal) Policy changes/recognition – Handcuffing Option (Achieved?) Simultaneous response – (Achieved) Patient transport – (Achieved) In car camera – No use option. – (Achieved) Getting all this in writing? (Ask me at the next conference)