1. Second Legislated Review of Community Treatment Orders Ministry of Health and Long-Term Care November 9, 2012

2. Overview of Presentation Community Treatment Orders (CTOs) Second Legislated Review of CTOs Methodology of the Second Legislated Review of CTOs Summary of Findings Recommendations Next Steps Questions and Contact Information 2

3. Community Treatment Orders (CTOs) 3

4. 4 Second Legislative Review of CTOs Under the Mental Health Act, the Minister is required to review the use and effectiveness of CTOs every five years after the completion of the first review. The first review was posted by the Ministry in May 2007. R.A Malatest conducted the second review of CTOs. A Reference Committee with representation from internal and external stakeholders provided advice to the consultants. The second CTO review, covering the period from 2004 to 2010, addressed the following questions as required by Section 33.9 of the Mental Health Act: Reasons that CTOs were or were not used during the review period; Effectiveness of CTOs during the review period; and Methods used to evaluate the outcome of any treatment used under CTOs.

5. 5 Limitations and Strengths of the Review Limitation Limited time frame for the review. Information for the review was collected from April to early May 2012. To mitigate issues associated with the limited time, the evaluation team used a number of approaches to reach people including outreach through the CTO coordinators, LHINs and provincial organizations. Strengths The review captured the breadth of stakeholder views. The consultants used a combination of quantitative and qualitative methods to arrive at their findings and recommendations, including: Literature Review; Analysis of Quantitative Data; Focus Groups and Key Informant Interviews; Online Survey. The consultants were successful in capturing views from 539 stakeholders that represent the broad range of views about CTOs.

6. Profile of CTOs 6

7. Profile of people who are subject to a CTO 7

8. 8 What was the effectiveness of CTOs during the review period? The lack of thorough and reliable administrative data made it difficult to evaluate the effectiveness of CTOs compared with other forms of treatment. In the survey of 411 people, the main reasons for using CTOs were to reduce the frequency of hospitalizations (76%) and ensure a team supported community treatment plan (76%). Most respondents to the survey indicated that CTOs were effective in addressing the revolving door between hospital and community (64%) and reducing hospital admission rates (63%). “It is hard having your child hate you because they are in hospital. They hate you less when on a CTO because it allows them to come home and calm down.” – Substitute Decision- Maker “My experience has been that it’s less about the actual CTO and more about how few supports there are to make them successful. The CTO idea makes sense. However, how can it work properly when a strong plan cannot be presented?” – Inpatient Mental Health Worker Summary of Findings

9. 9 Summary of Findings (cont’d) What are the reasons that CTOs were or were not used during the review period? Reasons for using CTOs: improved access to services and supports and improved stability and quality of life. Reasons for not using CTOs: time and effort required to manage CTOs and the challenge that mandatory outpatient treatment can pose to personal autonomy. “My CTO is a good thing. I’m getting out more. Doing more. I feel better.” – CTO Consumer “ I think we as physicians, psychiatrists in particular fail to use the Mental Health Act for the benefit of the patient. We get caught in ”well, the CTO is a lot of work…” – Psychiatrist What were the methods used to evaluate the outcome of any treatment used under CTOs? Clinical judgement was a primary method to evaluate the outcome of CTO consumers. Administrative data also provided some information about treatments used under CTOs. “It’s a tough call to know when to end a CTO because some people go on and do really well, and others relapse quickly even though they were doing really well (on the CTO).” – CTO Coordinator/ Case Manager “For the second one, I didn’t have any say what so ever. I thought it would be an open discussion, but it was just signing paperwork.” – CTO Consumer

10. Recommendations 1) Mental health care providers and consumers should continue to have access to CTOs. The review found that most clients, health care professionals, friends and families hold positive views and opinions about CTOs. 2) The MOHLTC should support further research to understand what it is about CTOs that underpin their effectiveness. Several aspects of the delivery and implementation of CTOs require further investigation in order to determine the effectiveness of CTOs. Examples of topics include: What constitutes “best practice” for CTOs? What is included in community treatment plans and why? 10

11. Recommendations (cont’d) 3) The MOHLTC should continue to work with service providers and the LHINs to ensure that robust central data are available to track, at a minimum, the numbers of CTOs being issued, who they are issued by and the profile of consumers issued a CTO. Similar to the first review, this review cited significant issues with CTO data and availability of data. It was not possible to evaluate the effectiveness of CTOs as compared to other treatment approaches using existing data. 4) The MOHLTC should lead the development of province wide program standards. According to the review, there is variation of CTO coordinators across the province in terms of roles, responsibilities and levels of interactions with consumers and community services which undermines the ability to effectively assess the CTO program. 11

12. Recommendations (cont’d) 5) Increased education about and awareness of CTOs is required and the MOHLTC should work with professional and other stakeholder groups to develop and disseminate information and educational material about CTOs. The findings found the lack of healthcare provider information and awareness about CTOs was limiting access to CTOs for those who would benefit. 6) The MOHLTC should consider whether a review of the safeguards in place for consumers is warranted. During the review some stakeholders stated that they do not think the appropriate balance between the mandatory nature of CTOs and protecting the rights of consumers has been reached. 12

13. CTO Coordinator Feedback RecommendationFeedback From the CTO Coordinators Mental health care providers and consumers should continue to have access to CTOs. There was a general support to continue this program. The MOHLTC should support further research to understand what it is about CTOs that underpin their effectiveness. Need research to develop future standards of practice but research must have a global target while recognizing diversity in settings. The MOHLTC should continue to work with service providers and the LHINs to ensure that robust central data are available to track, at a minimum, the numbers of CTOs being issued, who they are issued by and the profile of consumers issued a CTO. An on-line data entry form for CTO coordinators. Need consistent data collection and reporting across the province to inform evaluation and research questions. 13

14. CTO Coordinator Feedback RecommendationFeedback From the CTO Coordinators The MOHLTC should lead the development of province wide program standards. More training and supports for CTO Coordinators Standards should cover roles and responsibilities of CTO Coordinators as well as others involved in the CTO process. Increased education about and awareness of CTOs is required and the MOHLTC should work with professional and other stakeholder groups to develop and disseminate information and educational material about CTOs. CTO Coordinators should be central to the development of education/awareness of CTOs. There is a need for up-to-date standardized education material which should. The MOHLTC should consider whether a review of the safeguards in place for consumers is warranted. Develop standards on what should be in a Community Treatment Plan (scope and content). More flexibility regarding Rights Advice 14

15. Your Turn! Your Feedback on Community Treatment Order Recommendations 1) Mental health care providers and consumers should continue to have access to CTOs. 2) The MOHLTC should support further research to understand what it is about CTOs that underpin their effectiveness. 3) The MOHLTC should continue to work with service providers and the LHINs to ensure that robust central data are available to track, at a minimum, the numbers of CTOs being issued, who they are issued by and the profile of consumers issued a CTO. 4) The MOHLTC should lead the development of province wide program standards. 5) Increased education about and awareness of CTOs is required and the MOHLTC should work with professional and other stakeholder groups to develop and disseminate information and educational material about CTOs. 6) The MOHLTC should consider whether a review of the safeguards in place for consumers is warranted. 15

16. THANK YOU 16 Contact Information: Anne Bowlby, Manager Mental Health and Addictions Unit. Email: Anne.Bowlby@ontario.ca Anne.Bowlby@ontario.ca Sirad Mohamoud, Senior Policy Advisor Mental Health and Addictions Unit. Email: Sirad.Mohamoud@ontario.caSirad.Mohamoud@ontario.ca Bobbi Clifton, Senior Policy Advisor Mental Health and Addictions Unit. Email: Bobbi.Clifton@ontario.caBobbi.Clifton@ontario.ca