Alberta's community treatment order legislation and implementation: the first 18 months in review.
Providing the appropriate level of treatment and care to individuals with serious and persistent mental disorders can be a significant clinical challenge. Some individuals become caught in a "revolving door" cycle of formal hospitalization when they meet the criteria for involuntary admission, respond to psychiatric treatment, and are discharged once stable, only to deteriorate in the community and require re-admission. Other individuals require long term hospitalization in psychiatric facilities as the nature of their symptoms and/or disabilities cannot be adequately and safely managed by resources available in the community on a completely voluntary basis. On January 1, 2010, Community Treatment Order (CTO) legislation was proclaimed for the first time in Alberta. (1) This provided an option for the community management of these patients.
This article provides information about the first 18 months of implementation of CTOs, based on the experience of Alberta clinicians and health care administrators, and the Mental Health Patient Advocate (Advocate). Brief background information will be reviewed and demographics of patients cared for under CTO legislation to date will be provided, as will a discussion of lessons learned and challenges to be resolved.
Prior to the enactment of CTO legislation by way of Bill 31, the Mental Health Amendment Act, a substantial consultation process occurred. A legislative committee held public meetings, and submissions were heard from concerned individuals, as well as representatives from professional organizations, advocacy and consumer groups.
During consultations on Bill 31, the Advocate was supportive of the introduction of CTOs, viewing them as a way to support recovery from mental illness. The Advocate's 2007 written submission on the Bill stated: "There is an evolving recognition of the role that empowerment plays in mental illness and recovery. Experience from other jurisdictions shows that CTOs work best when clients and substitute decision-makers are consulted and involved in the formulation of a CTO." (2)
The Advocate submission also advised that appropriate checks and balances should be included in legislation to reduce the impact of CTOs on patients' rights under the Canadian Charter of Rights and Freedoms. Protections should include the right to independent review of the need for a CTO, the right to appeal unfavourable decisions to the courts, and to access legal counsel. Additionally, "when they cannot afford legal counsel, legal aid should be provided. A standard practice for all patients placed on CTOS is a formal explanation of their rights." (3)
The Advocate's support was also contingent on the appropriate supports being available to patients in the community. "Recovery is limited unless the social determinants of health (e.g. treatment, housing, income, meaningiul activities) are addressed. Indeed the successful implementation of legislation that focxises on CTOs is predicated upon collaborative approaches to address these fundamental supports for patients." (4)
Most of the Advocate's recommendations were accepted. Persons under CTO were accorded the same rights and protections as formal patients, including the right to access the Advocate. Legal Aid was provided at no cost regardless of income to those appealing their CTO to a Review Panel.
Amendments to the Mental Health Act
The amended Alberta Mental Health Act (the "Act") sets out the criteria under which a CTO may be written. A CTO may be issued if two physicians, one of whom must be a psychiatrist, are of the opinion that the person is suffering from a mental disorder and that they meet applicable criteria to ensure that their psychiatric condition has proved to be chronic. Thus, the person must, in the preceding 3-year period, on 2 or more occasions for a total of at least 30 days, have been a formal patient in a facility, or have been lawfully detained in a custodial institution while meeting the criteria required to be a formal patient, or some combination of the two. Alternatively, the person might have been previously subject to a CTO within the immediately preceding 3-years, or while living in the community exhibited a pattern of recurrent or repetitive behavior that indicates the likelihood of harm to self or others or to suffer substantial physical or mental deterioration or serious physical or mental impairment if the person does not receive continuing treatment or care while living in the community. Note that almost all CTOs written to date in Alberta have been initialed while the person was a formal patient.
An assumption is made that living in the community is a less restrictive alternative than formal hospitalization. Prior to issuing a CTO, however, it must be evident that the treatment or care that the person requires exists in the community, is available to the person and will be provided to the person. The person must also be determined to be able to comply with the treatment or care requirements set out in the CTO.
The person must provide informed consent to the CTO if competent. The Act sets out the mechanism for appointing a substitute decision maker if the person is not competent. Consent for the CTO is not required in a circumstance where the person has exhibited a history of not obtaining or continuing with treatment or care that is necessary to prevent the likelihood of harm to others, and the CTO is reasonable in the circumstances and would be less restrictive than retaining the person as a formal patient. Note that the consent to a CTO in Alberta is not a consent to specific treatment and does not permit treatment (i.e. medication) to be administered without the person's further informed consent.
The duration of a CTO is 6 months, and the Act provides for a psychiatrist to cancel, amend, or renew a CTO for an additional 6 months. Currently, a few individuals are on their third renewal. If a psychiatrist has reasonable grounds to believe that a person subject to a CTO has failed to comply with the terms of the CTO and if reasonable efforts have been made to inform the person or assist in compliance with the CTO, then the psychiatrist may issue an order instructing a peace officer to apprehend the person and convey the person to a facility for psychiatric evaluation to determine if the CTO should be cancelled or amended. If the CTO is cancelled, then the patient must either be released or admitted as a formal patient.
The Two Legislated CTO Oversight Mechanisms
(i) Mental Health Act Review Panels
Mental Health Act Review Panels are empowered to hear applications from the person or the person's representative to cancel the person's CTO. Additionally, Review Panels must review all CTOs if the CTO is renewed after the first 6-month period, and at the time of every second renewal after that. While the Act permits a Review Panel to overrule the treatment wishes of a competent formal patient under specific circumstances, this is not the case for a competent patient subject to a CTO.
During the first 18 months, there were 63 Review Panel Hearings for persons on CTOs: 50 were deemed applications (a time-based mandated review) and 13 were initiated by the person or another individual. Of the deemed applications, 96% were upheld (only two CTOs were cancelled), and of patient-originated applications, one was cancelled.
Review Panel Chairs have indicated anecdotally a general satisfaction with the process and with the considerable work done to ensure that charts and relevant documents are made available as needed and where needed. Concerns have in some instances been voiced about the capacity of some persons to provide truly informed consent. (5)
(ii) Mental Health Patient Advocate's Role in CTOs
The second oversight mechanism is the Mental Health Patient Advocate (Advocate). The Advocate provides oversight by helping to promote and protect the rights of persons under CTOs. Established in 1990, Alberta's Mental Health Patient Advocate Office (MHPAO) was and remains unique in Canada as the only investigative body legislated to deal exclusively with complaints and concerns from or relating to involuntary mental health patients.
The recent amendments to the Act extended the jurisdiction of the Advocate to include persons under CTOs. (6) The extended jurisdiction means that when persons become subject to a CTO, they must be advised of their right to contact the Advocate for rights information and to express concerns and complaints about any aspect of their rights, care and treatment. The Advocate must investigate and resolve any such complaints. The Advocate also has the authority to investigate without complaint "any procedure of a regional health authority or an issuing psychiatrist relating to the issuance, amendment or renewal of a community treatment order." (7)
Role of Alberta Health Services (AHS)
Alberta Health Services (AHS) as the province's lead for CTO implementation reports to Alberta Health and Wellness. In addition, AHS coordinates and consults with other government partners such as Human Services (former AB Housing and Urban Affairs), AB Solicitor General and Public Security, and AB Justice and Attorney General, as well as consumer advocacy groups to continue to develop processes and to complete a formal evaluation of CTOs. For instance, the work with Human Services has been to examine opportunities and processes for CTO clients to access housing supports, if required and appropriate, within the CTO Treatment and Care Plan (Form 19, Part V).
AB Solicitor General and Public Security is responsible for administration and oversight of policing, as well as the role of peace officers and sheriffs. Education, coordination and process development has been underway regarding issuance of an apprehension order and transport the individual back to the designated facility.
Consultation with consumer advocacy groups such as the Alliance on Mental Illness and Mental Health, Canadian Mental Health Association, and Schizophrenia Society of Alberta have been ongoing - both in relation to education sessions for consumers and families and upcoming client experience surveys.
The First 18 Months
One may ask - how successful has implementation of CTOs in Alberta been thus far? The response to this question requires that we address not only the number of CTOs wrillen in Alberta but also the behind the scenes work reJaled to legislative interpretation and process development.
Based on experiences from other jurisdictions, most notably Ontario, the CTO planning committees projected that 50 CTOs would he issued in the first year (66 were in tact written) and thai up to 150 CTOs would be issued in total by the end of the second year. (8) As of November 17, 201 1, 2 38 CTOs have been issued; of the individual CTOs written in the past 18 months, 164 were active at the end of November. Calgary, Edmonton, and the Central Zone (including Ponoka and Red Deer) have had the majority (92%) of CTOs, but now more than 30 Alberta communities, including two First Nation reserves, have individuals who are on CTOs. During the first 18 months (from January 1, 2010 to September 30, 2011), 69% of persons consented to their CTO; 20% had substitute decision maker consent to the CTO; and 11% were issued a CTO without consent.
The demographic data has been fairly consistent throughout the first 18 months, with minor variations from year one to year two. Currently, there are three individuals who are 16-17 years of age, as well as one 14 year old who have been issued a CTO. The table on the lacing page provides a more complete picture of the CTOs issued in Alberta.
What has Worked Well?
Two components have contributed to the apparent early success of CTOs:
1. A dedicated provincial CTO administrative and clinical team provides education, legal interpretation, clinical advice, rights notification, forms advice and problem solving, and offers coordination and evaluation. The establishment of a network of CTO Zone leads seems to have been crucial to on-site co-ordination, the ability to liaison, obtaining feedback and front-line problem solving assistance and consultation; and
2. Service Enhancement funding. Seventy per cent of the funding provided to support the implementation of CTOs has been in the form of "service enhancement dollars" intended to support the CTO processes and dedicated resources; examples of this include Assertive Community Treatment Teams, or other outreach and support services. With Service Enhancement funding, a foundation has been developed. This funding has been integral to the current uptake of CTOs. The service enhancement funding enabled the development of a CTO structure and staff within the AHS Zones to assist in completing forms, providing ongoing educational and informal support to clinical teams and ensuring adherence to legislation, facilitating coordination between facility and community, providing case management in some cases, enhancing outreach supports, and collaborating with the Provincial CTO administrative team.
Feedback from Physicians and Others
Feedback was canvassed from 55 involved physicians by way of discussion groups held in early 2011. Anecdotal support for CTOs as a useful treatment option for select patients was strong. The importance of administrative assistance and involvement in the CTO issuing process, repeated educational initiatives, and access to knowledgeable local and provincial professionals was emphasized. Co-ordination between facility and community treatment teams was judged essential from initiation forward. Assertive community treatment and police-mental health teams were considered by some to be essential. The physicians also reported anecdotes that suggested positive support from impacted families for their loved ones on CTOs.
Reports from a September 2011 CTO focus group of the CTO leads and coordinators cite the following benefits to date:
1. Generally and anecdotally, indications are that CTO clients are in the community for longer periods without readmission, and clients are participating for the first time in activities and/ or attending support groups;
2. Reports are positive from community-based service providers who are listed on a CTO regarding the continuity of care and problem solving approaches that come from CTOs; and
3. Person-centered planning for the CTO Treatment and Care Plan and ongoing coordination with the relevant community has elicited comments from clients and families indicating that this led to empowerment for the clients.
The CTO formal Evaluation Plan includes client and system level measures that will provide information about the effectiveness of CTOs and their impact. The Plan is comprehensive, and encompasses measures related to:
1. The success of implementation (for instance, uptake, access to appropriate information, and degree of collaborative, coordinated approach);
2. The impact of the legislation on the addiction and mental health care system; and
3. The effectiveness of CTOs as a treatment option for clients, and the response by families and significant others.
This evaluation was developed in consultation with ministry, community and AHS zone partners. The information will help inform the legislative review scheduled to be completed by September 1, 2015.
For ongoing success, it is critical to have the supporting processes, documents, and a provincial and zone network of CTO expertise m place. Developing the Guide to the Alberta Mental Health Act and Community Treatmefit Order Legislation (9) was a significant deliverable; plans lo develop a policy and practice manual are scheduled for completion in 2013.
What Needs Further Work?
Full implementation of CTO legislation is ongoing. Availability of dedicated resources has been helpful in addressing issues and areas that need development or clarification as they arise. Many questions regarding legislation interpretation and CTO processes have been vetted and addressed. However, some areas are still outstanding.
The following have been raised as issues related to the legislation itself and will be addressed as part of the evaluation and/or legislative review (stated previously):
1. Is a duration of 6 months for the 1M CTO too short lo determine whether a CTO is working?;
2. Should the 12 hour period between the first and second examination be increased; some reports indicate that it is difficult to complete both examinations;
3. What purpose is served by having to cancel the CTO if the person needs to be admitted as a formal patient for short-term stabilization, only to go back on a CTO after discharge;
4. Is an appropriate process to ensure a valid consent is obtained in place and being followed; and
5. Information sharing protocols are to be developed where required and feasible under privacy laws regarding persons subject to CTOs.
Other areas exist that require clarification:
1. Emergency department policies/processes established to deal consistently with CTO clients who are non-compliant and brought in on Apprehension Orders;
2. Determination of processes related to CTOs initiated in custodial institutions; and
3. Further coordination with the Office of the Public Guardian.
Response from Advocate to Successes and Issues--First 18 months
Since the introduction of CTOs in January 2010, the Advocate office has been closely monitoring the impact of this new treatment option on its clients. As of November 20, 201 1 r a total of 1 5 persons subject to CTO have called the Advocate office, which represents nearly eight per cent of all CTOs issued. This compares to the roughly ten percent of persons subject to certificates who contact the Advocate Office each year. Eleven of the individuals were in the community, three were inpatients and one was tinder dual status (a single Form 1 and a CTO).
Most of the inquiries pertained to rights under the Act. Advocate staff conducted six informal investigations as a result of the calls from CTO clients. Two of the complaints were partially supported and dealt with the issues of legal status and medication. The remaining complaints, which were unsupported, were about courtesy of staff, quality of care and participation in care.
According to Advocate Office files lo date, a number of repeat Advocate Office clients appear 10 have successfully remained in the community under a CTO, or have remained in the community longer than usual before needing to return lo hospital. Family members who have contacted the Advocate office have also expressed satisfaction with CTOs, indicating that their loved ones are now receiving required treatment and care in the community.
Advocate staff have observed other early successes. For example, the need to work in partnership to set up CTOs appears to have resulted in increased dialogue among physicians, other health care providers and service providers in the community, resulting in enhanced continuity of care. It also appears that treatment team members and CTO coordinators are doing a thorough and consistent job of providing timely rights notification to clients. To date, CTO coordinators have shown they know their caseload well and have been quick to respond to any inquiries from the Advocate office.
Of course there are bound to be challenges with any new initiative. While CTOs appear to be popular among those who have consented to them, the Advocate's office has heard expressions of resentment from non-consenting CTO clients about the restrictions placed on them. Even among consenting clients, being under CTO can have its downsides. For example, some clients have talked about being lonely, stating they miss the social interaction of being in hospital. Clients unable to work speak of having nothing to do all day. Such comments point to the need to consider social/occupational activities for clients when developing their CTOs and raise the question of whether there are sufficient community programs to engage such individuals so that they don't become isolated.
Apart from client comments, the Advocate office has also encountered some emerging legal and procedural issues and questions that continue to be monitored. One legal question that has emerged concerns dual status. The Advocate received a complaint from a CTO client who voluntarily went to the hospital with a medical concern and was detained under an admission certificate for stabilization purposes, thus resulting in his dual legal status under the Act. As the Act is silent on dual status, the Advocate met with staff and legal counsel from AHS and Alberta Health and Wellness to discuss what should happen when someone subject to a CTO voluntarily goes to the hospital and is certified for assessment, or as a formal patient. Is it in keeping with the spirit of the Act for someone to be certified and under CTO at the same time? Or is this defeating the whole purpose of the CTO, which theoretically is a community-based alternative to certification?
It was agreed that psychiatrists should have the flexibility to decide whether or not to cancel the CTO in this type of scenario. The benefit of not cancelling the CTO is that, once stabilized, the individual could be returned to the community under the existing order, thus avoiding the significant amount of time and paperwork required to issue a new one. However, it was agreed that, ideally, dual status should not endure for prolonged periods. It was also agreed that it is necessary to monitor the issue to determine whether or not it be recommended that the Act be amended to include a time limit on dual status, or to allow for the suspending of a CTO while a person is being stabilized in hospital.
The introduction of CTOs has led to some interesting shifts in how Review Panel hearings are conducted. Since CTO clients are not confined to hospitals, the geographic area that Review Panels must cover has been vastly expanded. In order to keep travel costs down, Review Panels sometimes rely on videoconferencing to connect parties in different locations. There have been instances when the CTO client and legal counsel have been in separate locations during the hearing, able to communicate only via a video screen. While they may have had the opportunity to speak in confidence prior to the hearing, is proper legal representation possible when the client and lawyer are unable to speak confidentially to one another during a legal proceeding? This issue is still outstanding and warrants further investigation and comment.
A Snapshot of Overall CTO Progress in Alberta
CTO work is still very much in its infancy in Alberta. But, thus far, the majority of those involved in working with CTOs would probably agree that it's been a great piece of legislation that has been long overdue.
After the first 18 months of implementation, the uptake and use of CTOs in Alberta, has had some positive impacts. However, there are still significant areas where further work is required: for example, the continued education of specialized groups; the development of processes related to specific partners, including law enforcement, housing, emergency departments; and an assessment of budgetary needs and service delivery models to support CTOs in the long run.
While the official evaluation of the effectiveness of CTO legislation will take another year or so, there have been significant anecdotes and some data such as patterns of re-admission to indicate that CTOs are becoming an effective option to assist some individuals to stay well while living in the community. Final analysis of the successes, areas for improvement, and impact will come from the pending formal evaluation of CTOs and the legislative review.
(1.) Mental Health Act, RSA 2000, c M-13, Mental Health Amendment Act, SA 2007 c 35, s S (adding s 9.1) (CTO in force January 1, 2010) [Act],
(2.) Mental Health Patient Advocate, Submission to the Legislative Assembly Standing Committee on Community Services, Review of Bill 31, Mental Health Amendment Act, 2007, August 24, 2007, pg. 5.
(3.) Ibid at 4.
(4.) Ibid at 9.
(5.) Presentation, AHS Community Treatment Order Planning Day, September 20, 2011. Joan Met/, Chair, Review Panel Calgary and South
(6.) Act, supra note I at s 45(1).
(7.) Patient Advocate Regulation, Alta. Reg. 148/2004 at s. 4
(8.) Dreezer & Dreezer Inc., "Report on the Legislated Review of Community Treatment Orders, Required Under Section 33.9 of the (Ontario) Mental Health Act" (December 2005), online: (http://www.health.gov.on.ca/english/public/pub/ministry_reports/dreezer/dreezer.pdf).
(9.) Alberta Health Services, "Guide to the Alberta Mental Health Act & Community Treatment Order Legislation" (2010), online: (http://www.albertahealthservices.ca/hp/if-hp-mha-guide.pdf).
Demographics from 193 CTO Individuals (January 01, 2010 - September 30, 2011) Gender: 65% male; 35% female Age: average age = 37 years Marital Status: 20 years and younger = 6% 70% never been married 21 -30 years = 30% 19% separated or divorced 31 -50years = 41% 10% Married (1 % widowed) 50 and older = 23% Educational level: (N = 17) Housing: 50% some high school 21 % Private (Self/Spouse) 16% completed high school 14% Private (Parents/family) 33% some post secondary 24% Rental 12% Subsidized 11 % Assisted Living Facility Employment status: 12 % Shelter (1 % homeless) 89% unemployed 9% Group Home 9% pan-Time 4% full-time Primary Diagnosis: Typical Treatment & Care Plan: 49% Schizophrenia, Medication Management - 98% 20% Psychotic Disorder Psychiatrist: 77% 11% Bi-polar disorder, Mental Health Outreach (ACT/AOS /CET, PACT): 52% 15% Schizoaffective CTO Nurse/Community Nurse: 17% Disorder Mental Health Clinic/Therapist: 19% Housing = 9% Physician's Care: 5% Note: Mental health outreach includes Assertive Community Treatment Teams, Assertive Outreach Services, Community Extension Teams, and Police and Crisis Teams. Other service providers include: Outpatient Forensic-Services, Housing, Child and Family Services, Geriatric Mental Health, Addiction/Concurrent Disorder Treatment, OMHA, Family Support Services, Guardians/Trustees, and Probation officers.
Fay Orr, Alberta Mental Health Patient Advocate.
Doug Watson M.D., Medical Lead, Mental Health Act and Community Treatment Orders, Alberta Health Services.
Aggy King-Smith, Manager, Addiction & Menial Health, Community Treatment Initiatives/Community Treatment Orders, Alberta Health Services.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Giving Voice 2: Advocacy & Mental Health|
|Author:||Orr, Fay; Watson, Doug; King-Smith, Aggy|
|Publication:||Health Law Review|
|Date:||Mar 22, 2012|
|Previous Article:||Field notes.|
|Next Article:||Alberta's community treatment orders: Canadian and international comparisons.|