Psychiatric Patient Advocate Office Mental Health Trends and Issues - - PowerPoint PPT Presentation

Psychiatric Patient Advocate Office

Mental Health Trends and Issues - CMHA Sarnia Ryan Fritsch, Legal Counsel March 3, 2011

OVERVIEW OF THE MENTAL HEALTH SYSTEM

• This presentation is an overview of the mental health system

as seen through the work of the PPAO

• There are a vast array of perspectives on concepts like

recovery, empowerment, rights and treatment

• There are many different consumer/survivor/ex-user groups,
• ther advocacy organizations, professional bodies,

independently managed hospitals, researchers, and governmental actors with different perspectives

• Our perspective is as rights advisers and patient advocates

having a province-wide mandate

• We do not speak for the Ministry of Health; PPAO has arms-

length independence, independently retained legal counsel SPEAKING FOR AN-OTHER

OVERVIEW OF THE MENTAL HEALTH SYSTEM

• Map of the Ontario Mental Health System
• Mandate and Activities of the PPAO
• Emerging Issues and Trends
• Discussion

OUTLINE

MAP OF THE ONTARIO MENTAL HEALTH SYSTEM

PPAO The Client? DEB MATTHEWS

Minister of Health

MANDATE AND ACTIVITIES OF THE PPAO

• Established in 1983 as the first province-wide patient advocacy program

in Canada

• Cluster of patient deaths at CAMH – inquests and reports – cited

advocacy as addressing power and communication imbalances and providing a perspective external to the care team

• Charter of Rights and Freedoms 1982: s. 7, 9, 10 and 15 - advocacy

and rights advice as a check and balance to bring the Mental Health Act into compliance

• Independent from the MoHLTC under a MoU (1993)
• Province-wide Rights/Advocacy Mandate:
• Rights Advice (71/74 Sch 1 hospitals)
• Patient Advocacy (10 major MH facilities)
• Systemic and Law Reform and Public Education

MANDATE AND ACTIVITIES OF THE PPAO

• Ensures that patients involuntarily detained under the

Mental Health Act, or found incapable of consenting to treatment under the Heath Care Consent Act, understand what has happened to them and what legal options are available

• The provision of Rights Advice essentially follows the

Charter of Rights and Freedoms 1982 s. 7, 9 and 10: liberty rights accorded the principles of fundamental justice, freedom from arbitrary detention, right to be informed of reasons for detention, given the opportunity to retain and instruct counsel, provided with adequate due process protections

• Rights advisers must meet face-to-face with the patient and

work only on an instructed basis RIGHTS ADVICE

MANDATE AND ACTIVITIES OF THE PPAO

• PPAO provides rights advice over 25,000 times a year
• PPAO is rights adviser at 61 of 64 hospitals with a MH ward

and the 10 major MH hospitals in Ontario

• Rights advisers meet with a patient within 24 hours of

receiving notice (“promptly”)

• Rights advice was provided in over 44 languages in 2009
• All rights advisers in the province must complete the four

day PPAO certification course, recently updated RIGHTS ADVICE

MANDATE AND ACTIVITIES OF THE PPAO Nine rights advice situations arise under the MHA:

• involuntary status (Form 3)
• involuntary status renewal (Form 4)
• involuntary status renewal transfer (4th Form 4)
• incapacity to consent to treatment under the Health Care Consent Act

(Form 33)

• incapacity to manage property (Form 21)
• continuing incapacity to manage property (Form 24)
• incapacity to consent to the collection, use and disclosure of personal

health information under Personal Health Information Protection Act (Form 33)

• admission as an informal patient between the ages of 12 and 15

(Form 27)

• community treatment orders (Form 49) – patient and SDM

RIGHTS ADVICE

MANDATE AND ACTIVITIES OF THE PPAO RIGHTS ADVICE Rights Advice in Primary Hospitals 2008

• 70% related to

involuntary detention

• 14% related to

treatment incapacity

• 10% related to

property incapacity

MANDATE AND ACTIVITIES OF THE PPAO RIGHTS ADVICE Community-based rights advice in 2008

• 73% related to

involuntary detention

• 11% related to

treatment incapacity

• 9% related to

community treatment

• rders
• Fraction of persons

between age of 12 and 15 (Form 27)

MANDATE AND ACTIVITIES OF THE PPAO

CCB Applications filed by the PPAO (on behalf of client) in 2008

CIVIL MENTAL HEALTH SYSTEM

MANDATE AND ACTIVITIES OF THE PPAO

• Assists in-patient clients with issues related to quality of life, quality
• f care, access to justice, treatment, social services and

entitlements, hospital policy development, hospital staff education, and the development of systemic issues

• 12 full-time Patient Advocates across the province:
• 1 at each of Kingston, Brockville, St. Thomas, London,

Hamilton, North Bay, Thunder Bay, Whitby

• 2 at each of CAMH and Penetanguishene
• Assist clients in both the civil and forensic mental health system
• Penetanguishene is the only maximum-level secure facility in

Ontario

• Advocacy services limited to in-patients

PATIENT ADVOCACY

MANDATE AND ACTIVITIES OF THE PPAO

• Instruction-based => client control, participation, responsibility,

empowerment

• Bridge between treatment team and patient
• Agent of trust – seen as neutral / safe party
• Help overcome communication barriers
• Early warning system / patient feedback mechanism (service

innovation and risk management)

• Reduce pressure on health care team to “do it all”
• Activation and actualization of legal rights
• Patient Advocacy For Health Care Quality: Strategies For Achieving

Patient-Centered Care by Jo Anne L. Earp, Elizabeth A. French and Melissa B. Gilkey (2007)

PATIENT ADVOCACY: PRINCIPLES & BENEFITS

MANDATE AND ACTIVITIES OF THE PPAO ADVOCACY Advocacy in Primary Hospitals 2008

• 3400 advocacy issues

addressed

• 50% of issues related to legal

and access to justice matters

• 50% of clients in the forensic

mental health system; 27% involuntarily detained in the civil system; 14% voluntary patients

MANDATE AND ACTIVITIES OF THE PPAO

• Rental housing issues once in care
• Behavioural triggers and restraint
• Language / Ethnic Origin Discrimination in Care
• Personal Health Information Rights under PHIPA
• CTO / ACTT terms
• NCR / Disposition appeals

PATIENT ADVOCACY CASE EXAMPLES

MANDATE AND ACTIVITIES OF THE PPAO

• PPAO engages in a wide variety of law and systemic reform

activities informed by the experience of our client and inquiries from the public

• PPAO present on many advisory boards: Legal Aid Ontario,

Human Services and Justice Coordinating Committee Toronto, CAMH Restraint Committee, Toronto Police Board, CCB Board and Bar Committee

• Litigation (coroner’s inquests, human rights tribunal cases,

intervener in civil and criminal cases)

• Stakeholder engagement: consumer/survivor groups,

housing, hospitals, policing, legal services, government

• Reports, journal articles, media

SYSTEMIC LAW REFORM AND EDUCATION

MANDATE AND ACTIVITIES OF THE PPAO Recent PPAO Achievements:

• Inquest into the death of Jeffrey James (2008) and

development of model restraint policy at CAMH

• Inquest into the death of Ryan Coulter (2009)
• Police Record Check Coalition – development of province-

wide guideline for disclosure of mental health information in police background checks with Ontario Assoc. of Chiefs of Police (2011)

• Cross-border disclosure of mental health information to US

Immigration / Dept. of Homeland Security (2011)

• “Best Efforts” policy for CTO Rights Advice (Bill 16 MHA

amendments) (2010) SYSTEMIC LAW REFORM AND EDUCATION

MANDATE AND ACTIVITIES OF THE PPAO

Other PPAO Systemic Activities 2010/2011:

• OHRC Consultation on Mental Health Strategy
• Law Commission of Canada Consultation on Disability and the Law
• MH Commission of Canada human rights consultation
• Hospital Satisfaction Survey and need for province-wide MH Advocacy program
• Updating the Rights Adviser Training Course
• Upcoming report on experience of clients in the forensic system
• Developing human rights test cases
• Submissions to the Legislature:
• Bill 16 amending the MHA (CTO order for examination, transfer rights,

best efforts and PGT rights advice)

• Bill 21 introducing the Retirement Homes Act (restraint, rights advice)
• Regulations under the LTCHA
• Select Committee Report on Mental Health & Addictions
• www.ppao.gov.on.ca - viewed 3 million times a year; 45 InfoGuides

SYSTEMIC / LAW REFORM WORK AND EDUCATION

OVERVIEW OF THE MENTAL HEALTH SYSTEM CURRENT TRENDS AND EMERGING ISSUES “Where are we headed?”

MANDATE AND ACTIVITIES OF THE PPAO CURRENT TRENDS AND EMERGING ISSUES

Stigma and Access to Primary Health Care

• Inquest into the Death of Ryan Coulter (Dec 1-3, 2009)
• treating the pathology rather than the person
• drug-seeking behaviours vs. attempt to communicate legitimate needs
• detention and choice in service; contra CPSO policy?
• Discrimination case example: ER admission misinterpretation of primary

needs (diabetes) vs. mental health => pending human rights complaint

• Savage v. South Essex Partnership NHS Trust [2008] UKHL 74; [2008]

WLR (D) 386: a human right to mental health care? The court confirmed that health providers are not outside the reach of Article 2 of the ECHR protecting the right to life. The court acknowledged that human rights protections promote an obligation on the part of health care providers to break through the “stigmatization barrier” and provide health care to patients according to the law of accommodation

• implications for communication barriers, equality of services, use of

restraint/seclusion, etc.

MANDATE AND ACTIVITIES OF THE PPAO CURRENT TRENDS AND EMERGING ISSUES

Police Records Checks

• #1 issue on our website -- InfoGuide read 750 times per month
• MHA s. 17: police can make a non-criminal apprehension to bring a person to

hospital for assessment; know nothing about the illness or diagnosis

• Creates a transaction record that may be reported as “information on file” or

“relevant information” in a police record check / vulnerable sector screening

• Problem: each municipal police force sets own assessment, retention, review,

correction, excision and reporting procedures; 5-27 yrs range; no standard; police collecting PHI (contra M/FIPPA)

• Ontario Association of Chiefs of Police, Ont. Human Rights Commission,

PPAO / Police Record Check Coalition => new Guideline Policy for Ontario

MANDATE AND ACTIVITIES OF THE PPAO

Driver’s License Suspensions

• #2 issue on our website - InfoGuide read 600 times per month - Ministry of

Transportation sends people to us! Effects thousands of people per year

• Automatic suspension procedure – “shoot first, questions later”
• Doctors are obligated under the Highway Traffic Act to notify the Ministry of

Transportation if when of the opinion that a patient “is suffering from a condition that may make it dangerous for such person to operate a motor vehicle.” (HTA s. 203(1)).

• Problems: shoot first and ask questions later; simplistic criteria (four pages in a CMA

document); suspension without a complete picture of the medical condition;

• Problems: suspension can force consumer/survivors to reveal their mental illness to
• thers, violating their privacy rights and forcing them to disclose their condition to

employers or volunteer organizations as is contrary to the Human Rights Code; injury to their dignity and self-worth because of disability; A sudden lack of transportation can have catastrophic effects on the recovery of consumer/survivors; undermines the formation of trust between doctor and patient which in turn can shatter the therapeutic relationship and dissuade clients from seeking help

• Case example: rural family, fill-in doctor

CURRENT TRENDS AND EMERGING ISSUES

MANDATE AND ACTIVITIES OF THE PPAO

Driver’s License Suspensions (con’t)

• Procedural unfairness / accommodation: Appellants are provided with no legal support.

Appellants frequently complain to us that there is no one they can talk to about the issue. The MoT suspends licenses before showing that there is a bona fide reason to do so based

• n presumptions about dangerousness of disability; expensive evaluation and re-testing; 2

years to hear appeal

• The SCC has identified the right of drivers to have their license eligibility determined based
• n an individual functional assessment rather than exclusively on a diagnosis, with a

corresponding responsibility for licensing authorities to accommodate drivers wherever possible within safe limits: British Columbia (Superintendent of Motor Vehicles) v. British Columbia (Council of Human Rights), [1999] 3 S.C.R. 868

• HRTO:
• Track J.M. v. St. Joseph’s Health Care 2010 HRTO 633 re MCIT
• Howden v. Ontario (Transportation) 2010 HRTO 515 re downgraded commercial

license refused hearing before the HRTO because of License Appeal Tribunal; not quite on point

• Recommendation:
• In our submission there seems to be no bona fide or rational connection between the

harm which this policy seeks to avoid and the extremely disproportionate harm it causes to consumer/survivors of psychiatric services.Even if there was a connection between the policy and its effect, we further submit that the way this policy is being

• perationalized by the Ministry of Transportation is so unnecessarily opaque, punitive,

and arbitrary that discriminates against persons with mental illness.

CURRENT TRENDS AND EMERGING ISSUES

MANDATE AND ACTIVITIES OF THE PPAO

Diversion and Criminalization of Mental Illness

• Estimated that 30% of persons needing mental health services enter through

the criminal justice system; 30% of persons in criminal justice system have a mental illness but accounts for 80% of the recidivism

• Huge drain on policing: TPSB in 2009: 30% of calls related to persons in

mental distress; 75,000 man hours; 52,000 police officers referred to calls; 395 deployments of tasers of which 50% were against persons in crisis

• Alternatives to criminalization: diversion
• Mobile Crisis Intervention Teams + Peer Support Crisis Centres.

Pro: avoids criminalization and hospitalization: Con: fractured, uncoordinated services; few beds (34 for Toronto!); max stay 30 days but no supportive housing to go to; little regulation or oversight; police may collect PHI and correlate to police record check/vulnerable sector screen

• Track J.M. v. St. Joseph’s Health Care 2010 HRTO 633 re MCIT
• Diversion / discharge and ACTTeams. Pro: No criminal charges, no

incarceration; Con: little regulation or oversight. ORB? CCB? HRTO?

CURRENT TRENDS AND EMERGING ISSUES

MANDATE AND ACTIVITIES OF THE PPAO

Occupational Health and Safety Act “Workplace Safety Amendments”

• Barrier to accessing services, excuse not to provide accommodation;
• misinterpretation of behaviours as dangerous or threatening (speaking

loudly, gestures, etc.)

• Education context – bans from university grounds
• Health Care context – results in seclusion/restraint, criminal charges against

patient

• Other services? Notion that OHSA may apply where it doesn’t to impose a

barrier to service

CURRENT TRENDS AND EMERGING ISSUES

MANDATE AND ACTIVITIES OF THE PPAO

Access to Justice

• Bon Hillier v. Milojevic, 2010 ONSC 435: use of amicus at Superior Court for

appeals from CCB (numbers dropping from 50 to 15 a year)

• Appeals from NCR findings on summary convictions - no assistance; difficult

to find lawyers to help “challenging clients”; more complex process than appeal from indictable to OCA

• Provincial Offences Act? Nothing. Engages Safe Streets Act issues,

intersection of mental health, disability and poverty, etc. Potential new volunteer / duty counsel model under development (in Toronto)

• Ontario Court of Appeal: Amicus panel for ORB appeals
• Duty counsel within dedicated psychiatric hospitals to help with intersection
• f mental health and criminal, family, immigration and administrative law
• New Human Rights Legal Support Centre providing more oversight of MH

system

CURRENT TRENDS AND EMERGING ISSUES

MANDATE AND ACTIVITIES OF THE PPAO CURRENT TRENDS AND EMERGING ISSUES

Shift of services to the community -- need for broad-based advocacy

• PPAO “Every Door is the Right Door” submission
• Mental health advocacy needs to occur across a

wide variety of fragmented sectors and be available in informal situations: peer crisis support, housing, social benefits, employment, jail / diversion, home care, community treatment

• Advocacy limited to institution-based treatment
• Must be independent and instruction-based, free of

best interests or institutional conflicts

Psychiatric Patient Advocate Office

55 St. Clair Avenue West Suite 802 Toronto, Ontario, M4V 2Y7 800.578.2343 Ryan Fritsch, Legal Counsel ryan.fritsch@ontario.ca 416.327.7002