Mobile Crisis InterventionThe Next Decade of Service

St. Joseph’s Health Centre

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

St. Joseph’s Health Centre

Canada

Ontario

Greater Toronto Area

Greater Toronto Area

SJHC

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

SJHC Statistics for 2010-2011

Beds: 376Admissions: 21,657Births: 3,080Ambulatory care visits: 272,689 Surgical Cases: 31,568Diagnostic Imaging Procedures: 165,125Emergency Department Visits: 93,741

Mental Health ED Visits: 7,248

Mental Health and Addictions

• 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

Mental Health and Addictions• 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

Hospitals in Toronto

SJHC

SJHC MHA ED visits compared to PEERS

0

1000

2000

3000

4000

5000

6000

7000

US Psych DT(homeless)

DT(Manhattan)

Uptown East End

MHA ED visits

(works for us)

socialized health care

OHIP• 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.

LHINThe 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)

LHIN Priorities• 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

MCITs in TorontoHOSPITAL PARTNER TPS

DIVISIONSSTART-UP YEAR

St. Michael’s Hospital 51/52 2000/1

St. Joseph’s Health Centre

11/14 2005/6

The Scarborough Hospital

41/42/43 2006/7

Humber River Regional Hospital

12/31 2006/7

TPS Divisions

SJHC MCIT Catchment Area

SMH MCIT Catchment Area

Scarborough Hospital MCIT Catchment Area

Humber River Regional Hospital MCIT Catchment Area

ParkdaleThe 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 homesA 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)

Parkdale

Parkdale

Parkdale

MCIT STATS 2011-12

Visits/calls: 903

Number of individuals served: 594

Telephone Consultations: 324

MCIT

TPS Chie

f + B

oard

MCIT ci

ty-wide In

specto

r

14 Div.

S.

Sergeant

11 Div. S.

Sergeant

11Div. PC

14 Div. PC

SJHC R

N

SJHC M

anager

SJHC corporate objectives,

policies + procedures

MCIT

LHIN P

rioriti

es

Managing a team

What’s Working

40%

What’s working• 2000 Pre-MCIT 2007

Post-MCIT

Source: St. Michael’s Hospital, 2007

How do we do it? 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

Future goals

TrainingCity-wide coverage /standardization

EMS

Training for RN’s• Driving police vehicles• Firearms safety• Use of force

City-wide coverage

EMS• Communication between EMS & MCIT.

• Avoid unnecessary transports to hospital.

• Stop transport of people threatening suicide by EMS prior to MCIT arrival.

One our success stories:• 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

Mobile Crisis InterventionThe Frontline Nurse Perspective

Mobile Crisis Intervention Team

• “Bringing the Emergency Room to the person in Crisis”

MCIT:• 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 (1300-2300 hrs)

Purpose of MCIT:• 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)

Mental Illness

• 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

MCIT : Who do we serve ?• 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

How do we get dispatched:

• Dispatched (radio calls)

• Divisions / Supervisors

• MCIT Cell• Hospitals / Doctors• Community agencies• Families• In car Computer /

volunteer

MCIT: calls we attend • 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

Calls we do not attend:• 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.

MCIT: What do we do ?• 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

CIT01

CIT01

CIT01

CIT01

CIT01

Difference in models of care used between the 2 disciplinesPolice : Use of Force

WheelNurse : Non-violent Crisis

Intervention Model

On the scene arrival:• 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

MCIT : Goals• 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

Challenges – Nurses Perspective

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)

Benefits to having RN attend on scene crisis

• 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

Medical issue presenting as mental illness: call MCIT 01 attended

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)

On Scene:• 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.

Presenting issues:• 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

Medical Condition:? Hypertension?• 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 weatherDown cast, worried lookingSeeing unknown black male and unknown animal

Risk Assessment:• 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.

Outcome:• 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.

Final Diagnoses/Outcome :• 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.

One our success stories:• 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

The Psychiatrist’s Perspective

“What is Working Well”

“What is Working Well”

Nothing!Good RelationshipWith Police

Information Flow: Hospital

Information Flow: MCIT

“Perspectives of Psychiatry”

Disease

Dimensional

Behavior

Life Story

“Perspectives of Psychiatry”

Disease

Dimensional

Behavior

Life Story

Treat

Coach

Interrupt

“Rescript” (psychotherapy)

“Perspectives of Psychiatry”

Disease

Dimensional

Behavior

Life Story

Treat

Coach

Interrupt

“Rescript” (psychotherapy)

Requires patient engagement

“Mr. X”Disease

Dimensional

Behavior

Life Story

Schizophrenia

Mild MR, Narcissistic

Threatening, Assault

“unsocialized”

Requires patient engagement

Towards the Future

Consulting psychiatrist for every MCIT.

Liaison with Mental Health Courts

END OF ACT 3

Mobile Crisis Intervention

The Police Officers Perspective

The Toronto Police Service Uniformed Officers – 5,629 Population Served – 2,855,085 Gross Operating Budget – 1,000,778,700 Largest urban police

service in Canada.

• •

Calls for Service - 2011• Total calls received

– 2,067, 938• Total calls

dispatched – 921,722

• Calls dispatched in 11 & 14 Divisions

• 97,171

EDP Calls City Wide

2009 – 16,976

2010 - 17,513

2011 – 19,454

11 & 14 Division

2009 – 2785

2010 – 2970

2011 - 3336

Calls We Attended

2009 – 482 2010 – 545 2011 – 665

Hospital vs. Police “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

The Perfect Team

The Uniform

“Depending on the background of the citizen, the police uniform can elicit emotions ranging from pride and respect, to fear and anger”Richard Johnson, The Psychological Influence of the Police Uniform

“We know that contact with police is often traumatic for people with mental illness.”

Canadian Mental Health AssociationStudy in Blue and Grey, 2003

Plainclothes OptionLess intimidatingMore approachable

Shows understanding

Less noticeable to neighbors or bystanders.

Decreases Stigma

Alternate Uniforms

Specialized Units = Special Identification

UPDATED DESIGNS

Our Cars

VEHICLE OPTIONS

LITTLE THINGS

We’ll take you to the hospital

Sorry, It’s our Policy

Why?• “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

ARE THEY NECESSARY?No Handcuffs

reduces**

- Stress - Anxiety- Shame- Embarrassment- Stigma

(** All risk factors have been assessed)

Benefits

• Continuity of Care• Trust• Future contact

Training = Understanding

“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

Top to Bottom• 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.

Goals worth reaching for.• 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)

Questions