Form 20 (British Columbia - Leave Authorization), Extended Leave, and Recalls

• Extended leave is a type of leave for an involuntary patient where they remain certified, but are granted leave from the designated facility for more than 14 days.
  • It is intended to be a person-centered, therapeutic approach, where an individual can continue to receive mandated care and treatment, but in their own community.
• Persons on extended leave maintain the same rights as any other patient certified under the BC Mental Health Act as per Form 13.
• Extended leave requires the completion of a Form 20 and involves long-term, collaborative support and assistance.

The Form 20 specifically identifies the physician in the community who will assume care of the patient while on extended leave and authorizes/requires the following:

1. Clinical care of the patient
2. Completion of renewal certificate
3. Renewal and modification of conditions of leave
4. Recall from leave
5. Discharge of the patient

• In planning for the successful release (not discharge - this would be a Form 17) of an involuntary patient on extended leave, conditions and restrictions must be specified and documented on the Form 20.
• Examples of conditions for extended leave might include:
  • Taking medications as prescribed
  • Attending appointments with a Community Mental Health Team
  • Living in a predetermined geographic location/residence
• As per the Preliminary Mental Health Act Standards, compulsory conditions should be least restrictive, include only those essential to prevent re-hospitalization, permit reasonable choice as to geographic location of residence, and be part of a comprehensive community treatment plan.

• Once a patient is on extended leave and living in the community, an involuntary patient will require ongoing treatment, supervision, care and support from community care providers.
• Extended leave can continue as long as the involuntary status of the patient is maintained through correct renewal procedures, or until the patient is recalled to hospital, or discharged.

• When would a new Form 20 be required? A new Form 20 is required only if one of the following apply:
  • Conditions of leave change
  • A different community physician assumes the care of the patient
  • A patient is recalled to hospital and discharged again on extended leave
• Note that a new Form 20 is not be required when another physician temporarily covers for the patient’s regular physician.

• Extended leave may continue as long as the involuntary status of the patient is maintained through correct renewal procedures (e.g. - additional Form 6s), or until the patient is recalled to hospital, or discharged formally (via a Form 17).

• If a patient has been on Extended Leave for 12 or more consecutive months, the Mental Health Act requires that the patient's file be reviewed by the Mental Health Review Board on whether they should still be certified.
• The Extended Leave Review Panel Hearing Directive Form must be given the patient.

A patient can be recalled by a director or a physician if there is evidence that the patient:

1. Requires treatment in a designated facility,
2. Requires care, supervision and control in a designated facility to prevent the patient’s substantial mental or physical deterioration or for the protection of the patient or the protection of others, and
3. Will not voluntarily return to a designated facility.

• If the conditions of a patient's extended leave are not being met (e.g. - patient stops taking medications or following up with mental health team), the patient may be recalled to the designated facility that released them or transferred to another designated facility.
  • A physician does this by completing a Form 21 (Director's Warrant (Apprehension of Patient)).
• Ensure you are familiar with your health authority's policies on recalling a patient to hospital.
  • Police may bring a patient back provided a valid Form 4 or Form 6 is available to them.

• If a patient has been on extended leave for less than 6 months and is recalled and admitted, the patient does not need a new Form 4 or Form 6 completed
• This is because the patient is still considered “admitted”
• Whatever Form 6 (or Form 4 for that matter) was in effect at the time of the recall would still apply until it expires, at which time, another Form 6 would filled out (if applicable)
  • i.e. - if a patient has been on extended leave for 4 months and is recalled to hospital, the expiry date of the last Form 6 that was completed is used

• If a patient is on extended leave for 6 consecutive months or longer and is then recalled and admitted, the Mental Health Act states they must be treated like a newly admitted involuntary patient.
  • You can think of the Form 21 as being equivalent to two Form 4s, so no Form 4s are issued during this type of an admission!
  • Thus, a new Form 6 is created that uses the date of recall (i.e. - the date they were brought into hospital) as the new admission date and also resets to back to the renewal periods of 1 month (first Form 6), 3 months, 6 months, and so on.
• The patient is entitled to all the rights of a newly admitted patient, and you must give the patient a Form 13 (or Form 14 if age 16 and under) to inform them of their rights.
• Although not explicitly stated in the MHA, a Form 5 should ideally be present in the patient's chart, even though Form 4s are not needed.

• If a patient presents to the Emergency Department while on extended leave and the hospital physicians are unaware the patient is already certified, they might inadverently complete new Form 4s and admit the patient under Section 22 of the Mental Health act.
  • If this happens, the new Form 4s do not nullify the extended leave.
  • Whenever possible, steps should be taken to avoid these new section 22 admissions (i.e. - new Form 4s) of involuntary patients on extended leave.
  • Emergency department staff should attempt to contact the community physician, community mental health resources and the psychiatric inpatient unit in regard to recall/re-admission.
• Under these circumstances, once hospital staff are aware the patient is already certified, the original Renewal Certificate (Form 6) remains valid and any new Form 4s should be disregarded.
  • Once it is determined the patient requires readmission, a new Form 6 will be completed and the dates will then reset.
  • A new Form 6 only occurs if the patient has exceeded the 6 month renewal timeline for a readmission (see Recalling section above).