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teaching:on-mha:form-45-47-49-cto [2020/01/09 06:37]
psychdb [Eligibility Criteria]
teaching:on-mha:form-45-47-49-cto [2020/05/07 20:22] (current)
psychdb old revision restored (2020/05/07 20:18)
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-====== Form 45, 47, and 49 (Community Treatment Order) ======+====== Form 45, 47, and 49 (Community Treatment Order - CTO) ====== 
 +{{INLINETOC}}
 ===== Primer ===== ===== Primer =====
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 A **Community Treatment Order (CTO)**, is a provision under the [[teaching:​on-mha:​home|Ontario Mental Health Act]] that allows a physician to mandate supervised treatment on a patient when they are discharged from hospital. The overall goal of CTOs is to prevent mental health deterioration due to medication non-compliance. This is especially applicable in patients with a history of deteriorating when off medication, and show improvement when they are back on medications. ​ A **Community Treatment Order (CTO)**, is a provision under the [[teaching:​on-mha:​home|Ontario Mental Health Act]] that allows a physician to mandate supervised treatment on a patient when they are discharged from hospital. The overall goal of CTOs is to prevent mental health deterioration due to medication non-compliance. This is especially applicable in patients with a history of deteriorating when off medication, and show improvement when they are back on medications. ​
  
-In Ontario, an active CTO will allow you to order a patient back to hospital for assessment (by issuing a Form 47). A CTO expires every 6 months, but can be renewed. Each year, there is also a board hearing to justify whether a CTO needs to remain in place to ensure that personal liberties are not infringed. CTOs are used throughout the world, and the specific criteria to be eligible for a CTOs varies between different jurisdictions. +In Ontario, an active CTO allows ​a patient ​to be recalled ​back to hospital for assessment (through ​issuing a Form 47). A CTO expires every 6 months, but can be renewed. Each year, there is also a [[teaching:​on-mha:​consent-capacity-board-hearings|Consent and Capacity Board (CCB)]] ​hearing to justify whether a CTO needs to remain in place (to ensure that personal liberties are not infringed). CTOs are used throughout the world, and the specific criteria to be eligible for a CTOs varies between different jurisdictions. 
-<​HTML><​script async src="//​pagead2.googlesyndication.com/​pagead/​js/​adsbygoogle.js"></​script+</​WRAP>​ 
-<!-- Leaderboard -->+<WRAP third column>​ 
 +<panel type="​info"​ title="​Download CTO Forms" icon="​fa fa-download"​ no-body="​true">​ 
 +| <button type="​success"​ block="​true"​ icon="​fa fa-download">​[[http://​www.forms.ssb.gov.on.ca/​mbs/​ssb/​forms/​ssbforms.nsf/​GetFileAttach/​014-3760-41~1/​$File/​3760-41_.pdf| Form 45]]</​button> ​  | 
 +| <button type="​success"​ block="​true"​ icon="​fa fa-download">​[[http://​www.forms.ssb.gov.on.ca/​mbs/​ssb/​forms/​ssbforms.nsf/​GetFileAttach/​014-3761-41~1/​$File/​3761-41_.pdf| Form 47]]</​button> ​  | 
 +| <button type="​success"​ block="​true"​ icon="​fa fa-download">​[[http://​www.forms.ssb.gov.on.ca/​mbs/​ssb/​forms/​ssbforms.nsf/​GetFileAttach/​014-3764-41~1/​$File/​3764-41_.pdf| Form 49]]</​button> ​  | 
 +</​panel>​ 
 +</​WRAP>​ 
 +</​WRAP>​ 
 +<​HTML>​ 
 +<script async src="//​pagead2.googlesyndication.com/​pagead/​js/​adsbygoogle.js"></​script>​
 <ins class="​adsbygoogle"​ <ins class="​adsbygoogle"​
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-(adsbygoogle = window.adsbygoogle || []).push({});​ +     (adsbygoogle = window.adsbygoogle || []).push({});​ 
-</​script></​HTML>​ +</​script>​ 
-===== Eligibility Criteria ​=====+</​HTML>​ 
 + 
 +===== Issuing a CTO ===== 
 +===Form 49 ====
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-In order to issue a CTO (i.e. - a Form 45) all of following criteria need to be met: +**Form 49** (//Notice of Intention to Issue or Renew Community Treatment Order//)is the initial notice ​given to the patient ​to let them know a physician intends to start or renew a CTO.
-  - **The patient is certifiable** (i.e. - the patient currently criteria for Box A or Box B in the Form 1) +
-  - **Patient must have ''​2''​ or more admissions to a psychiatric facility for a cumulative period of ''​30''​ days in the last ''​3''​ years** ( and the reason for admission must be for the same condition (e.g. - schizophrenia) each time when meeting the above criteria). +
-  - **A community treatment plan must be created by the physician** (i.e. - what is the proposed mandated treatment once the patient is discharged from hospital?​) +
-  - **The patient must have been examined within the past 72 hours** +
-  - **Rights advice must given** (to both the patient ​and their substitute decision maker (SDM) if applicable)+
  
 </​WRAP>​ </​WRAP>​
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-<callout type="​danger">​ +<callout type="​danger" title="​There Is Another Kind of Form 49!" icon="​true">​ 
-Remember the admission period does not include the Form 1 assessment period ​(i.e. - the first 72 hours) +There is a completely different and unrelated **[[teaching:​on-mha:​form-49|Form 49 (Warrant of Committal)]]** issued through ​the Ontario Review Board (ORB), which is essentially a detention order. Don't confuse the two!</​callout>​
-</​callout>​+
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
  
-==== Form 49 ==== +==== Form 45 ==== 
-<callout type="​danger"​ title="​There Is Another Kind of Form 49!" icon="​true">​ +**Form ​45** (//Community Treatment Order//), is the Form that issues the CTO formally, and details the conditions of the treatment ​order in the community.
-There is a completely different and unrelated ​**[[teaching:​on-mha:​form-49|Form 49 (Warrant of Committal)]]** issued through the Ontario Review Board (ORB), which is essentially a detention ​order. ​Don't confuse the two!</​callout>​+
  
-A **Form 49** (//Notice of Intention to Issue or Renew Community Treatment Order//), is the initial notice given to the patient to let them know a physician ​intends to start or renew a CTO.+==== Complete Steps ==== 
 +<WRAP group> 
 +<WRAP half column>​ 
 +Only a physician ​may issue or renew a CTO.
  
-==== Form 45 ==== +  - **Determine eligibility for a CTO** 
-A **Form ​45** (//Community Treatment Order//), is the Form that initiates ​the CTO formallydetails ​the conditions ​of the treatment ​order in the community.+    * Does the patient meet at least ''​1''​ of the following criteria? 
 +      * Patient has been a patient in a psychiatric facility on ''​2''​ or more separate occasions in the last ''​3''​ years, or 
 +      * Patient has been a patient in a psychiatric facility for a cumulative period of ''​30''​ days or more in the last ''​3''​ years. The admission period **__does not__** include the Form 1 assessment period (i.e. - the first 72 hours of admission), or 
 +      * Patient has been the subject of a previous Community Treatment Order 
 +  - **Develop a Community Treatment Plan (CTP)** 
 +    * CTP is a document of a comprehensive plan of community based treatment, care, or supervision that is less restrictive than being detained in a psychiatric hospital. 
 +    ​Involve the patient, [[teaching:​on-mha:​consent-capacity#​substitute-decision-makers-sdms|substitute decision maker]] (SDM) (if applicable),​ the outpatient team, and anyone else (e.g. - social worker) who will be involved in the CTO to develop the CTP 
 +  - **Notify the hospital CTO coordinator** (varies by hospital) 
 +    * The CTO Coordinator will provide the issuing physician with the CTP and Form 49 
 +  - **[[teaching:​on-mha:​consent-capacity|Capacity Assessment]]** 
 +    * The CTP is a distinct treatment under the [[teaching:​on-mha:​home|Health Care Consent Act (HCCA)]] and thus, the patient must be assessed specifically assessed for capacity to consent to the CTP itself. This assessment must be documented in the chart. 
 +    * If the patient is incapable, informed consent for the CTP must be obtained from the SDM and documented. <callout type="​danger"​ icon="​true"​ title="​Don'​t Forget This Step!">​Regardless of whether the patient is capable or incapable for a medication treatment, you must additionally assess whether the patient is capable to consent to the CTP itself as well and this must be **documented** in their chart! The CTP is a unique treatment in and of itself (i.e. - just because a patient is incapable for an antipsychotic,​ does not mean they are necessarily incapable for a CTP (though it usually is the case)!</callout>​ 
 +  - **Certifiability ([[teaching:​on-mha:​form-1-42#​box-a-criteria|Box A or Box B]] criteriaassessment** 
 +    * The issuing physician must assess whether the patient meets the criteria under s.33.1(4)c of the MHA and document thisthat is
 +      * Does the patient meet the criteria for a [[teaching:​on-mha:​form-1-42|Form 1]], [[teaching:​on-mha:​form-3|Form 3]], or [[teaching:​on-mha:​form-4|Form 4]] under either Box A or Box B criteria? 
 +        * Is the patient suffering from a mental disorder such that he or she needs continuing care, treatment or supervision in the community?​ 
 +        * If the patient does not receive care, treatment, or supervision in the community, is he/she likely to cause serious bodily harm to him/herself or another person, suffer serious physical impairment, or suffer substantial mental or physical deterioration?​ 
 +  - **Signing the final Forms** 
 +    * The CTP must be signed within ''​72''​ hours of conducting the assessment in Step 5.  
 +      * The original Form 49 and the CTP must signed by all parties must be placed on the chart. 
 +      * One copy (each) of the Form 49 and the CTP goes to the patient, the SDM (if applicable),​ and CTO Coordinator (so that they can request Rights Advice for the patient/​SDM) 
 +    * Steps 45, and 6 are ideally, all done at the same time. 
 +  - **Confirmation ​of Rights Advice (Form 50)** 
 +    * A CTO cannot be issued until both the client (plus SDM, if applicable) have obtained rights advice (or best efforts to provide rights advice have been unsuccessful) 
 +    * The CTO Coordinator will contact the physician when rights advice has been completed. 
 +  - **Complete the Community Treatment Order (Form 45)** 
 +    * The physician and patient (or SDM) signs the Form 45 in order to complete the CTO. 
 +    * The patient/SDM must sign //before// the physician. 
 +    * The Form 45 is then given to the: 
 +      * Patient or SDM (if applicable) 
 +      * Outpatient clinic/​hospital (where the care will be delivered) 
 +      * Officer-in Charge 
 +      * Others named in the treatment plan (e.g. the monitoring psychiatrist,​ case manager, etc.) 
 +      * CTO Coordinator 
 +  - **Complete the Notice of issuance or Renewal of Community Treatment Order (Form 46)**
  
 +</​WRAP>​
 +<WRAP half column>
 +<callout type="​default"​ title="​Order of Issuing Forms for a CTO">​
 +  - Form 1 (//​Application by Physician for Psychiatric Assessment//​)
 +  - Form 33 (//Notice to Patient under Subsection 59(1) of the Act and under Clause 15(1) (a) and 15.1 (a) of Regulation 741//)
 +  - Form 49 (//Notice of Intention to Issue or Renew a Community Treatment Order//)
 +  - Form 50 (//​Confirmation of Rights Advice//)
 +  - Form 45 (//​Community Treatment Order//)
 +  - Form 46 (//Notice to Person of Issuance or Renewal of Community Treatment Order//)
 +</​callout>​
 +
 +<callout type="​default"​ title="​After a CTO is Issued">​
 +  * **To renew a CTO**: issue a Form 48 (//​Application to Board to Review Community Treatment Order//) and Notice to Board by Physician of Need to Schedule Mandatory Review of Community Treatment Order — Section 39.1 (4)
 +  * **To recall a patient for examination or assessment**:​ issue a Form 47 (//Order for Examination - Sections 33.3(1) and 33.4(3) of the Act//)
 +</​callout>​
 +
 +</​WRAP>​
 +</​WRAP>​
 +
 +===== Recalling and Order for Examination =====
 ==== Form 47 ==== ==== Form 47 ====
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 A **Form 47** (//Order for Examination//​),​ can be issued by a physician when a patient is non-adherent to an agreed-upon treatment plan as laid out in the Community Treatment Order (Form 45). The patient is brought to a healthcare facility by law enforcement. This does not need to be a hospital emergency room - it can be a clinic, or any other area where a physician works. The patient is then seen for examination and the treatment is then given to the patient. The physician who //​receives//​ the Form 47 when the patient is brought into hospital can give the treatment, it does not have to be the same physician who issued the Form 47. A **Form 47** (//Order for Examination//​),​ can be issued by a physician when a patient is non-adherent to an agreed-upon treatment plan as laid out in the Community Treatment Order (Form 45). The patient is brought to a healthcare facility by law enforcement. This does not need to be a hospital emergency room - it can be a clinic, or any other area where a physician works. The patient is then seen for examination and the treatment is then given to the patient. The physician who //​receives//​ the Form 47 when the patient is brought into hospital can give the treatment, it does not have to be the same physician who issued the Form 47.
 +</​WRAP>​ 
 +<WRAP half column>
 <callout title="​Good Practices for Issuing a Form 47" type="​tip"​ icon="​true">​ <callout title="​Good Practices for Issuing a Form 47" type="​tip"​ icon="​true">​
   * You must specify the hospital/​location where you want the patient should be brought (e.g. - the patient has health records there and you want them to go there)   * You must specify the hospital/​location where you want the patient should be brought (e.g. - the patient has health records there and you want them to go there)
-  * The patient can be given the medication/​treatment as outlined in their CTO, and they **cannot** contest it or apply for hearing +  * When issuing ​Form 47, attach the Form 45 (CTO) and Community Treatment Plan. This is important, because the Form 45 dictates the treatment plan, and the physician receiving the Form 47 needs to know what treatment is.
-  * A Form 45 (CTO) should always go with a Form 47. This is important, because the Form 45 dictates the treatment plan, and the physician receiving the Form 47 needs to know what treatment ​plan is.+
 </​callout>​ </​callout>​
 +</​WRAP>​
 +</​WRAP>​
  
- +==== Common Myths and Errors ====
-===== Common Myths and Errors ​=====+
 There are several common errors that physicians may make when assessing a patient brought in on a Form 47. Most commonly a patient brought into hospital on a Form 47 are seen in the emergency department. There are several common errors that physicians may make when assessing a patient brought in on a Form 47. Most commonly a patient brought into hospital on a Form 47 are seen in the emergency department.
  
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 ^ "A patient on a CTO is always incapable." ​                                       | Almost true. Most patients on a CTO are deemed incapable to consent. However, there are patients who are //capable// who also consent to a CTO as a "​safety net." ​                                                                                                                                                                 | ^ "A patient on a CTO is always incapable." ​                                       | Almost true. Most patients on a CTO are deemed incapable to consent. However, there are patients who are //capable// who also consent to a CTO as a "​safety net." ​                                                                                                                                                                 |
 ^ “I deem them to be not certifiable at this time.” ​                               | A patient on a CTO is by definition, certifiable under Box B criteria of the Mental Health Act. Your one-time assessment of the patient at this time does not overturn the certifiability. ​                                                                                                                                        | ^ “I deem them to be not certifiable at this time.” ​                               | A patient on a CTO is by definition, certifiable under Box B criteria of the Mental Health Act. Your one-time assessment of the patient at this time does not overturn the certifiability. ​                                                                                                                                        |
-^ "I deem this patient to be capable at this time, and cannot ​initiate ​treatment" ​ | If the patient was previously found incapable, you cannot overturn a finding of incapacity based on your one-time assessment of the patient when they are brought in on the Form 47. If a patient ​is incapable (as typically is the case), they continue to be assumed incapable to consent to the treatment outlined in the CTO.  | +^ "I deem this patient to be capable at this time, and cannot ​give the CTO treatment" ​ | If the patient was previously found incapable, you cannot overturn a finding of incapacity based on your one-time assessment of the patient when they are brought in on the Form 47. If a patient ​was incapable ​when the CTO was issued ​(as typically is the case), they continue to be assumed incapable to consent to the treatment outlined in the CTO right now as well.  | 
-^ “I have not been able to reach the SDM, therefore I cannot ​initiate ​treatment." ​ | You still need to give the treatment, because there is already a treatment plan in existence as documented in the CTO. You do not need to contact the SDM as they have already given permission. ​                                                                                                                                  |+^ “I have not been able to reach the SDM, therefore I cannot ​give the CTO treatment." ​ | You still need to give the treatment, because there is already a treatment plan in existence as documented in the CTO. You do not need to contact the SDM as they have already given permission. ​                                                                                                                                  |
 ^ “I cannot give this person the treatment, because they are refusing it.” ​        | The patient cannot refuse treatment because a treatment plan has already been outlined in the CTO. You are legally able to enforce treatment. ​                                                                                                                                                                                     | ^ “I cannot give this person the treatment, because they are refusing it.” ​        | The patient cannot refuse treatment because a treatment plan has already been outlined in the CTO. You are legally able to enforce treatment. ​                                                                                                                                                                                     |
 </​panel>​ </​panel>​
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 ===== Resources ===== ===== Resources =====
-==== For Patients ==== +{{page>​teaching:on-mha:home#​resources&​nouser&​noheader&​nodate&​nofooter}}
-[[https://​www.sse.gov.on.ca/​mohltc/​ppao/​en/​Pages/​InfoGuides/​2016_CommunityTreatmentOrders.aspx?​openMenu=smenu_InfoGuides|Psychiatric Patient Advocate OfficeCommunity Treatment Orders]]+
  
 {{tag>​form}} {{tag>​form}}