On behalf of the Ontario Federation of Community Mental Health and Addiction Programs attached are recommendations and rationale regarding the Request for Proposals to provide the review of Community Treatment Orders as required by the Act.



That the contract is awarded to an organization at “arm’s length” from the Ministry or any provider associated with CTO’s (e.g. A university without a CTO program or a consulting group that has not and is not working with an agency that provides CTO support).



Rationale: To be credible with all stakeholders it is critical that this review must not only be free from any real or perceived conflicts of interest but it must be done in the most impartial manner possible with sound research practices.



That the review seeks understanding of who is on a CTO, specifically: age, gender, ethno-racial characteristics, socioeconomic status, housing, marital status, geographic location, education, diagnoses.



Rationale: Such demographics provide for a better way of comparing CTO’s with other options for the client group and may point out strengths and weaknesses.



That the review seeks understanding of why someone is on a CTO.



Rationale: Much information needs to be gathered and analyzed to determine why someone was put on a CTO and why others were not. Data regarding previous treatments, including number and duration of voluntary and involuntary hospitalizations, previous police apprehensions, previous case management/ACT contacts, previous homelessness, episodes of both aggression and victimization would need to be analyzed.



That the review seeks to understand why some physicians are using CTO’s and some are not.



Rationale: It is critical to understand if and why some demographic groups are over represented. It would be important to get a sense from physicians about whether they have clients they believe would benefit from a CTO, but who may not meet criteria. Also of interest is the reasons CTOS are considered, but then not issued (i.e. consent withheld, lack of services, client doesn't meet criteria, other treatment deemed more suitable, etc.)



That the review seeks an understanding of the impact of a CTO.



Rationale: Impact on the individual, their family and community was a major objective of the legislation. The review must therefore include: qualitative research (e.g. the perspectives of patients, families, room mates/house mates, landlords, community treatment teams, psychiatrists signing CTO’s, CTO related staff (CTO coordinators and case managers)), and quantitative research (e.g. duration of CTO itself and its renewals, number and duration of voluntary and involuntary hospitalizations, police apprehensions, case management/ACT contacts, homelessness, episodes of both aggression and victimization, number of contacts with crisis services



That the review seeks an understanding of whether, all else being equal, some sub-populations are placed on CTO’s more frequently than others.



Rationale: It is essential to determine whether CTO’s are being disproportionately used in dealing with some populations. It has been suggested that some minority groups are over represented amongst those placed on CTO’s.



That the review include a comparative study on a similar client group to see whether intensive community supports achieve similar results without resorting to CTO’s.



Rationale: Social and monetary cost-effectiveness should also be reviewed.