Government of Ontario: Ministry of Health and Long-Term Care

1.Patient's date of birth (yyyy mm dd)

Patient's first and last initials

2.Date of issue (yyyy mm dd)

Issuing physician name

Organization/agency name and address

7. No. of psychiatric hospitalizations in past 6 months:
admissions

Print name of person completing this form

Date

Telephone no.

Please detach this Notice and give to the patient or Substitute Decision-Maker who provided consent on the CTO.

NOTICE OF DATA COLLECTION BY THE MINISTRY OF HEALTH AND LONG–TERM CARE

The amended Mental Health Act (Bill 68) requires that the Minister of Health and Long-Term Care establish a process to review community treatment orders (CTOs). The Ministry of Health and Long-Term Care has been given authority by the Information and Privacy Commissioner/Ontario to collect patient information indirectly from physicians who issue, renew or re-issue CTOs. The information collected will be anonymous and will be used for the sole purpose of establishing and conducting reviews of community treatment orders as set out in section 33.9 of Bill 68.

If you have any questions or concerns about the collection of this information, or require further information, please contact Manager, Monitoring, Standards and Evaluation, Operational Support Branch, Ministry of Health and Long–Term Care, 5700 Yonge St., Mezzanine Level, Toronto ON M2M 4K5, Telephone: (416) 327–7350.

3780–41 (00/12)
7530–5589

Instructions:

1. The CTO Information Record was developed to facilitate the requirement in Bill 68 which states that CTOs must be reviewed.

2. It is the physician's responsibility to complete the CTO Information Record at the time of issuing, renewing, or re-issuing a CTO, for all CTOs issued, renewed, or re-issued.

3. The "Data Definitions and Guidelines for Completing CTO Information Record" are available as a reference. Please refer to these to assist with completing the form.

4. The CTO Information Record is most easily completed at the time of issuing, renewing, or re-issuing the CTO and completing the Form 45.

5. The completed CTO Information Record should be submitted to Administrative Assistant, CTO Information Project, Finance and Information Management Branch, Ministry of Health and Long-Term Care, 5700 Yonge St. 4th floor, Toronto ON M2M 4K5.

6. If you have questions or require further information regarding the CTO Information Record, please contact Administrative Assistant, CTO Information Project, Finance and Information Management Branch, Ministry of Health and Long-Term Care, 5700 Yonge St. 4th floor, Toronto ON M2M 4K5. Tel: (416) 327–9184.

Data Definitions and Guidelines for Completing CTO Information Record

Item 1. Date of birth

Data Definition

Date of birth of the person getting the CTO

Valid Options

Date format (yyyy/mm/dd)

Rationale for Collecting Data

To provide demographic information for monitoring CTO utilization by age

Item 1. First and last initials

Data Definition

First name and last name initials of the person getting the CTO

Rationale for Collecting Data

To create a unique identifier (along with Date of Birth) to link records for persons receiving multiple CTOs for monitoring CTO utilization and outcomes

Item 2. Date of issue

Data Definition

Date when the CTO was issued by the physician

Valid Options

Date format (yyyy/mm/dd)

Rationale for Collecting Data

To monitor CTO utilization at any given time and duration of time people are under CTOs when CTOs are renewed or re-issued

Item 2. Issuing physician name and work address

Data Definition

Name of physician who is issuing the CTO, name and address of organization/agency where the physician is working. Address provided should be the address where the patient's health record is kept.

Rationale for Collecting Data

To provide CTO utilization information for different regions, communities, etc.

Item 3. Service where patient is issued the CTO

Data Definition

Service affiliation of patient and physician at the time CTO is issued

Valid Options

As listed on form. Only one should be checked off. If 'Other' is checked, the type of service should be specified.

Rationale for Collecting Data

To provide CTO utilization information around types of service where CTOs originate

Item 4. Consent provided by

Data Definition

Who provided consent for the CTO?

Valid Options

1. Patient or
2. Substitute Decision-Maker

Rationale for Collecting Data

To monitor provision of consent

Item 5. CTO

Data Definition

Whether the current CTO is the first one to be issued for this patient, a renewal or a re-issue. A renewal is a continuance of a previous CTO. A Re-issue is a CTO that is not the first for the patient, yet is being issued after some time (>1 month) has lapsed without a CTO

Valid Options

1. 1st Issue
2. Renewal
3. Re-Issue

Rationale for Collecting Data

To monitor CTO utilization and duration of time people are under CTOs

Item 5. Total number of CTOs patient has had

Data Definition

Total number including current one

Valid Options

Answer should reflect what is known to the best knowledge of the physician

Rationale for Collecting Data

To monitor CTO utilization and duration of time people are under CTOs

Item 6. Sex

Data Definition

Sex of the patient

Valid Options

1. Male
2. Female

Rationale for Collecting Data

To provide demographic information for monitoring CTO utilization by sex

Item 7. No. of psychiatric hospitalizations in past 6 months

Data Definition

Total number admissions to an inpatient psychiatric service that the patient has had in the six months prior to the date of issuing the current CTO.

Valid Options

Record no. of psychiatric hospitalizations in past 6 months

Rationale for Collecting Data

To obtain a baseline measure of psychiatric hospitalizations in the six months prior to CTO and during CTO(s)

Item 8. Service Involvement during previous 6 months

Data Definition

Services patient had received during previous 6 months from date of issue of current CTO

Valid Options

Check all that apply on list provided on form. Specify other service(s). If information not known, check 'Don't know' option

Rationale for Collecting Data

To obtain a baseline measure of service involvement six months prior to CTO and during CTO(s)

Item 9. Services to be involved in current CTO

Data Definition

Services to be involved in the treatment plan in the current CTO

Valid Options

Check all that apply on list provided on form. Specify other service(s)

Rationale for Collecting Data

To monitor range of services involved in CTO treatment plans

Item 10. Legal system involvement

Data Definition

Patient's involvement with legal system during previous 6 months

Valid Options

Check all that apply on list provided on form. If information not known, check 'Don't know' option

Rationale for Collecting Data

To obtain a baseline measure of legal system involvement six months prior to CTO and during CTO(s)

Item 11. Psychiatric diagnoses

Data Definition

Patient's diagnostic categories of mental disorder, as diagnosed by a recognized health professional

Valid Options

Check all that apply from list provided on form. Specify other disorder(s)

Rationale for Collecting Data

To obtain clinical descriptive information about clients/patients who are under CTOs

Item 12. (a) Lives with

Data Definition

Who, if anyone, the patient usually lives with

Valid Options

Check all that apply from list provided on form

Rationale for Collecting Data

To provide demographic information for monitoring CTO utilization by living situation

Item 12. (b) Housing type

Data Definition

The usual housing type of the patient

Valid Options

Check one from list provided on form.

Rationale for Collecting Data

To provide demographic information for monitoring CTO utilization by living situation

Name, date, telephone no. of person completing form

Data Definition

Contact information of person completing form. This is usually the physician, but could be a delegate

Rationale for Collecting Data

To have contact information in the event questions arise about the information provided on the form.