II An Evaluation of the Toronto Mobile Crisis Response Team Program
III Evaluation Recommendations
--submitted by Maritt Kirst, Amy Katz and Vicky Stergiopoulos. The original report on which it is based was written by Maritt Kirst, Renira Narrandes, Kate Francombe Pridham, Janani Yogalingam, Flora Matheson and Vicky Stergiopoulos, Centre for Research on Inner City Health, St. Michael’s Hospital
Quick facts about Mobile Crisis Intervention Teams
In Toronto, Mobile Crisis Intervention Teams (MCITs) consist of a mental health nurse, and a police officer trained to respond to people experiencing mental health crises. There are currently six MCITs in Toronto, each based out of a hospital and covering police divisions in geographic proximity. MCITs are available seven days a week, and depending on the team, will work as early as six am and as late as 11 pm.
How are MCITs deployed? Can I call them?
If someone calls 911 about a mental health crisis in the community, regular (non-MCIT) police officers (Primary Response Units) will always respond first to assess the safety of the situation. If first responder officers identify that the situation is safe, and that an MCIT team should be called, an MCIT will be dispatched by the Toronto Police Communications department. Sometimes, people (family members, providers, someone in crisis) call 911 asking directly for MCITs. While, in these cases, an MCIT might eventually be deployed, regular police officers will always respond first.
What types of calls do MCITs attend?
MCITs are requested by Primary Response Units to respond to mental health crisis calls including thoughts of suicide or self-harm, distorted psychotic thinking, anxiety, overwhelming depression and those who may be experiencing a temporary breakdown of coping skills.
What happens to people when they are responded to by MCITs?
MCITs will attempt to de-escalate the situation in the moment. If they identify that further treatment is needed, MCITs will apprehend people and take them to the hospital, or will not apprehend them and, rather, refer them to community services. Depending on the situation, MCITs will follow up with people following the initial interaction to see how they are doing.
II An Evaluation of the Toronto Mobile Crisis Response Team Program
A small body of evaluative literature from the US and Canada exists on MCITs/co-response programs. Findings show that these programs can be cost-effective, and reduce burden on the criminal justice system and officer time on scene (Baess, 2005; Kisely et al., 2010; Lamb et al., 1995; Scott, 2000). Research has also found that people in crisis and family members have positive ratings of satisfaction with MCITs/co-response programs (Baess, 2005; Forchuk, Jensen, Martin, Csiernik, & Atyeo, 2010; Ligon & Thyer, 2000; Scott, 2000). However, key program factors that contribute to successful outcomes are less well understood (Brown Cross et al., 2014), and in-depth perspectives of people who are responded to by MCITs/co-response programs are underrepresented in the literature.
In 2013/14, the Centre for Research on Inner City Health (CRICH) at St. Michael’s Hospital in Toronto was asked to evaluate Toronto’s MCIT program. The purpose of this evaluation was to document and understand processes of MCIT service delivery in Toronto, and identify facilitators and challenges in implementation. Furthermore, the evaluation sought to gain an understanding of levels of satisfaction with the program among stakeholders.
MCITs in Toronto
Toronto Police Services and area hospitals partnered in 2002 to develop an MCIT program to respond to individuals experiencing mental health crises in the community. The MCIT program currently includes six teams based out of partnering hospitals. MCITs comprise a team manager, mental health nurses and police officers trained in crisis intervention. Each team is linked with particular police divisions in geographical proximity to the hospital. Regular, Primary Response Unit (PRU) police officers are dispatched to all mental health crisis calls to assess individual and community safety, and the appropriateness of an MCIT response. If considered appropriate by the PRU, the MCIT is dispatched to the call by the police services communications department. In November 2013, the Toronto Central Local Health Integration Network (TC-LHIN) provided funding to develop a city-wide program linking the existing teams through a collaborative planning structure.
Perception and awareness of MCITs
CRICH’s evaluation study involved a series of qualitative interviews and focus groups with program stakeholders to learn more about program operations, facilitators and challenges. Purposeful sampling was used to engage 57 stakeholders including people working within thehealth system, police service and hospital stakeholders, program managers, MCIT teams, community members and people responded to by MCIT teams. Interviews and focus groups were conducted between November 2013 and February 2014 and lasted approximately 45 minutes to two hours.
The evaluation yielded a number of important findings on the process of MCIT program implementation and service delivery. Overall, program stakeholders, including police, staff, community agencies, health system partners and people responded to by MCITs felt that the program is meeting its key goals to respond to individuals in crisis, and treat them in the community in order to prevent unnecessary hospitalization and criminalization:
“I think the [MCIT] interventions themselves have been successful in de-escalating some potentially explosive situations, and I think there have been situations where lives have been saved as a result of the intervention of the team. So, I think those things are the primary successes of it.” – Health system stakeholder
Differences in opinion emerged regarding the mandate of the program. Some community members believed that MCITs should be first responders to mental health crisis calls, while currently MCITs are secondary responders to non-violent crisis situations that do not present a safety risk.
People who were responded to by MCITs expressed having positive experiences with the teams, and emphasized that these experiences were related to interactions during which the teams were caring, made them feel respected and heard, and gave them choice in the context of the interaction:
“They [team members] seemed to be…very willing to listen to me. That’s my biggest thing is… if I feel like people are just attacking me or not listening to my side of the story or treating me like I…don’t have a brain to think with, then I get very defensive and… scared, so I put my back up and it doesn’t always go well.” – Person responded to by MCIT
Less positive interactions occurred when people did not feel heard and respected, did not feel that they had choices, and were left feeling criminalized.
Facilitators and challenges to implementation
A number of facilitators and challenges to program implementation and optimal service delivery were identified through the study. With respect to facilitators, existing partnerships between the police and the health system, between the MCITs and emergency departments (EDs), and MCITs and community agencies are viewed as positive and important to the functioning of this complex program. Furthermore, team members are proud and invested in the work that they do. Teams are viewed as knowledgeable in how to engage with people in crisis, and in terms of their capacity to refer people to relevant community services. The knowledge and experience brought by the nurse is highly valued by a variety of stakeholders in these interactions, as are team procedures for following up with people to prevent repeat crises.
Challenges to program implementation and service delivery reflect the complexity of the program. Despite the fact that partnerships between the various program stakeholders are viewed as positive, some of these relationships require more work in order to better support the program. Toronto Police and health system stakeholders feel removed from each other’s professional cultures, and this is often reflected in a lack of awareness of the program mandate among the regular police Primary Response Units (PRUs) and a lack of buy-in for the program in some police divisions. Also related to this cultural/organizational distance were issues of role clarity, whereby team members may step into each other’s roles, and a desire by many team members to be more involved in program decision-making.
Further relationship-building appears to be needed in some hospital EDs, as teams often report a lack of prioritization of admission leading to long wait times and an inability for teams to attend other calls:
“… You have a patient that’s been assessed by the psychiatric nurse, they’ve been apprehended, they go to a hospital and they’re waiting… for two to four hours before they can see the psychiatrist. The psychiatrist could be right in the room next door, but they have to be… medically cleared, by the ER doctor…” - Police stakeholder
Mixed views on certain resources and team practices emerged in discussions with stakeholders. There appears to be a debate among program stakeholders as to whether police officers should be in uniform or in plain clothes, and the extent to which current uniforms distinguish the nurse from the police officer. Differing views also emerged on whether teams should be driving marked or unmarked cars, and concern that current vehicles are not appropriate – i.e., people feel criminalized when taken away in a police car to the hospital. A lack of clarity on certain team responsibilities, such as whether teams should always be secondary versus primary response, as well as whether and how teams should be conducting follow-ups, also appeared to hinder service delivery. Challenges in communication between dispatchers and teams were also discussed as negatively affecting team ability to attend calls.
Finally, some stakeholders discussed the need for greater awareness and availability of non-police crisis services in the city to reduce the demand on police services and MCITs. A number of people responded to by MCITs echoed this recommendation for a more coordinated system, and expressed a desire for greater assistance with accessing supportive services that assist with system navigation like case management.
III Evaluation Recommendations
The evaluation study highlighted a number of program strengths to be built upon and challenges to be addressed in order to improve implementation and service delivery across MCITs. Key recommendations for program improvement include:
- Improved police organizational support for the program by raising awareness of the program mandate among the regular police divisions (PRUs). Raising awareness of the program mandate will also serve to improve capacity to respond appropriately to mental health issues and knowledge of resources in the community within divisional policing.
- Clear communication to program partners and community on the mandate of the MCIT program. This is necessary to address different perceptions of the purpose of the program, for example the types of calls to which the MCITs should be responding in light of confusion among community members regarding whether MCITs should be involved in more volatile, potentially violent encounters.
- Clarification of certain team responsibilities and procedures:
- It should be clarified whether primary response (without the PRU) by teams is ever appropriate, for example when teams have had previous contact with someone.
- Clarification on whether follow-ups should be a program priority is needed. If teams will be conducting more consistent follow-up, it should also be considered whether they should follow-up with people in person or by phone.
- Improved external and internal feedback mechanisms have been requested by a number of stakeholders. In the area of external mechanisms, more communication and input from community stakeholders and people responded to by MCITs was recommended and could be addressed through the creation of a community advisory committee or linkage with an existing committee. With respect to internal feedback, greater inclusion of frontline staff in program-decision making should be considered.
- Resolution of debates on equipment, such as team cars and uniforms is recommended. With respect to cars, some stakeholders have recommended that an unmarked SUV with a light pack would address challenges concerning vehicle comfort and potential stigma when transporting people to hospital.
- More comprehensive training for teams and PRU officers was recommended. It was recommended that teams receive more cross-sector training in each other’s areas of expertise for the purposes of bridging their different professional cultures (i.e., nursing/mental health and police cultures). For example, additional training in safety and the police system for nurses, and training in mental health de-escalation and the mental health system for police officers were viewed as helpful. It was also recommended that PRU officers receive real-time training involving ride-alongs with MCITs to raise awareness of the program mandate and build capacity for positive engagement with people in crisis. Furthermore, given the intensive work of the MCITs, more opportunities for teams to meet and debrief were recommended as this was viewed by many as a valued activity – the same opportunities should be provided to PRU officers.
- The program is already exploring expansion – it is recommended that this process involve the consideration of a more effective dispatch process whereby dispatch and MCITs are in more regular communication. This will overcome challenges in ability for dispatch to locate the teams and increase capacity for teams to respond to calls. In the future, the program may want to consider a more centralized dispatch system to overcome current issues with dispatch and the impact of varying divisional support on service delivery.
For more information and to read the full evaluation report, please visit http://www.crich.ca/reports/mcit.
Baess, E. P. (2005). Integrated Mobile Criss Response Team (IMCRT): Review of Pairing Police with Mental Health Outreach Services. Victoria, BC: Vancouver Island Health Authority.
Forchuk, C., Jensen, E., Martin, M. L., Csiernik, R., & Atyeo, H. (2010). Psychiatric crisis services in three communities. Canadian Journal of Community Mental Health, 29(SUPPL. 5), 73-86.
Kisely, S., Campbell, L. A., Peddle, S., Hare, S., Pyche, M., Spicer, D., & Moore, B. (2010). A controlled before-and-after evaluation of a mobile crisis partnership between mental health and police services in Nova Scotia. Can J Psychiatry, 55(10), 662-668.
Lamb, H. R., Shaner, R., Elliott, D. M., DeCuir, W. J., Jr., & Foltz, J. T. (1995). Outcome for psychiatric emergency patients seen by an outreach police-mental health team 12. Retrieved 9502838, b8t, 46, from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med3&NEWS=N&AN=8590113
Ligon, J., & Thyer, B. A. (2000). Client and family satisfaction with brief community mental health, substance abuse, and mobile crisis services in an urban setting. Crisis Intervention and Time-Limited Treatment, 6(2), 93-99.
Scott, R. L. (2000). Evaluation of a mobile crisis program: effectiveness, efficiency, and consumer satisfaction. Psychiatr Serv, 51(9), 1153-1156.
Toronto Central Local Health Integration Network funds over 170 health service providers, including a community care access centre, community health centres, community support services, hospitals, long-term care homes and mental health and addiction services that deliver a variety of services. http://www.torontocentrallhin.on.ca/
The Centre for Research on Inner City Health (CRICH) at St. Michael’s has a mission to reduce health inequities through innovative research that supports social change. It conducts research to better understand the linkages between poverty, social exclusion and poor health. It works in partnerships with non-researchers to produce evidence that can be used in practice, and works in collaboratively with diverse policy sectors, including housing, transit, education, corrections and community and social services.