File # 394-2-51 Evaluation Report: Community Mental Health Initiative

File # 394-2-51  Evaluation Report: Community Mental Health Initiative
File # 394-2-51
Evaluation Report:
Community Mental Health Initiative
Evaluation Branch
Performance Assurance Sector
November, 2008
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Acknowledgements
The Evaluation team would like to thank all the staff, offenders, and community service
providers who took time to share their thoughts on the CMHI by completing a survey or agreeing
to participate in an interview.
We would like to thank staff who provided information and documentation utilized in this
evaluation. In particular, we would like to express our appreciation to the Evaluation
Consultative Group Members, including Health Services (Natalie Gabora-Roth), Community
Reintegration Operations (Robert Safire), Aboriginal Relations (Jennifer Hayward), Women
Offender Sector (Chris Hill, Mark Christie), Performance Management (Lisa Hill), Performance
Assurance (Jennifer Guillon, Jessie Rylett), and Regional Psychiatric Center (Prairies; Treena
Witte). Thanks also to Andrea Moser, Jane Laishes, Michael Martin, and Thanujah Yogarajah
for their assistance responding to specific questions and providing information.
We are also grateful for the assistance provided by staff members who coordinated the site visits
(Pacific Region: Gurjit Toor, Heather Pierce, Treena Prox, Karen Sloat; Prairies Region: Amy
Howie, Lisa Gluck, Clarence Turgeon, Jason Mackenzie, Darrell Lindsey; Ontario: Johanna
Kudoba; Quebec, Martine Lacroix, Stéphanie Gérin and Suzanne Pelletier; Atlantic: Paul
Harris).
Thank you to the Executive Steering Committee for your feedback and guidance. Terry
Nicholaichuk, Deqiang Gu, and Treena Witte at the RPC were instrumental in providing many of
the analyses in this report. When additional analyses were required they worked diligently to
provide these under very pressing timeframes.
We would also like to thank Vanessa Anastasopoulos for her assistance with conducting
interviews. Kelly Taylor provided methodological advice and peer review assistance, and Cara
Scarfone and Amanda Nolan also made various editorial contributions. The Team would also
like to thank Mark Nafekh for data analysis assistance and Annie Yessine for her analytical
expertise. Thank you to Lindsey Pecaric for her assistance providing a cost-effectiveness
literature review.
Jean-Pierre Rivard, Ghalib Dhalla, Robert Riel, and the regional personnel provided invaluable
assistance gathering the financial data, and Cameron Bouchard from the Public Safety Geomatics
Division provided expertise and assistance in generating the geo-mapping analysis.
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Evaluation Team Members
Nicole Allegri
Senior Evaluator
Kendra Delveaux
Director Evaluation
Duyen Luong
Evaluation Officer
Hongping Li
Evaluation Officer
Tamara Jensen
A/Evaluation Officer
Dennis Batten
Evaluation Officer
Krista Barney
Evaluation Assistant
Elizabeth Loree
Evaluation Assistant
Michael Henighan
Evaluation Assistant
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Evaluation Report:
Community Mental Health Initiative
SIGNATURES
_________________________
Lynn Garrow
Associate Assistant Commissioner
Policy & Research
______________
Date
_______________________
Pamela Yates
Director General
Evaluation Branch
_______________
Date
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Executive Summary
Introduction
Addressing the mental health needs of federal offenders is one of Correctional Service Canada’s
(CSC) five strategic priorities (CSC, 2008a). In 2007/08, 10% of men offenders and 22% of
women offenders in federal custody were identified as presenting with mental health problems at
intake. These percentages represent 67% and 69% increases, respectively, since 1996/97 (CSC,
2008b). In the 2006 report of the Standing Senate Committee on Social Affairs, Science and
Technology on mental health care in Canada, Out of the Shadows at Last, also known as the
Kirby Report (Kirby, 2006), the Committee challenged CSC to meet the mental health standards
of care for offenders under federal jurisdiction that are typically afforded to non-offender
populations. Moreover, the Committee specifically recommended that CSC provide services to
ensure continuity of mental health care from the institutions to the community.
CSC is mandated by legislation (86(1) of the Corrections and Conditional Release Act [CCRA],
1992) to provide mental health services to federally sentenced offenders although the provision
of these services have been deemed inadequate (see Canadian Public Health Association, 2004;
Correctional Investigator Canada, 2004; and Kirby, 2006). Findings and recommendations from
the Kirby Report, as well as reports from the Office of the Correctional Investigator (2004), CSC
Review Panel (2007), and the Government of Canada’s Performance Report (2007b) have
highlighted the need and provided additional support for the development of a comprehensive
mental health strategy. CSC is implementing such a strategy for federal offenders, the
fundamental goal of which is to ensure a continuum of mental health services to offenders from
institutional intake to release into the community. This approach focuses on: (1) intake screening
and assessment; (2) primary care; (3) intermediate care; (4) intensive care (at Regional
Treatment Centres); and (5) transitional care. In 2005, following submission by the Health
Service Branch, Treasury Board allocated funds to implement the Community Mental Health
Initiative, the fifth component of the overall Mental Health Strategy.
The Community Mental Health Initiative (CMHI), implemented in 2005, falls within the
transitional care component of the national mental health strategy. The key components of the
CMHI are:
•
•
•
•
Increased discharge planning, provided by clinical social workers, for offenders with
mental disorders at men’s and women’s institutions;
Allocating mental health specialists (clinical social workers and mental health nurses) to
support offenders with mental disorders (OMDs) residing in the community [including
Community Corrections Centres (CCCs) and Community Residential Facilities (CRFs)];
Providing resources and services to respond to the special needs of OMDs in the
community (e.g., contracts and funds for psychiatry and other mental health
interventions, specialized assessments, tutors, etc.); and
Providing mental health training to correctional services staff, halfway house staff, and
community partners (Champagne, Turgeon, Felizardo, & Lutz, 2008).
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CMHI Budget
A total of $29.1 million over a five year period for the Community Mental Health Initiative was
approved in 2005. The majority of the funding ($15.3 million) was designated for salaries,
including $7.8 million for operating costs and approximately $6 million for common services,
employee benefit plans, and accommodations.
Evaluation Strategy
An evaluation strategy was developed by the Evaluation Branch in consultation with the
evaluation consultative group, comprised of stakeholders from CSC Health Services, Aboriginal
Initiatives Directorate, Women Offender Sector, Performance Management Branch, and
Regional Psychiatric Centre Prairies Research Branch. The purpose of the evaluation was to
provide information required to make investment decisions in the area of community mental
health beyond the expiration of the funding in March 2010. Due to the recent implementation of
the CMHI, the evaluation was primarily implementation focused, but immediate and
intermediate outcomes were assessed where possible given the availability of data.
Qualitative and quantitative methodologies were utilized to conduct the evaluation. Information
was collected through:
• Surveys of CSC staff members who had experience working with offenders with mental
disorder in August 2008;
• Interviews with offenders in the community who received services from community
mental health specialist teams;
• Consultations with regional coordinators to develop implementation timelines;
• Automated data collection, including queries of CSC’s Offender Management System
(OMS) and other databases created and maintained by Health Services and the Regional
Psychiatric Centre (RPC);
• Review of relevant documentation, including implementation and post-implementation
reports from the RPC, the mental health training summary report from CSC’s Health
Services Sector, operational documents, relevant CSC policies and procedures, and
financial documentation from the Integrated Management Reporting System (IMRS); and
• Review of relevant literature, including government and non-government publications,
reports from international jurisdictions, and academic and professional publications.
To examine the effectiveness of the CMHI in the successful reintegration of offenders into the
community, outcomes for offenders who received discharge planning services and community
mental health specialist services were compared to a historical comparison group that did not
receive CMHI services.
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Key Findings
SUMMARY FINDING: The community mental health initiative remains consistent with
CSC priorities, government-wide objectives, and practices in other jurisdictions and addresses a
realistic need for mental health services among CSC offenders. The CMHI resulted in increased
access to mental health services, including discharge planning services and mental health
services in the community provided by community mental health specialists or contractors.
Offenders who received community mental health specialist services were less likely to be
suspended or revoked than the comparison group who did not receive CMHI services. Some
implementation challenges were observed, including delays in staffing CMHI positions (which
resulted in re-profiling and lapses of CMHI funding), challenges related to information sharing
between the institution and the community, and some stakeholders reported that some offenders
in need of mental health services were not being referred for services.
Objective 1: Relevance
FINDING 1: The CMHI remains consistent with departmental and government-wide
priorities
FINDING 2: Given the increasing number of offenders entering CSC with mental health
disorders, there is a need to provide services for these offenders to address their
mental health needs and assist them to successfully reintegrate into the community.
FINDING 3: The CMHI is consistent with other jurisdictions’ practices, particularly those
that employ community-based models of mental health intervention for offenders.
Objective 2: Implementation
FINDING 4: Delays in implementing CMHI services were attributed primarily to staffing
challenges. Successful implementation of the CMHI was more likely when there were:
(1) dedicated human resource and administrative support to expedite the staffing
processes; and (2) a wide recruitment campaign to draw many potential candidates to
staff the initiative.
FINDING 5: Discharge planning referrals are not occurring in accordance with CMHI
guidelines regarding timeframes (i.e., nine months prior to anticipated release date).
FINDING 6: The most common reason for CMHI referral rejections occurred because
offenders did not meet inclusion criteria. Staff also suggested that some offenders in
need of services were not being referred. Examination of findings suggests that this
may be due to a lack of knowledge among CSC staff members regarding CMHI
referral criteria, lack of reliable tools to facilitate early identification of those in need
of services, and/or a lack of available services in the communities to which the
offenders are being released.
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FINDING 7: Implementation challenges were reported related to coordination and
information sharing among institutional and community mental health and case
management teams
FINDING 8: Existing CMHI sites appear to be well-placed to serve offenders with mental
health needs as demonstrated by the number of offenders with mental health needs at
existing CMHI sites. However, there are several CSC sites with significant proportions
of of offenders with mental health needs that have not been identified for CMHI
services.
FINDING 9: Implementation delays have led to several instances of re-profiling and lapses
of CMHI funding. Financial data for the CMHI have not always been coded
consistently utilizing the appropriate cost-centres in IMRS
Objective 3: Success
FINDING 10: Mental health training was provided to 830 individuals in the community
and 352 CSC institutional staff members who worked with individuals with mental
disorders. Among institutional staff, trainees were primarily CSC nurses. The training
was effective in improving community personnel’s mental health knowledge and selfperceived competency to work with offenders with mental disorders.
FINDING 11: Offenders referred to, and accepted for, CMHI services, including discharge
planning and community mental health specialist services, are receiving these services.
However, data regarding their termination from these services may not always be
consistently recorded in CMHI database.
FINDING 12: The number of CMHI service contracts and number of offenders receiving
services have increased over time. Contract services are being delivered in a timely
manner and few offenders referred for services were waitlisted or not provided with
the services.
FINDING 13: Community capacity building efforts have increased over time and servicebuilding contacts have generally focused on the areas of highest need or importance
according to CMHI referrals.
FINDING 14: Stakeholders generally reported enhanced continuity of care and services,
although some concern was reported regarding continuity of care after warrant
expiry.
FINDING 15: Stakeholders generally reported that the CMHI contributed to an improved
quality of life for offenders. However, the CMHI standardized assessment of quality
of life was not administered to offenders per CMHI guidelines. As a result, findings
pertaining to this assessment were inconclusive due to small sample sizes.
FINDING 16: The majority of offenders received either clinical discharge planning (CDP)
or community mental health specialist (CMHS) services, but not both. Offenders
receiving CMHS services were less likely to be suspended or revoked than the
comparison group, after statistically controlling for pre-existing group differences.
There was no evidence to suggest that the CDP group differed from the comparison
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group with respect to these outcomes. These preliminary findings should be
interpreted with caution due to small sample sizes and short follow-up times.
Objective 4: Cost-Effectiveness
FINDING 17: Although the CMHI has demonstrated several positive short-term outcomes,
limitations related to financial coding and the short implementation period precluded
the ability to conduct a reliable cost-effectiveness analysis at this stage of the CMHI.
Recommendations
RECOMMENDATION 1: To sustain and enhance mental health services provided in the
community, CSC should support the implementation of mental health services
through the development of a strategic staffing process and recruitment campaign.
RECOMMENDATION 2: Procedures or processes to improve early identification of
offenders’ mental disorder and treatment needs should be explored in order to enable
accurate identification of offenders with mental health needs, to better facilitate
treatment referrals, and to establish continuity of care from an earlier stage.
RECOMMENDATION 3CSC should explore and develop mechanisms to increase
information-sharing across institutional and community mental health and case
management teams.
RECOMMENDATION 4: Several sites that are not presently included in the CMHI that
have large proportions of offenders with mental health needs should be considered for
CMHI services, through reallocation or expansion of CMHI services.
RECOMMENDATION 5: CSC should ensure accurate, standardized coding of CMHI
expenditures in financial databases to ensure that expenditures are adequately
recorded and monitored and so the cost-effectiveness of the CMHI can be adequately
assessed at some future time.
RECOMMENDATION 6: Additional mental health training should be provided to
institutional staff members, including parole officers and other case management team
members in order to assist in identifying OMDs and providing early referrals for
CMHI services.
RECOMMENDATION 7: Offenders accepted for CMHI services should be tracked to
ensure that treatment has been provided and to monitor the length of time that
offenders receive services
RECOMMENDATION 8: CSC should continue to support and enhance the level of
services available to offenders with mental disorders in the community. Further, CSC
should explore the development of additional partnerships/links with organizations
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(such as provincial governments and non-governmental organizations) to facilitate
continuity of care following warrant expiry.
RECOMMENDATION 9: CSC should review the Quality of Life Scale administration
guidelines to ensure that guidelines for administration are practical and develop
procedures to ensure that CMHI staff engage offenders in completing the assessment
of quality of life as per the guidelines.
RECOMMENDATION 10: CSC should review the possible reasons for lack of continuity
from CDP services to CMHS services. Based on this review, CSC should develop
strategies and procedures to better impact community reintegration for CDP
offenders.
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Table of Contents
ACKNOWLEDGEMENTS ....................................................................................................... III
EVALUATION TEAM MEMBERS ......................................................................................... IV
EXECUTIVE SUMMARY ........................................................................................................ VI
TABLE OF CONTENTS ......................................................................................................... XII
LIST OF TABLES ................................................................................................................... XIV
LIST OF FIGURES ................................................................................................................. XVI
LIST OF APPENDICES ....................................................................................................... XVII
ACRONYMS ......................................................................................................................... XVIII
INTRODUCTION......................................................................................................................... 1
Background – Mental Health: A Global Perspective ................................................................ 1
The Federal and Provincial Perspective ..................................................................................... 3
CSC Policy and Legislation .......................................................................................................... 4
The Community Mental Health Initiative (CMHI) ................................................................... 5
Discharge Planning .............................................................................................................. 6
Community Mental Health Specialists ................................................................................ 7
Community Partnerships through Contract Services........................................................... 7
Mental Health Training for Community Correctional Staff ................................................ 7
Governance Structure .................................................................................................................. 9
CMHI Financial Budget and Expenditures.............................................................................. 10
EVALUATION STRATEGY .................................................................................................... 13
Evaluation Goals ......................................................................................................................... 13
Logic Model ................................................................................................................................. 13
Measures and Procedure ............................................................................................................ 14
Financial Data .................................................................................................................... 14
Key Informant Interviews and Surveys ............................................................................. 14
Automated Data Sources ................................................................................................... 15
Measures ............................................................................................................................ 16
Analysis ............................................................................................................................. 19
Limitations ................................................................................................................................... 20
Sample .......................................................................................................................................... 23
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KEY FINDINGS ......................................................................................................................... 30
Evaluation Objective 1: Relevance ............................................................................................ 30
Government and Departmental Priorities .......................................................................... 30
Need for Services to Address Mental Health Needs of Offenders .................................... 32
Consistency with Other Jurisdictional Practices ............................................................... 34
Evaluation Objective 2: Implementation .................................................................................. 36
CMHI Implementation and Staffing .................................................................................. 36
CMHI Referrals ................................................................................................................. 47
Coordination and Information Sharing .............................................................................. 52
Location of CMHI Sites .................................................................................................... 54
CMHI Budget and Expenditures ....................................................................................... 71
Evaluation Objective 3: Success ................................................................................................ 76
Impact of Community Mental Health Training ................................................................. 76
Receipt of DPS and CMHS Services ................................................................................. 80
Community-Based Contract Services ................................................................................ 83
Community Capacity Building .......................................................................................... 86
Continuity of Services ....................................................................................................... 89
Offender Quality of Life .................................................................................................... 93
Impact of CMHI on Reintegration to the Community ...................................................... 95
Evaluation Objective 4: Cost-Effectiveness ............................................................................ 101
REFERENCES .......................................................................................................................... 106
APPENDICES ........................................................................................................................... 111
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List of Tables
Table 1: Total Resources and Costs per Year (in Thousands) ............................................... 11
Table 2: Funding for CMHI....................................................................................................... 12
Table 3: Salary and Operating Expenditures by Region for Fiscal Years 2005/06, 2006/07,
2007/08 ................................................................................................................................. 12
Table 4: Demographic, Criminal History, Risk Variables and Security Level at Release for
the CDP, CMHS and CMHI Comparison Groups .......................................................... 25
Table 5: Types of Mental Disorders, Functional Impairment, and Substance Abuse for the
CDP, CMHS and CMHI Comparison Groups ................................................................ 27
Table 6: Staff Respondent Position Titles ................................................................................. 28
Table 7: CMHI Sites Selected in Each Region ......................................................................... 38
Table 8: Regional Implementation Timelines and Staff Survey Results ............................... 46
Table 9: Clinical Discharge Planning and Community Mental Health Specialist Referrals
and Acceptance Region ...................................................................................................... 50
Table 10: Implementation Challenges with respect to CDP and CMHS............................... 53
Table 11: Percentage of Offenders with Women and Aboriginal Sub-population Offenders
with Current Mental Disorder by Region ........................................................................ 54
Table 12: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Atlantic Region ............................................. 56
Table 13: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Quebec Region .............................................. 59
Table 14: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Ontario Region ............................................. 62
Table 15: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Prairies Region ............................................. 65
Table 16: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Pacific Region ............................................... 68
Table 17: Re-profiling of CMHI Funding (in thousands) ....................................................... 71
Table 18: Budgeted and Actual CMHI Spending for All Canada (in thousands) ................ 72
Table 19: Number of community personnel who received the national mental health
training packages ................................................................................................................ 77
Table 20: Average Pre- and Post-Training Mental Health Quiz Scores................................ 78
Table 21: Self-Perceived Competence in Working with Offenders with Mental Disorders:
Results from the CSC Staff survey .................................................................................... 80
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Table 22: Total CDP Accepted Referrals by Region, Race, and Gender .............................. 81
Table 23: Total CMHS Accepted Referrals by Region, Race, and Gender........................... 82
Table 24: Community Contracted Services and Utilization ................................................... 84
Table 25: National Community Capacity Building for CDP and CMHS Services by
Quarter ............................................................................................................................... 87
Table 26: Offender Perception of the Continuity of Services as Rated Using the Alberta
Continuity of Services Scale for Mental Health ............................................................... 90
Table 27: Quality of Life Scores for the CMHS Group within the First Month of Release 93
Table 28: Release Types for the CDP, CMHS, and CMHI Comparison Groups ................. 96
Table 29: National CMHI Operating and Salary Costs for 2007/08 .................................... 103
Table 30: Cost-Savings Analyses for CMHS Participants .................................................... 105
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List of Figures
Figure 1: Correctional Service Canada’s Community Mental Health Initiative.................... 9
Figure 2: Governance Structure of the CMHI ......................................................................... 10
Figure 3: Reintegration Needs of Offenders Interviewed for the Evaluation ....................... 34
Figure 4: Overview of CMHI Implementation ........................................................................ 39
Figure 5: Atlantic Region CMHI Implementation Timeline .................................................. 41
Figure 6: Quebec Region CMHI Implementation Timeline .................................................. 42
Figure 7: Ontario Region CMHI Implementation Timeline................................................... 43
Figure 8: Prairie Region CMHI Implementation Timeline .................................................... 44
Figure 9: Pacific Region CMHI Implementation Timeline..................................................... 45
Figure 10: Perceptions of Clarity of CDP Referral Criteria by Perceptions of CDP Referral
.............................................................................................................................................. 48
Figure 11: Offenders with Identified Mental Health Needs in Atlantic Region Offices ...... 57
Figure 12: Offenders Receiving CMHI Services in Atlantic Region Offices ......................... 58
Figure 13: Offenders with Identified Mental Health Needs in Quebec Region Offices ....... 60
Figure 14: Offenders Receiving CMHI Services in Quebec Region Offices ......................... 61
Figure 15: Offenders with Identified Mental Health Needs in Ontario Region Offices ....... 63
Figure 16: Offenders Receiving CMHI Services in Ontario Region Offices ......................... 64
Figure 17: Offenders with Identified Mental Health Needs in Prairies Region Offices ....... 66
Figure 18: Offenders Receiving CMHI Services in Prairies Region Offices ......................... 67
Figure 19: Offenders with Identified Mental Health Needs in Pacific Region Offices ......... 69
Figure 20: Offenders Receiving CMHI Services in Pacific Region Offices ........................... 70
Figure 21: CMHI National Expenditures (Operating and Salary) for 2007/08 .................... 73
Figure 22: CMHI Expenditures by Cost Centre and Region for 2007/08 ............................. 74
Figure 23: Percentage of CMHI Accepted Offenders Identified with Anticipated Discharge
Needs at Referral ................................................................................................................ 88
Figure 24: Suspension and Revocation Rates for CDP, CMHS, and Comparison Groups at
the 6-Month Follow-Up ...................................................................................................... 97
Figure 25: Survival Function for the CDP, CMHS, and Comparison Groups (Suspensions)
.............................................................................................................................................. 99
Figure 26: Survival Function for the CDP, CMHS, and Comparison Groups (Revocations)
............................................................................................................................................ 100
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List of Appendices
Appendix A: Community Mental Health Initiative Evaluation Matrix .............................. 112
Appendix B: CSC's Community Mental Health Initiative Logic Model ............................. 118
Appendix C: Themes from Open-Ended Questions Survey and Interview Questions ...... 119
Appendix D: Referral Profiles from RPC Implementation Report #2 ................................ 130
Appendix E: Mental Health Training and Results ................................................................ 136
Appendix F: Recidivism - Additional Data and Analyses ..................................................... 138
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Acronyms
ACSS-MH
ACT
CDP
CSW
CD
CCC
CMHI
CMHS
CRF
CS
CPPR
CSC
CCRA
DPR
HS
IMRS
IPO
LFI
MH
MHCC
MOU
OIA
OMD
OMS
PO
QoL
RPC
RPP
UN
WED
WHO
Alberta Continuity of Service Scale for Mental Health
Assertive Community Treatment
Clinical Discharge Planner
Clinical Social Worker
Commissioner’s Directive
Community Correctional Centre
Community Mental Health Initiative
Community Mental Health Specialist
Community Residential fFcility
Community Strategy
Correctional Plan Progress Report
Correctional Service Canada
Corrections and Conditional Release Act
Departmental Performance Report
Health Services
Integrated Management Reporting System
Institutional Parole Officer
Level of Functional Impairment
Mental Health
Mental Health Commission of Canada
Memorandum of Understanding
Offender Intake Assessment
Offenders with Mental Disorders
Offender Management System
Parole Office
Quality of Life Scale
Regional Psychiatric Center
Report on Plans and Priorities
United Nations
Warrant Expiry Date
World Health Organization
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Introduction
Background – Mental Health: A Global Perspective
In 2001, the World Health Organization (WHO) estimated that roughly 450 million
people worldwide had a neuropsychiatric disorder, with depression being the most common, and
the number of people with some form of mental illness was projected to increase dramatically.
Despite the WHO’s high estimate of the prevalence of mental illness worldwide, there is a
general lack of mental health policies, programs, and community care worldwide (WHO, 2005a).
The impact of mental illness is far-reaching, and has many immediate and long-term effects, both
economic and social. For example, depression is considered to be the fourth leading cause of
disability adjusted life years lost and is projected to become the second leading cause of
disability worldwide by 2020 (WHO, 2001).
The stigma surrounding mental illness also continues to be a problem worldwide. The
stigma or discrimination related to mental illness prevents some people from seeking help
(Saxena, Thornicroft, Knapp & Whitefoot, 2007). However, there is some research that suggests
that social networks and family support may be beneficial to those with mental illness (Hamid,
Abanilla, Bauta & Huang, 2008).
In its World Health Report, the WHO (2001) made 10 key recommendations to all
countries for improving mental health and mental health care. Of these, a few are of particular
interest for CSC’s Community Mental Health Initiative:
•
Provide care in the community;
•
Involve communities, families and consumers;
•
Establish national policies, programmes and legislation; and,
•
Link with other sectors, such as non-governmental organizations
The WHO emphasizes the need for countries to have national mental health legislation,
which is important to prevent human rights abuses (including discrimination), to uphold basic
human and legal rights and to provide access to appropriate mental health care (WHO, 2005b).
However, according to the WHO, 25% of countries do not have any national mental health
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legislation (WHO, 2003). While this should be a concern for all aspects of society, it is also a
major issue for offenders with mental illness, including people with mental disorders who are
incarcerated as an alternative to receiving treatment in the community or in mental health
facilities (WHO, 2005b).
The large numbers of individuals with mental disorders incarcerated in prisons is a byproduct of, among other things, the unavailability or reduced availability of public mental health
facilities, the implementation of laws criminalizing nuisance behaviour, the widespread
misconception that all people with mental disorders are dangerous, and the intolerance in society
toward difficult or disturbing behaviour (WHO, 2005b). Furthermore, some countries lack legal
traditions that promote treatment (as opposed to punishment) for offenders with mental
disorders.
The United Nations (UN) has provided standards for mental health care generally, and for
the mental health care treatment of offenders in particular. The UN (1966) outlines the right to
the highest attainable standard of physical and mental health, which is a crucial right that is part
of the International Bill of Human Rights.
UN documents (1977, 1988, 1990a, 1991) outline offenders’ rights to mental and
physical health care, whether they are in custody or in the community. Some of the factors
emphasized by the UN include the need to treat people with mental disorders in the community
whenever possible, a focus on reintegrating offenders back into the community, and the need to
involve organizations beyond those directly involved in the criminal justice system, such as
NGOs or other government agencies.
The UN (1977, 1988, 1990a, 1990b, 1991) also provides guidelines for the treatment of
offenders. For example, persons with mental disorders or illness should both live in the
community and be treated in the community. In addition, reintegration plans need to be started at
the beginning of the offender’s sentence, and psychiatric or psychosocial treatment should
continue after release (UN, 1977). The UN (1977, 1990a, 1990b) suggests that community
reintegration should involve governments, communities, social institutions, and other appropriate
agencies in the reintegration of offenders.
2
The Federal and Provincial Perspective
The federal government has increased support for mental health intervention in the past
several years. The 2007 Speech from the Throne emphasized the need for “respect and dignity
for people with mental illness” (Government of Canada, 2007a). The 2007 and 2008 budgets
have shown an increasing commitment to mental health and assisting those with mental illness.
As a result of the recommendations made in the report Out of the Shadows at Last, the federal
budget in 2007 established the Mental Health Commission of Canada (MHCC), and committed
$15 million a year to this Commission, starting in 2009/10 (Department of Finance, 2007). In
2008, the federal government contributed another $110 million to the MHCC for projects on
mental health and homelessness (Department of Finance, 2008). At this time, the MHCC has
many key initiatives and committees underway, including a research project examining
homelessness, an anti-stigma campaign, and an advisory committee on mental health and the law
(Mental Health Commission of Canada [MHCC], 2008).
According to a report describing expenditures on mental health and addictions for
Canadian provinces for 2003/04, a total of $6.6 billion was spent on mental health from both the
public and private sectors (Jacobs et al., 2008). Canadian public mental health spending is lower
than most developed countries and is below the minimum acceptable amount, which is 5% of
health expenditures according to the Mental Health Commission Report in Europe. The national
average for mental health spending is $172.00 per person, per year (Jacobs et al., 2008) with
Saskatchewan, Newfoundland, Labrador, and Ontario spending the lowest per capita amounts for
mental health care among the provinces.
In keeping with the federal government’s increased spending on mental health initiatives,
most provinces have funded programs and initiatives related to mental health or mental illness in
their 2007 or 2008 budgets. Provincially-funded services have included, but are not limited to:
addictions centres (Ontario, Newfoundland & Labrador); mental health emergency rooms
(Manitoba); increasing the number of mental health and residential treatment beds (Alberta);
creation of mental health courts (Alberta and Nova Scotia); enhancement of community-focused
services (Nova Scotia & New Brunswick); and enhanced legal aid services for those who appear
before the court under the Mental Health Act (Newfoundland and Labrador; Boudreau, 2008;
Government of Newfoundland and Labrador, 2008; Province of Alberta, 2008; Province of
Manitoba, 2008; Province of Nova Scotia, 2008; Province of Ontario, 2008).
3
CSC Policy and Legislation
CSC is mandated by law to provide every inmate with:
a) essential health care; and,
b) reasonable access to non-essential mental health care that will contribute to the inmate’s
rehabilitation and successful reintegration into the community (Corrections and
Conditional Release Act [CCRA], 1992, s. 86[1]).
In addition to the CCRA, Commissioner’s Directive (CD) 850: Mental Health Services
provides a policy framework within which CSC provides mental health services to offenders.
The objective of the policy is to ensure that offenders have appropriate access to professional
mental health services. These services are expected to contribute to the improvement and
maintenance of inmates’ mental health and adjustment to incarceration and assist them in
becoming law-abiding citizens (CSC, 2002). Mental health services and programs for inmates
shall provide a continuum of essential care for those suffering from mental, emotional, or
behavioural disorders, consistent with professional and community standards (CSC, 2002).
Health care in Canada is typically the responsibility of the provincial/territorial
governments. However, offenders residing in federal penitentiaries are the financial
responsibility of the federal government (i.e., CSC). Once the offender is released to the
community, government responsibility depends upon where the offender is released (CSC,
2008a). Offenders on full parole, statutory release and day parole who are residing in a
Community Residential Centre (e.g., half-way houses), receive essential health services paid by
the applicable provincial health care plan. CSC is still responsible for providing essential health
services for offenders residing in Community Correctional Centres (CCC). The policy also states
that CSC is responsible for other non-insured health care expenses for offenders residing in
Community Correctional Centres or Community Residential Centres who are unemployed and
have no other source of income and who are otherwise ineligible for all other forms of
government/community assistance (CSC, 2008a).
CSC has implemented a strategy to ensure a continuum of mental health services to
federal offenders from institutional intake to release into the community. This approach focuses
on: (1) intake screening and assessment; (2) primary care; (3) intermediate care; (4) intensive
4
care (at Regional Treatment Centres); and (5) transitional care. In 2005, following submission to
Treasury Board, funding was allocated to implement the Community Mental Health Initiative
(which had been referred to previously as the Substantive Support Initiative as well as the
Community Mental Health Strategy in some CSC documents), The Community Mental Health
Initiative (CMHI) falls under the fifth transitional component of the overall Mental Health
Strategy (i.e., transitional care).
The Community Mental Health Initiative (CMHI)
In May 2005, funding was approved for the Strengthening Community Safety Initiative,
of which the CMHI was a part. The Strengthening Community Safety Initiative included three
new programs or activities for CSC, including: (1) the subject of the current evaluation - the
CMHI; (2) the Integrated Police and Parole Initiative (designed to enhance information sharing
to allow for the earlier apprehension of offenders who are unlawfully at large and to provide
more effective supervision and intervention with higher-risk offenders); and (3) the provision of
expanded information to victims (to be provided within existing CSC resources). The initiative
also included funding for several activities in other departments, related primarily to the
provision of additional services for victims and offenders with mental health needs. Other
departments that also received funding through the Initiative included: National Parole Board,
Office of the Correctional Investigator, Department of Justice, and Department of Public Safety. 1
The CMHI was designed to aid offenders with serious mental disorders (OMDs) to
reintegrate into the community by providing care through clinical discharge planning, support
from mental health professionals in the community, training of CSC and mental health resource
staff in the community, and assisting OMDs to access specialized services such as psychiatric
care. These services are provided in conjunction with existing case management and community
resources to maintain a high level of continuity of care for OMDs discharged to the community.
CMHI services from mental health specialists are targeted towards offenders with major
mental disorders (i.e., schizophrenia and other psychotic disorders, mood disorders, and other
psychiatric disorders) or personality disorders (excluding antisocial personality disorder) causing
significant impairment of functioning. Offenders with moderate to severe impairment due to
acquired brain injury, organic brain dysfunction, developmental disability, or intellectual
1
Formerly called the Department of Public Safety and Emergency Preparedness (PSEP)
5
impairment also qualify for these services (Champagne, Turgeon, Felizardo & Lutz, 2008). The
CMHI was intended to improve correctional results and enhance quality of life for OMDs. The
initiative was implemented in 2005 and has four key components (discharge planning,
community mental health specialist services, contracts with commnity service providers, and
staff training) each of which are discussed in greater detail next.
Discharge Planning
Clinical discharge planning (CDP) is the transitional service that supports OMDs being
released from the institution to the community. The discharge plan is designed to identify
transitional needs of OMDs prior to their release into the community in an effort to promote a
sense of stability for offenders who are particularly vulnerable at this time. The primary goal of
clinical discharge planning services is to ensure the continuity of mental health care for released
offenders (Champagne et al., 2008). The clinical discharge planner works collaboratively with
the offender to assess his/her psychosocial needs, to identify required community resources, and
to establish links between the offender and these resources. Offenders who meet the eligibility
criteria are referred by the institutional parole officer to clinical social workers (CSW) for CDP
services nine-months prior to their expected release date.
The referral criteria for clinical discharge planning services are:
•
Major mental disorders
o Schizophrenia and other psychotic disorders
o Mood disorders (e.g., major depression, bipolar disorder)
o Other disorders (e.g., obsessive-compulsive disorder)
•
Moderate to severe impairment from:
o Personality disorder excluding antisocial personality disorder (e.g., paranoid,
borderline, schizoid)
o Acquired brain injury or organic brain dysfunction (e.g., FASD)
o Developmental disability or intellectual impairment
6
Following a referral by the institutional parole officer, the clinical discharge planner
reviews the referral, including a review of the offender’s file to determine whether or not the
offender will be accepted for CDP services based on the above-indicated criteria.
Community Mental Health Specialists
The focus of community mental health services is to ensure continuity of care for OMDs
under federal supervision in the community. The key services offered by Community Mental
Health Specialists (CMHS) are: comprehensive assessment and intervention planning; direct
service provision; advocacy; coordination and support; implementation, monitoring and
evaluation; and community capacity building. The CMHS (either a clinical social worker or a
community mental health nurse) works with the offender’s parole officer, community services,
and support workers to further enhance integrated offender management. They also work toward
removing barriers to service delivery and contribute to community capacity building.
Collaborative efforts strive toward achieving successful community integration through
promotion of public safety and enhancement of OMDs’ quality of life. The offender referral
criteria for CMHS services are the same as for the discharge planning services (see above).
Community Partnerships through Contract Services
A key principle of the delivery of mental health services is the development of links or
working relationships between CSC and non-CSC organizations that will provide OMDs with
necessary support and resources after release (Champagne et al., 2008). Contracts for services
are arranged by the regions, and are not limited to the 16 existing CMHI sites, thus expanding
the breadth of the initiative to include CMHI services in additional areas beyond the 16 CMHI
sites. Services range in nature but are frequently provided by psychiatrists, psychologists,
community service agencies providing bed space for offenders to reside at their facilities, and
personal aid workers assisting with daily functioning needs and socialization.
Mental Health Training for Community Correctional Staff
The fourth component of the CMHI is mental health training. The objective is to provide
“mental health training to correctional services, halfway house staff, parole offices and
7
community partners targeted to receive new community mental health positions” (Champagne et
al., 2008, p. 3). Mental health training is coordinated by NHQ. National trainers are responsible
for ensuring quality assurance and standardized delivery of the package nationwide and
developing regional training capacity through the delivery of Train the Trainers sessions and cofacilitation. The national trainer provides training on the national training package to the CSWs
and community mental health nurses, who in turn deliver the training locally. The training
package covers nine modules over a 2 day period. These modules are: Introduction; Myths and
Realities; What is Mental Disorder; Mental Disorders; Fetal Alcohol Spectrum Disorder
(FASD); Risk and Mental Disorder; Effective Strategies; Resources; and Legislation. There are
three forms of training packages: (1) a 2-day generic training which was delivered to all staff
who work with OMDs; (2) a train the trainer (TtT) session package which is a 5 day training
package that includes the 2 day generic training; and (3) a package specifically for women
offenders which puts a greater focus on dialectical behaviour therapy, personality disorder
(namely, borderline personality disorder), and the Mental Health Strategy for Women Offenders.
The CMHI is summarized schematically, and services that are newly implemented and
others that are enhanced as part of the CMHI are identified in Figure 1 (Champagne et al., 2008,
p. 4)
8
Figure 1: Correctional Service Canada’s Community Mental Health Initiative
Discharge Planner
Discharge Planner
In Treatment Centres
For Institutions
Transitional Care
Other Parole Offices
•
•
16 Parole/Area Offices
•
Funds for specialized
mental health
services/contracts
Training opportunities
•
•
New service
New service for some regions,
CCCs
enhanced for others
CRFs
Mental health
specialists (social
worker/nurse)
Mental health training
Funds for specialized
mental health
services/contracts
Healing
Other
Lodges
OMDs
living in
community
Governance Structure
The governance of the CMHI falls within the responsibilities of the Assistant
Commissioner, Health Services. Regionally, the initiative is managed through the Regional
Director, Health Services, and the Regional Coordinator of the CMHI. The front-line staff
dedicated to the initiative (Community Clinical Social Worker, Clinical Social Worker –
Discharge Planner in the institution, and Community Mental Health Nurse) fall under the direct
supervision of the Regional Coordinator, CMHI. There may also be accountability to the
Assistant Warden, Intervention, the Community Correctional Centre Director, or the Area
9
Director for some front-line staff, depending on their work location. The governance structure
for the CMHI is presented in Figure 2.
Figure 2: Governance Structure of the CMHI
Assistant Commissioner, Health Services
Regional Director, Health Services
Regional Coordinator, CMHI
Community Mental Health Staff
(Clinical Discharge Planner & Community
Mental Health Specialists)
CMHI Financial Budget and Expenditures
In May 2005, $29.1 million over a five year period for the CMHI was approved, the
majority of which ($15.3 million) was designated to pay the salaries for 47 full-time CMHI
positions,2 including 8 discharge planners, 6 ambulatory care team members, 30 community
mental health team members, 2 mental health trainers, 1 contract management individual, and 1
evaluation coordinator. Operating costs for the initiative totalled to $7.8 million, and the
remaining funds (approximately $6 million) were designated for common services, employee
benefit plans, and accommodations (see Table 1).
2
See the Results-based Management and Accountability Framework (RMAF) in Annex F of the Treasury Board
Submission (2005)
10
Table 1: Total Resources and Costs per Year (in Thousands)
FTEs
Salary
Operating
Common Services
EBP
Accommodation
Total allocation
2005/06
47
1,792
930
107
358
233
3,420
2006/07
47
3,380
1,725
198
677
440
6,420
2007/08
47
3,388
1,715
198
678
441
6,420
2008/09
47
3,388
1,715
198
678
441
6,420
2009/10
47
3,381
1,725
198
676
440
6,420
Total
15,329
7,810
899
3,067
1,995
29,100
Although funding for the initiative was approved in May 2005, funding for the first year
of the initiative was not received until December 2005. 3 In addition, implementation challenges
resulted in significant delays staffing the CHMI positions. Given these issues, CSC sought to reprofile $2 million from 2005/06 to 2006/07. In September 2006, CSC reported that delays in
CMHI staffing (including the scarcity of health professionals) was expected to result in
additional lapses. Therefore, CSC initiated a request to re-profile an additional $3.3 million, of
which $1.1 million was to be carried forward each year for the fiscal years 2007/08 to 2009/10
(see Table 2). At this time, CSC also initiated some changes to the structure of the initiative.
Specifically, ambulatory services and discharge planning were merged together as an integrated
service in order to emphasize the discharge planning function and the transition of the offender
from an institution or treatment centre to the community. Six additional CMHI positions were
created to provide overall management and coordination (five Regional Coordinators and a
National Coordinator). In total, 51.5 FTEs were designated for the CMHI.
On February 12, 2007, another request for re-profiling was submitted and approved, in
which an additional $2 million from 2006/07 was added to the original carry-forward plan, to be
distributed over the next three fiscal years as shown in Table 2. In total, after all three re-profiles
of funds, a little more than $1.5 million was re-profiled to the CMHI budgets for each of the
fiscal years 2007/08, 2008/09, and 2009/10 (i.e., from the original budgets of $6.4 million, the
budgets increased to just over $8 million for each of the final 3 years of the initiative).
3
The reason funds for the CMHI were released later then originally anticipated was because this was a new
Initiative and the funds were to be released through Supplementary Estimates A, which were planned to be tabled to
Parliament in September-October 2005. However, the Government was defeated in late 2005 and a general election
was called for January 2006. The Treasury Board decision letter indicated that departments would have to manage
the risks associated with any spending that occurred in advance of Parliamentary approval.
11
Table 2: Funding for CMHI
Budget ($000)
2005/06
2006/07
2007/08
2008/09
2009/10
Total
Original Budget
3,420
6,420
6,420
6,420
6,420
29,100
1st Re-profile
(2,000)
2,000
2nd Re-profile
(3,300)
1,100
1,100
1,100
3rd Re-profile
0
(1,989)
755
655
579
Total Revised Budget
1,420
3,131
8,275
8,175
8,099
29,100
Notes: Budget includes salary, operating, employee benefit plan, common services, and accommodation. Values
presented in the parentheses represent funds carried forward from the year of interest.
Overall expenditures for each of the regions for the fiscal years 2005/06, 2006/07, and
2007/08 are shown in Table 3. Major areas of expenditures included: (1) discharge planning
services; (2) community mental health specialists; (3) mental health training; (4) regional mental
health contracts (5) adjunctive services; (6) valuation and research; and (7) management and
coordination. Expenditures have increased from approximately $500,000 in 2005/06 to just over
$3 million in salary and operating costs in 2007/08 when most of the regions were fully staffed
and began accepting referrals. Expenditures were somewhat greater in the Prairie Region which
was staffed and implemented earlier than the remaining regions.
Table 3: Salary and Operating Expenditures by Region for Fiscal Years 2005/06, 2006/07,
2007/08
2005/06
2006/07
2007/08
Region
Salary
Operating
Salary
Operating
Salary
Operating
Atlantic
67,842
29,563
180,479
141,485
551,468
374,331
Quebec
25,827
3,961
188,181
44,002
102,997
110,682
Ontario
0
3,205
30,642
29,786
2,048
76,092
Prairies
10,608
18,829
202,746
179,710
749,266
434,037
Pacific
65,968
15,212
288,514
240,122
281,930
332,389
NHQ
177,772
136,378
194,461
59,004
204,501
13
Total
348,016
207,148
1,085,023
694,110
1,892,212
1,327,544
Note that these figures include operating and salary costs only. Employee benefit plans, accommodations, and
common services were not included.
Source: Comptroller’s Branch
12
Evaluation Strategy
Evaluation Goals
The goal of the evaluation was to provide information required to make investment
decisions in the area of community mental health beyond the expiry date of the funding at the
end of March 2009/10. The continued relevance, success, cost-effectiveness, unintended
outcomes, and implementation issues associated with the initiative were assessed. Note that
implementation of the initiative was delayed due to difficulties staffing CMHI positions.
Therefore, the evaluation was implementation focused. However, the success of the initiative as
it related to achievement of immediate and intermediate outcomes were assessed where possible
given the state of implementation and the availability of reliable data. The comprehensive
evaluation matrix is shown in Appendix A, identifying the CMHI evaluation questions,
performance indicators, and sources.
Logic Model
The Logic Model for the CMHI is shown in Appendix B. As described earlier, the CMHI
includes four main activities, namely: staff training, the provision of community mental health
specialist services, clinical discharge planning, and establishment of community service
partnerships through contracts.
Immediate outcomes of the CMHI include:
•
Increased staff awareness of mental health issues;
•
Standardized provision of services;
•
Offender access to available services; and
•
Increased availability of services and support for offenders with mental disorders being
released and in the community.
Intermediate outcomes of the CMHI include:
•
Improved services for offenders with mental disorders;
•
Improved correctional outcomes for offenders with mental disorders; and
13
•
Improved quality of life for offenders with mental disorders.
Ultimately, the goal of the CMHI is to contribute to the safe accommodation and
reintegration of eligible offenders into Canadian communities by providing them with reasonable
access to mental health care.
The extent to which these outcomes have been achieved will be explored further in the
evaluation results.
Measures and Procedure
A multi-method approach incorporating qualitative and quantitative methodology was
utilized to address the evaluation objectives. This included a review of program documentation
and reports (e.g., CMHI Guidelines), financial data, surveys and interviews with key informants,
and offender data extracted from the Offender Management System (OMS) and CMHI-specific
databases maintained by Regional Psychiatric Centre Prairies (RPC) and the Health Services
(HS) at NHQ.
Financial Data
Financial information was collected from the Integrated Management Reporting System
(IMRS). Representatives from the Comptrollers Branch provided a complete summary of CMHI
budgets, re-profiles in funding, and expenditures.
Key Informant Interviews and Surveys
Feedback regarding issues related to the relevance, implementation, and success of the
CMHI was obtained from three different key informant groups: (1) CSC staff; (2) offenders; and
(3) community service providers.
CSC Staff
An electronic survey was distributed through CSC internal email announcements (i.e.,
General Communication) to CSC staff members who had experience working with offenders
with mental disorders, including staff members who were directly involved with the CMHI as
14
well as others who were familiar with the CMHI. The survey was active for a period of 16 days
from August 25, 2008 to September 9, 2008. Informal contacts were also held with national and
regional CMHI personnel to establish implementation timelines and discuss implementation
challenges.
Offenders
Offender interviews were conducted at parole offices, CCCs, and institutions in each
region. The Evaluation Branch selected the site in each region that had the most CMHI offenders
currently under supervision. CMHS staff coordinated the offender interviews.
Community Service Providers
Surveys were conducted with community service providers, including agencies (e.g.,
John Howard Society, Stella Burry Community Services, etc.) and individuals (e.g.,
psychiatrists) under contract to provide services directly to offenders through CMHI. These
agencies were identified through bi-annual reports submitted to HS that also contained service
providers’ contact information. Where contact information was missing or out of date, agencies
were contacted directly for an update. The original list of community service providers consisted
of 42 independent agencies/organizations. Of these, 35 were contacted, and 7 were unreachable
for a variety of reasons (e.g., invalid email addresses). The surveys were sent through email to
the identified contact person at each agency, who was asked to complete the survey and to send it
to any colleagues within their agency who had direct knowledge of the CMHI. A follow-up
email was sent as a reminder to complete the survey, and also informed respondents that should
they have difficulty accessing the survey in the email, alternate arrangements were available.
Automated Data Sources
Finally, offender information (such as offender risk, need, demographic characteristics,
correctional outcomes, time spent in the community, and other pertinent information) was
extracted from the Offender Management System (OMS; automated database maintained by
CSC) and other databases created and maintained by Health Services at National Headquarters
and RPC. OMS is an electronic filing system designed to monitor and track offenders under the
15
supervision of the Correctional Service Canada. Data captured in OMS include the Offender
Intake Assessment (OIA), a comprehensive and integrated examination of offenders at the time
of their admission. The process begins with an assessment of immediate mental and physical
health concerns, security risk and suicide potential and offender risk factors and dynamic need
indicators. The OIA indicator “diagnosed as disordered currently” was used to identify those
offenders with mental health needs who were released to parole offices and CCCs across
Canada.
Measures
There were three assessment instruments used in the evaluation of the CMHI. The first
two, Alberta Continuity of Service Scale for Mental Health (ACSS-MH) and the Quality of Life
Scale (QoL) were intended to be administered directly to the offender in the course of their
treatment. Because very few ACSS-MH scales had been completed at the time of the evaluation,
the ACSS-MH questions were incorporated into the offender interviews. The third measure,
Level of Functional Impairment (LFI), was used for research purposes to rate the impairment of
both the treatment and comparison groups. A training questionnaire was also administered to
training participants.
Alberta Continuity of Services Scale for Mental Health (ACSS-MH)
The ACSS-MH (Adair et al., 2004) is a tool used to assess the service consumer’s (or in
this case, federal offenders participating in the CMHI initiative) perception of continuity of
services. The tool was adapted for use with CMHI participants (and certain questions were
omitted) so results may not be directly comparable to results reported in the literature. The
modified survey consisted of 40 items rated using a 5 point Likert scale from 1 (strongly
disagree) to 5 (strongly agree). The scale was administered by an interviewer during a face-toface interview by one of the evaluation staff members. Eighteen questions were worded
negatively, so reverse coding was necessary before summing the item scores to derive a total
score. The ACSS-MH is comprised of three subscales, namely system fragmentation (21 items),
relationship base (9 items), and responsive treatment (10 items). Questions focus on areas such
as service accessibility, service integration, individual or team mental health care providers, and
the overall satisfaction with the services received.
16
Quality of Life Scale (QoL)
The QoL was utilized to measure the overall quality of life of a client (Lehman, 1988).
Offenders were asked to complete 26 self-report questions from the scale. The questions were
answered on a 7-point scale ranging from “terrible” to “delighted” and focused on several key
areas including: general life satisfaction, living situation, daily activities, social relations, family,
finances, work, legal and safety issues, and health. According to CMHI guidelines, 4 the
questionnaire was to be administered to offenders at one-month, three-months, and six-months
after their receipt of community care. It can be administered by someone actively involved in
their care such as their clinical social worker or nurse (i.e., CMHS). Due to initial
implementation challenges, the QoL data were not collected on the majority of offenders. Data
were available at time 1 and time 2 (one and three months) for 36 offenders in the CMHS group.
Level of Functional Impairment (LFI)
The LFI scale was used as a research tool to assess treatment and comparison group
offenders’ degree of impairment in four areas including daily living/personal hygiene,
intellectual, occupational, and social/interpersonal functioning. OMS data were used to rate each
item on a four-point scale (0 – 3), with higher aggregate scores indicating greater impairment
(range of scale from 0 to 12). Total score ratings of 5 or greater constituted moderate to severe
functional impairment (CSC, 2008d). Inter-rater reliability was obtained on the LFI Rating Scale.
Five practice cases were rated, followed by 10 cases from the random sample. For the initial
10 cases, 8 out of 10 were consistently identified as being referred for services and an intra class
correlation of r = 0.34 for the overall functional impairment score. An additional 10 cases were
then rated. Of these 10 cases, 7 received the same referral decision from the raters and an intra
class correlation of r = 0.58 for the overall functional impairment score was obtained. Another 10
cases were rated and resulted in 8 out of 10 receiving the same referral decision and an
acceptable intra-class correlation (r = 0.86) overall (CSC, 2008d). The LFI was originally
designed to enable identification of a comparison group for outcome analysis in combination
4
Additional Measures for the Community Mental Health Initiative – Resource Manual.
17
with other indicators such as an Axis I diagnosis. Furthermore, LFI scores were used to provide
descriptive information about the treatment and comparison groups.
Training Evaluation Questionnaire
Participants were asked to complete a 15 item mental health training evaluation form, in
which 9 of the items asked participants to rate the usefulness of each of the nine modules of the
training program (i.e., introduction, myths and realities, what is a mental disorder, types of
mental disorders, cognitive disorders and FASD, risk and mental disorder, effective strategies,
resources, and legislative requirements) and another 3 asked the participants to rate the
usefulness of the participant resource manual, the trainer(s), and the overall training. These 12
items were rated on a 7 point scale from 1 (not useful) to 7 (very useful). Lastly, three openended questions were included to ask the participants to (1) provide suggestions for improvement
of the training; (2) identify topics that should be addressed in follow-up training sessions; and (3)
provide suggestions as to how the trainer could improve his/her delivery.
Mental Health Knowledge Quiz
Mental health training participants were asked to complete a 10 item mental health quiz
prior to and immediately following training. The quiz was comprised of multiple-choice and
true/false questions as well as fill-in-the-blank and open-ended questions. Topic areas addressed
in the quiz included (but was not limited to) mental health disorders, mental health symptoms,
treatments, side effects of psychotropic medications, and myths about OMDs.
Self-Perceived Competency Scale
The self-perceived competency scale is an 8-item scale designed to assess competencies
that were targeted by the training. Sample items were “I have knowledge to work effectively
with offenders with mental disorders” and “I have the skills to recognize symptoms suggestive of
the need for interventions by a mental health professional”. Each item was rated on a 7 point
scale from 1 (strongly disagree) to 4 (uncertain) to 7 (strongly agree). Participants of the mental
health training were asked to complete this scale prior to and immediately following training.
18
Analysis
Survey and Interview Data
Themes were generated from open-ended survey and interview questions, and were
compared across multiple team members to ensure agreement. Themes are presented in the
appropriate Key Findings sections below (and detailed in Appendix C). Key informant
interviews/survey questions were often asked on a 5-point Likert scale ranging from strongly
disagree to strongly agree (1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree;
4 = agree; and 5 = strongly agree). In general, interview/survey results were collapsed across the
agree and strongly agree categories to create an ‘agree’ category and the disagree and strongly
disagree categories were combined to create a ‘disagree’ category.
Geospatial Analysis
With the assistance of Public Safety Geomatics Division, evaluation team members
created two series of maps using ArcGIS software to provide a visual representation of the
locations of CMHI offices and the percentages of offenders who (a) were identified as having a
mental disorder at each supervising office in each region, and (b) who received CMHI services,
including CDP and CMHS services. The first set of maps identifies the percentage of offenders
at each site who are identified by the OIA indicator “diagnosed as disordered currently” while
the second set of map presents the proportion of offenders who received CDP and CMHS
services. For both series of maps, the symbology identifies the type of office (Parole Office or
CCC) and the presence or absence of CMHI services at each office.
Health Services (HS) Mental Health Training Summary Report
HS maintained databases on all issues related to mental health training as part of the
CMHI (e.g., attendance, training evaluation questionnaires, self-perceived competency scale,
mental health knowledge quiz) and produced a summary report on the outcomes of all of the 2
day training sessions delivered from January 2007 through June 2008. At the time when the
mental health training summary report was written, attendance records up to the end of 2007/08
were verified for accuracy against HRMS by HS staff for all CSC staff members. HS also
provided the evaluation team with access to their mental health training databases for additional
analyses reported in the present report.
19
Regional Psychiatric Centre (RPC) Data Analysis and Reports
RPC is under a Memorandum of Understanding (MOU) with NHQ Health Services to
manage CMHI data (e.g., referral and outcome data), and to provide a series of reports
documenting the pre-implementation, implementation and post-implementation milestones and
correctional outcomes at each stage of the initiative. According to the terms of the agreement,
RPC was expected to provide:
•
one pre-implementation report (documenting the establishment of the retrospective
comparison group);
•
five implementation reports (documenting the implementation of CMHI services for both
treatment groups); and,
•
two post-implementation reports (documenting the efficacy of CMHI in improving
correctional outcomes and enhancing the quality of life for OMDs). RPC has provided
some of the analyses included in the report and is cited as a source of these analyses
where applicable. 5
Limitations
There were several limitations that impacted upon the ability to examine the evaluation
objectives of CMHI, including the use of a historical comparison group, lengthy implementation
delays, an inability to identify offenders who may have dropped out or had their CMHI services
terminated shortly after accepting their referrals, the small number of offenders who received
both CDP and CMHS services to date, and the use of the OIA indicator as an index of CMHI
referral criteria.
The comparison group used for the effectiveness analysis was historical in nature. The
CMHI treatment recipients documented in the effectiveness analysis received treatment from
May to December 2007, but the comparison group was comprised of offenders eligible for
release between April 1st, 2003 and March 31, 2005. This was necessary to ensure no confounds
of the comparison group with respect to possible exposure to treatment through CMHI.
5
It should be noted that the first Post-implementation report was expected from RPC in March 2009. However,
when the deadline for evaluation completion was brought forward by six months, RPC agreed to provide an
additional Post-implementation report to be included in the evaluation
20
However, this adds a possible confound in that changes occurring over time might affect groups
differentially (i.e., cohort effect). As documented in other sections of the report, mental health
intervention is an increasing priority within the federal government and within CSC.
Enhancements to service availability and delivery in recent years in the institution may have had
an impact on the treatment groups, but not the comparison groups. This possible confound may
be limited as funding to begin to address elements of the institutional mental health strategy was
only provided in April 2007. However, there is no way to isolate the CMHI in relation to other
CSC initiatives occurring at the same time.
Lengthy delays in staffing positions resulted in delays in full implementation of the
initiative. As the national implementation timelines illustrate (see implementation section of the
report), there were many time consuming administrative tasks that took place prior to staffing
positions through competitive processes (e.g., creating job descriptions, classifying positions,
posting employment opportunities, running competitive process). Although the initiative was
announced in May 2005, the first offender referral for CMHI service was not made until two
years later in May 2007.
With a five-year initiative, implementation delays, and a requirement for an evaluation by
June 2009, there was a limited follow-up period to examine offenders’ progress in the
community. The effectiveness component of the evaluation included a potential follow-up time
for offenders of 6 to 13 months in the community (depending on when they began receiving
services). Descriptive data for CMHI offenders was provided through to June 2008. However,
the offender sample utilized for the outcome analysis (i.e., recidivism) included only offenders
referred for service from the beginning of the initiative (May 2007) until December 2007, in
order to allow for an adequate follow-up time in the community. Also, given the short period of
time in which the initiative was operational, the treatment groups are small (n = 53 for offenders
receiving discharge planning services; and n = 79 for offenders who have received community
mental health specialist services). Furthermore, treatment dosage should be considered as short
follow-ups (especially for CMHS participants) may limit the amount of CMHS service that can
be delivered. Given these reduced samples and very short follow-up times, it was difficult to
draw strong conclusions with the resulting data. Longer follow-up time and increased numbers
within each treatment group will be required to provide more reliable results. Also, it was hoped
that Aboriginal and women-specific correctional outcomes could be assessed. However, given
21
the small sample sizes, demographic information for these groups was reported but no further
analyses could be performed.
The treatment group dataset was generated with the receipt of a completed Referral for
Service form indicating that the offender was accepted for service. Once the CDP or CMHS staff
received a referral form from an offender’s parole officer, the hard copy was stored in the
offender’s file and an electronic copy was saved on the national network drive to be entered by
HS analysts. Receipt of this form indicating the offender was accepted for service marked the
offender as a treatment recipient. Acceptance to treatment was based on two criteria: (1)
presence of a major mental disorder, or (2) a moderate to severe impairment from a personality
disorder, acquired brain injury or organic brain dysfunction, or developmental disability or
intellectual impairment. The offender must have met the criteria and voluntarily agreed to
participate. If an offender was referred but refused to participate, the referral form would still be
submitted but the refusal decision noted and he or she would not be included as part of the
treatment group. However, if the offender received services that were later terminated (either by
the service provider or himself/herself), that information may not always have been consistently
recorded. Therefore, it is possible that offenders in the treatment group might not have received
treatment for any significant period of time and it was not possible to differentiate these
offenders from those who received more extensive treatment.
There were some offenders who received both CDP and CMHS services (n = 23; CSC,
2008c). It is unclear why this number was so low because ideally, continuity of service should be
provided from the institution through offender discharge planning, followed by CMHI services
provided by the CMHS team. Because the majority of CMHS offices are in large urban centres,
it was expected that more CDP recipients would have received CMHS services. Reasons for this
limited continuity of service may be related to implementation issues, in that offenders being
released to CMHI sites did not have adequate time to complete a CDP because the CDP service
was not yet operational in their releasing institution. Similarly, offenders who received CDP
services may have been released to sites that were not yet CMHS operational locations.
Because the group of offenders receiving both services was too small to analyse
independently, the offenders who received both CDP and CMHS services were included in both
treatment groups. Once the treatment group numbers increase, this group of offenders receiving
22
both services should be examined separately and in more detail to understand whether there is an
enhanced effect of receiving both services.
For the geo-mapping exercise, two sets of data are presented, one based on those who
received CMHI services and the other was a representation of offenders who have been
identified as having a mental health need in the community. Mental health needs were identified
using the OIA indicator “diagnosed as disordered currently”. The OIA indicator was used as a
proxy measure for those who met the CMHI referral criteria. The OIA indicator is not an entirely
accurate representation of those eligible for CMHI. First, the OIA indicator is based on offender
self-reported information and it is static (i.e., assessed only at intake, and is not updated during
the course of an offender’s sentence). In fact, a review of OMS data indicated that only 55% of
offenders who were accepted for CMHI services 6 had the OIA indicator “diagnosed as
disordered currently” on their OMS file, suggesting that not all offenders with serious mental
health needs were being identified utilizing this indicator. Second, the OIA indicator does not
take into account the referral criteria for the CMHI (described earlier, including the criteria of a
major mental disorder or severe impairment in one of several areas of mental functioning). Based
on a sample of CSC offenders with the OIA indicator selected for possible inclusion in the
CMHI outcome analysis comparison group, only 61% of those with the OIA indicator actually
met the CMHI referral criteria (CSC, 2008d).
Sample
Offenders Included in Quantitative Outcome Analysis
The sample included in the outcome (recidivism) analysis was comprised of three groups:
the clinical discharge planning recipients (CDP), the community mental health specialist service
recipients (CMHS), and a comparison group (CMHI Comparison; refer to Appendix D for
profiles of offenders referred for services). The two treatment groups (CDP and CMHS) included
all offenders who received services from the beginning of the initiative until December 2007, the
cut-off date that allowed for a potential 6-month community follow-up for the treatment groups.
The comparison group was generated by using a historical cohort of offenders who were
eligible for release between April 1st, 2003 and March 31, 2005, and who had the OIA indicator
6
This analysis was conducted for all offenders in the CMHI referral database who had been accepted for CMHI
services (CDP or CMHS) as of June 2008
23
“diagnosed as disordered currently” (CSC, 2008d). Those offenders who met the referral criteria
but did not receive services (because the CMHI had not been implemented at that time) became
the CMHI comparison group. The referral criteria for CMHI services include the presence of a
major mental disorder (e.g., schizophrenia, mood disorder) personality disorder (e.g., paranoid,
borderline, schizoid) with moderate to severe functional impairment or acquired brain
injury/organic brain dysfunction (e.g., FASD) or developmental disability/intellectual
impairment with moderate to severe impairment. Offenders with the OID indicator “diagnosed as
disordered currently” were identified and then rated using the LFI Scale to determine whether
they met the criteria. Those who did formed the CMHI comparison group and those who did not
were eliminated from further analyses.
Demographic and risk-related information is provided in Table 4. Overall, the majority
of offenders in the CDP, CMHS and CMHI comparison group were relatively young, male, and
had a low to moderate reintegration potential. However, some differences were observed
between the groups. Both the CDP and CMHS groups were significantly younger at the time of
index offence than the comparison group (F(2, 224) = 7.10, p < 0.05; CSC, 2008d) and the CDP
group was significantly younger at first release than both the CMHS and comparison groups
(F(2, 218) = 5.25, p < 0.05). There were a higher proportion of Aboriginal offenders in the CDP
group than in the other two groups. The CDP group had the smallest percentage of offenders
who had a high reintegration potential and the highest percentage of offenders who had a low
reintegration potential. In addition, the offenders who were accepted for CDP services were held
at higher levels of security (a variable usually associated with higher risk). The CMHS group had
a smaller proportion of offenders with Schedule I offences and significantly longer (F(2, 224) =
6.48, p < .05) index sentences than either the CDP or comparison group. The CDP group had
significantly more total prior convictions (F(2, 224) = 3.10, p < 0.05) than the CMHS group and
the comparison group (p < .056 on LSD post hoc analyses) and the differences on the number of
violent and non-violent convictions approached significance (See Table 4; CSC, 2008d, p. 12.)
24
Table 4: Demographic, Criminal History, Risk Variables and Security Level at Release for
the CDP, CMHS and CMHI Comparison Groups
CDP
(n = 53)
Demographic Variables
Age at Index Offence (years)
a
Age at Release (years)
Marital Status - Married/CL
Gender - Male
Race – Aboriginal
Criminal History & Risk Variables
Index Offence Type:
Schedule I
Sexual
1
Security Classification at 1st Release :
Maximum
Medium
Minimum
Missing Data/Prov/Unknown
1
Reintegration Potential :
Low
Medium
High
Comparison
Group
(n =95)
CMHS
(n = 79)
a
29.5 (8.6)
a
32.2 (8.5)
13 (24.5%)
42 (79.2%)
a
23 (43.4%)
39 (73.6%)
4 (7.5%)
Mean (SD)
a
31.5 (9.3)
b
36.3 (10.3)
Number (%)
19 (24.1%)
64 (81.0%)
b
18 (22.8%)
Number (%)
a
b
35.2 (9.7)
b
37.8 (10.0)
22 (23.2%)
85 (89.5%)
b
16 (16.8%)
b
46 (58.2%)
12 (15.2%)
72 (75.8%)
13 (13.7%)
12 (22.6%)
31 (58.5%)
a
6 (11.3%)
4 (7.5%)
6 (7.6%)
50 (63.3%)
19 (24.1%)
4 (5.2%)
7 (7.4%)
60 (63.2%)
b
25 (26.3%)
3 (3.2%)
30 (56.6%)
18 (34.0%)
5 (9.4%)
24 (30.4%)
36 (45.6%)
19 (24.1%)
Mean (SD)
b
6.2 (7.2)
a
a
a
b
b
43 (45.3%)
35 (36.8%)
17 (17.9%)
a
Index Sentence Length (years)
4.3 (3.1)
3.6 (2.8)
Number of Prior Convictions:
a
b
b
Non-Violent
22.6 (17.0)
15.8 (16.8)
16.9 (16.1)
a
b
Violent
3.6 (2.6)
2.6 (2.7)
3.2 (2.9)
Sexual
0.2 (0.7)
0.6 (1.6)
0.6 (1.2)
a
b
Total
26.4 (17.5)
19.0 (17.9)
20.7 (16.5)
Region
Number (%)
Atlantic
4 (7.5%)
19 (24.1%)
11 (11.6%)
Ontario
0 (0%)
9 (11.4%)
26 (27.4%)
Pacific
5 (9.4%)
17 (21.5%)
11 (11.6%)
Prairies
44 (83.0%)
33 (41.8%)
25 (26.3%)
Quebec
0 (0%)
1 (1.3%)
22 (23.2%)
Notes:
1) Post-hoc comparisons between pairs of groups were completed, where the overall test was significant, to
determine whether there were any differences among the three groups. Statistically significant differences between
the groups are identified with an a, b at p < .05.
2) 1 Security classification and reintegration potential had three level of the variable to be tested for each of the three
treatment/comparison groups. In order to minimize the chance of erroneously finding a difference (i.e., family-wise
error), comparisons were completed for CDP vs. comparison and CMHS vs. comparison groups only.
25
Additional information regarding the clinical profiles of the offenders in each of the CDP,
CMHS, and comparison groups is summarized in Table 5 (CSC, 2008d). The most common type
of mental disorder across all three groups was a major mental disorder, with mood disorder being
the most common (34% for CDP; 32% for CMHS; and 38% for CMHI). Offenders with
schizophrenia constituted 25%, 15%, and 37% of the CDP, CMHS, and comparison groups,
respectively. There was a significant difference between the groups on the LFI, 7 F(2, 224) =
4.75, p < 0.05. Post hoc analyses indicated that the CDP group had significantly higher scores on
the LFI scale (M = 5.7, SD = 2.1) than the CMHS (M = 4.8, SD = 2.5) and comparison groups
(M = 4.4, SD = 2.3). The CDP group’s mean score of 5.7 corresponds to a moderate to severe
functional impairment.
7
The LFI was used as a research tool as described in detail in the method section.
26
Table 5: Types of Mental Disorders, Functional Impairment, and Substance Abuse for the
CDP, CMHS and CMHI Comparison Groups
CDP
(n = 53)
1
CMHS
(n = 79)
Number (%)
b
46 (58.2%)
a
12 (15.2%)
25 (31.6%)
21 (26.6%)
2 (2.5%)
2 (2.5%)
9 (11.4%)
a
19 (24.1%)
13 (16.5%)
5 (6.3%)
Number (%)
Comparison
Group (n = 95)
Types of Mental Disorders
a
a
Major Mental Disorders:
40 (75.5%)
79 (83.2%)
b
Schizophrenia & Other Psychotic Disorders
13 (24.5%)
35 (36.8%)
Mood Disorders
18 (34.0%)
36 (37.9%)
Other (e.g., PTSD, OCD)
17 (32.1%)
24 (25.3%)
Schizophrenia & Mood Disorder
0 (0%)
5 (5.3%)
Schizophrenia & Other
1 (1.9%)
1 (1.1%)
Mood Disorder & Other
7 (13.2%)
9 (9.5%)
a
b
Personality Disorder
11 (20.8%)
39 (41.1%)
a
b
Acquired Brain Injury/Organic Brain Dysfunction
16 (30.2%)
8 (8.4%)
Developmental Disability/Intellectual Impairment
4 (7.5%)
10 (10.5%)
Functional Impairment (Moderate to Severe,
score of 2 or 3)
Daily Living/Personal Hygiene
17 (32.1%)
26 (32.9%)
28 (29.5%)
Intellectual
21 (39.6%)
21 (26.6%)
17 (17.9%)
Occupational
40 (75.5%)
43 (54.4%)
44 (46.3%)
Social/Interpersonal
24 (45.3%)
30 (38.0%)
39 (41.1%)
a
b
b
Mean (SD) Total Functional Impairment Score
5.7 (2.1)
4.8 (2.5)
4.4 (2.3)
Substance Abuse
Number (%)
History of Abuse:
50 (94.3%)
66 (83.5%)
83 (87.4%)
Missing Data
0 (0%)
3 (3.8%)
3 (3.2%)
Notes:
1)
1 Diagnosis is based on actual psychiatric diagnosis(es) when available or any documented reporting of
diagnosis(es) information in OMS for the comparison group.
2)
Post-hoc comparisons between pairs of groups were completed, where the overall test was significant, to
determine whether there were any differences among the three groups. Statistically significant differences between
the groups are identified with an a, b at p < .05.
Staff Survey Respondents
A total of 519 surveys were completed by staff members who had knowledge and
experience working with OMDs. 8 Staff position titles are described in Table 6.
8
A response rate could not be calculated as we did not know the total number of individuals at CSC who were
familiar with the CMHI.
27
Table 6: Staff Respondent Position Titles
Staff
(N = 519)
Position Title
Parole officer
Correctional Program Delivery Officer
Psychologist
Correctional officer
Nurse
Parole supervisor
Manager
Finance/Finance Clerk and admin/clerical
District/area director
Project Officer
Behavioural/Correctional counsellor
CMHI clinical social worker
CMHI nurse
CMHI discharge planner
CMHI regional coordinator
Unspecified
Other*
Missing
(n)
130
41
40
38
29
23
17
12
11
11
10
16
9
7
3
95
23
4
(%)
25
8
8
7
6
4
3
2
2
2
2
3
2
1
1
18
4
1
*Note: The Other category includes: Chaplain, Teacher, Warden and ACLO. Percentages may not total 100 due to
rounding.
Offender Interviewees
The Evaluation Branch teams conducted interviews with offenders in the following
locations: (1) St. Johns, Newfoundland (Parole Office and Her Majesty’s Prison); (2) Montreal,
Quebec (CCC Martineau); (3) Hamilton, Ontario (Parole Office); (4) Winnipeg, Manitoba
(Parole Office, Stony Mountain Institution); and (5) New Westminster and Vancouver, British
Columbia (Parole Offices). A total of 33 interviews were completed across the five regions in
Canada: 4 from the Pacific Region, 12 from the Prairie Region, 5 from the Ontario Region, 5
from Quebec Region, and 7 from the Atlantic Region.
Community Service Provider Survey Respondents
The original list of community service providers consisted of 42 independent
agencies/organizations. Of these, 35 were contacted, and 7 were unreachable for a variety of
28
reasons (e.g., invalid email addresses). A total of 14 community service providers completed
surveys, of which 5 were from one organization. Therefore, a total of 10 independent service
organizations returned surveys. Thus overall, feedback was obtained from 24% of the 42
organizations.
29
Key Findings
Evaluation Objective 1: Relevance
Evaluation Objective: Does the initiative remain consistent with departmental and governmentwide priorities, and does it realistically address an actual need?
Government and Departmental Priorities
FINDING 1: The CMHI remains consistent with departmental and government-wide
priorities
Government of Canada
According to Canada's Performance Report 2006/07, a report to parliament indicating the
spending and outcome areas of the federal government, there are two outcome areas that support
CMHI, both related to Social Affairs (Government of Canada, 2007b). First, the Government of
Canada recognizes that mental health and mental illness are priority issues for Canadians that
have broad economic and social impacts. The second spending area is related to the prevention
of crime and victimization by offenders through the direct delivery of rehabilitation programs
and services that reduce recidivism, delivery of such programs and services through partnerships
and formal arrangements with local communities, and improved information-sharing with
criminal justice partners.
CSC Performance Report
One of CSC’s key priorities is: “improved capacities to address mental health needs of
offenders”. The CSC Departmental Performance Report (CSC, 2007b) lists several results
commitments for mental health, including improved correctional results as measured by: (1) the
percentage of OMDs whose parole has been revoked, with or without a new conviction or
charge; (2) the percentage of OMDs returning to federal custody within two years of the end of
their sentence (i.e., after warrant expiry); and (3) the percentage of OMDs convicted of a new
offence within five years of the end of their sentence.
30
CSC Report on Plans and Priorities
CSC reported, through the 2006-07 Report on Plans and Priorities (RPP), that several
milestones had already been achieved in the implementation of the CMHI, namely: an evaluation
plan and a measurement strategy were developed; national mental health training had been
piloted; approximately 50% of newly created clinical positions were filled; and 25 regional
contracts for services directly to offenders with mental disorders were in place (CSC, 2006).
Report of the CSC Review Panel
Strengthening CSC’s strategy to treat and effectively manage offenders with mental
disorders was also highlighted in the recent CSC Review Panel’s Report of the CSC Review
Panel: Roadmap to Community Safety Report (2007). The report documents 12
recommendations specifically related to improving the treatment and management of offenders
with mental disorders, including enhanced community support and increased assessment of
mental disorders.
Office of the Correctional Investigator
The Office of the Correctional Investigator (OCI, 2007) noted twelve key barriers to
public safety in its most recent Annual Report, the first of which was the full implementation of
the CSC mental health strategy of which the CMHI is one component. According to the Annual
Report, the Office of the Correctional Investigator supports the Mental Health Strategy in place
at CSC and notes that CSC needs to build mental health care capacity.
Out of the Shadows at Last
In the 2006 report of the Standing Senate Committee on Social Affairs, Science and
Technology on mental health care in Canada, Out of the Shadows at Last, which was also known
as the Kirby Report (Kirby, 2006), the Committee challenged CSC to meet mental health
standards of care for offenders under federal jurisdiction that are typically afforded to nonoffender populations. Moreover, the Committee specifically made recommendations to CSC in
three key areas: (1) to achieve equivalent standards of care within the institutions and postrelease as those accessed by the general population; (2) that offenders should receive a full
31
mental health assessment by trained professionals at the time of their arrival into CSC custody;
and (3) that CSC take responsibility for ensuring continuity of care post-release. These
recommendations support the services offered by the CMHI.
CSC has made important changes internally to strengthen the commitment to mental
health provision. The CSC comprehensive mental health strategy was approved by Executive
Committee in 2004. In 2007, CSC also received almost $22 million to fund the Institutional
Mental Health Initiative over the next two years and $16.6 million per year permanent funding in
2008. In addition to the comprehensive mental health strategy and increased funding, the new
Health Services Sector governance model established in 2007 created a Mental Health Branch to
focus on these issues specifically.
Given all the above priorities placed on strengthening the response to the needs of
offenders with mental disorders, the goals and objectives of CMHI are consistent with achieving
governmental and CSC objectives.
Need for Services to Address Mental Health Needs of Offenders
FINDING 2: Given the increasing number of offenders entering CSC with mental health
disorders, there is a need to provide services for these offenders to address their mental
health needs and assist them to successfully reintegrate into the community.
The prevalence of mental disorders is higher among offenders than among the general
population (Brink, Doherty & Boer, 2001). Almost one-fifth (20%) of the federal offender
population has been previously hospitalized in a mental health facility (Motiuk, Boe & Nafekh,
2003). Major mental disorders (e.g., schizophrenia and mood disorders) are two to three times
more common in offenders than among the general population, and rates of most disorders are
higher for incarcerated women than incarcerated men. Not only is the prevalence of mental
disorders higher in incarcerated individuals, but the rate of mental disorders is increasing. The
changing offender profile indicates that since 1996/97, the prevalence of mental health problems
at intake among men and women federal offenders have increased 67% and 69%, respectively
(CSC, 2008b). More than one-out-of-ten male offenders and one-out-of-five female offenders in
federal custody have been identified at admission as presenting with mental health problems.
32
Since 1997 there has been an almost 80% increase in offenders who were on prescribed
medication at the time of admission. Overall, 14% of inmates had recent psychiatric or
psychological treatment prior to their incarceration. 9 Overall, 10% of men offenders and 22% of
women offenders are identified as having a mental health disorder at intake (CSC, 2008b).
Further, a recent evaluation of CSC’s correctional programs indicated that male offenders
who were identified at admission as having a mental disorder did not achieve successful
correctional results in several program areas (e.g., family violence and substance abuse) and had
limited results in other program areas (e.g., sex offender programs; Nafekh et al; under review).
These findings suggest that offenders with mental disorders may have more limited treatment
gains through participation in mainstream correctional programs.
Serious mental disorders are associated with other problems for offenders related to an
increased risk of re-offending, and a lack of stable accommodation and employment. The
characteristics of OMDs often place them at higher risk of repeat arrests and incarcerations
especially in the first few months following discharge. They are at a higher risk for failure in
treatment, continued criminality, violent behaviours, and violations of parole conditions (Lurigio,
Rollins, & Fallon, 2004).
Offenders suffering from a mental disorder often have many associated treatment needs
that should be incorporated into their case management. Offenders receiving treatment under the
CMHI were asked to indicate their needs when reintegrating from the institution into the
community and whether these needs have been met through the CMHI during the evaluation
interviews. The following results highlight the multiple need areas of offenders and the extent to
which they report that these needs have been met (Figure 3). It should be noted that mental
health follow-up was the highest reported need of the CMHI offender respondent group (91%; n
= 30).
9
Source – CSC’s Offender Management System
33
Frequency of offenders who had the specific need and whose need has
been met (N = 33)
Figure 3: Reintegration Needs of Offenders Interviewed for the Evaluation
Is this a need
Has the need been met
35
30
25
20
15
10
5
0
Needs
Note. The counts represent only those offenders who indicated that they had the need (out of a total of 33 offenders).
Note that there was some missing data evident for some of the needs indicators shown in the graph; therefore, the
total number of respondents may not always be 33 for each indicator. Offenders who indicated that they had the
need were then asked to indicate whether the need had been met.
Consistency with Other Jurisdictional Practices
FINDING 3: The CMHI is consistent with other jurisdictions’ practices, particularly those
that employ community-based models of mental health intervention for offenders.
As previously discussed, the UN suggests that people with mental disorders should be
treated in the community whenever possible (1991). The UN reports that offenders should live in
the community, be treated in the community, and their reintegration plans should be initiated at
34
the start of an offenders’ sentence (1977). Offering mental health services to OMDs residing in
the community is common practice among many countries (Roberts, Cummings, & Nelson,
2005; Wolff, 2005).
A popular approach to community treatment for individuals with major mental disorders
is Assertive Community Treatment (ACT), a multidisciplinary approach to mental illness that
encompasses a variety of services that are provided at all times (National Alliance on Mental
Health, 2008). The individuals who benefit most from this type of program are those suffering
from major mental disorders and those who struggle to function in their everyday lives. ACT
programs have often been found to achieve better mental health outcomes at lower cost than inor out-patient care at hospitals (Roberts et al., 2005).
ACT programs are similar to the CMHI in that care is designed to address multiple needs.
Community Mental Health Specialists work regularly with the offenders and advocate on their
behalf and establish other community partnerships with agencies, either through CHMI contracts
or other services. ACT programs have been widely used in Canada, the US, and the UK and have
been shown to be less expensive than institutionalized programming and other community based
programs (Chandler, Spicer, Wagner, & Hargreaves, 1999.)
A few other examples of initiatives similar to the CMHI have been found that support the
community-based model of mental health interventions for offenders:
•
New Jersey Prisons offers four re-entry programs to offenders with mental disorders. The
most intensive of these, the “super extensive re-entry coordination” program is most
similar to CMHI and provides reintegration planning for offenders 6 months prior to
release and follow-up services for 12 months following their release into the community.
(Wolff, 2005)
•
The Netherlands provides programming to offenders with mental disorders with the goals
of reduced recidivism and improved reintegration into society. Upon release, the
institution is responsible for making contact with probation services to establish the
appropriate connections for the individual (de Kogel, 2006).
•
In the United Kingdom, newly released OMDs are entitled to the same arrangements as
those who are being discharged from the hospital. The prison will allow the opportunity
for the Prison In-Reach team, Mental Health Team or Care Coordinator to contact the
35
appropriate services for the community based services that are needed by the OMD
(Department of Health, National Institute for Mental Health in England, 2005).
Based on these examples, the CMHI appears congruent with the practices of other
jurisdictions with respect to the treatment available to offenders with mental disorders upon
release.
Evaluation Objective 2: Implementation
Evaluation Objective: The CMHI was organized in such a way that goals and objectives can be
achieved. This involves appropriate linkages between activities, outputs, outcomes and long-term
outcomes.
CMHI Implementation and Staffing
FINDING 4: Delays in implementing CMHI services were attributed primarily to staffing
challenges. Successful implementation of the CMHI was more likely when there were: (1)
dedicated human resource and administrative support to expedite the staffing processes;
and (2) a wide recruitment campaign to draw many potential candidates to staff the
initiative.
In May 2005, funding was approved for the Strengthening Community Safety agenda, of
which CMHI was a part. The funding for CMHI included $29.1 million to be spent over a five
year period up to and including fiscal year 2009/10. Implementation of the initiative was
delayed, in part due to finalization of job classifications, creation of job descriptions, hiring staff
through competitive process in each of the regions, and other implementation challenges. The
first referral for service through the initiative was not made until May 2007.
National Implementation
One of the first steps toward national implementation was selecting the CMHI sites
across Canada. In order to identify CMHI community sites, each region was asked to submit a
proposal identifying up to four parole offices for receipt of mental health specialist services (i.e.,
placement of two mental health specialists). Twenty sites were proposed for inclusion in the
36
CMHI, and 16 of those sites were selected to receive one or two mental health specialists. The
sites were selected by a committee specifically established to review the regional submissions. 10
The review committee made decisions regarding sites based on three criteria:
1) The prioritized regional submissions (each region rank ordered their proposed sites in
order of which sites had the greatest need);
2) Data from CSC’s Research Branch on the number of inmates in each region who had the
OIA indicator “has a current disorder” at intake; and,
3) Specific information from review committee members regarding the mental health needs
at various sites.
Site selection results are presented in Table 7. All of the proposed sites from the Prairie
and Atlantic Regions were accepted by the review committee. In Ontario Region, the Ottawa
Parole Office was proposed but not approved, and in Quebec, Martineau CCC and Maisonneuve
Parole Office were proposed but not selected. In the Pacific region, Kelowna and Kamloops were
proposed and the approval was given for either Kelowna or Kamloops, but not both. In the end,
the decision was made to move the office from Kelowna or Kamloops to Vernon because
Vernon was central to both of these sites and services could be expanded to incorporate a larger
geographic region if the CMHI site was located in Vernon.
Quebec had four sites proposed, two of which were approved. Quebec Region had fewer
offenders identified as having a current mental disorder than any other region (7% compared to,
for example, 20% in Pacific Region). Martineau CCC was already providing mental health needs
for offenders who resided in that facility (i.e., mental health follow-up, pharmaceutical
assistance, referrals to community agencies, recreational activities, etc.). It was decided that
because there were existing resources already being committed to the provision of community
mental health services at Martineau CCC, this site would not receive additional resources. 11
10
Memorandum from Françoise Bouchard, Director General, Health Services, to Assistant Deputy Commissioners,
Correctional Operations, December 12, 2005
11
CMHI National Coordinator, Health Services, Personal Communication, August 2008.
37
Table 7: CMHI Sites Selected in Each Region
Region
Atlantic Region (4 sites)
Offenders with OIA Indicator
a
“Has a current disorder” (%)
17%
Quebec Region (2 sites)
7%
Ontario Region (3 sites)
13%
Prairie Region (4 sites)
11%
Pacific Region (4 sites)
20%
Parole Office Selected for CMHI
Moncton (New Brunswick)
Saint John (New Brunswick)
Halifax (Nova Scotia)
St. John’s (Newfoundland)
Quebec City (Quebec East/West)
St Jerome (Laurentides)
Hamilton
Toronto (Keele)
Kingston
Edmonton (Alberta)
Calgary (Alberta)
Winnipeg (Manitoba)
Regina (Saskatchewan)
New Westminster
Vancouver
Kelowna or Kamloops (the actual
final location was Vernon)
a Data provided from the Research Branch to Health Services cited in: Memorandum from Françoise Bouchard,
Director General, Health Services, to Assistant Deputy Commissioners, Correctional Operations, December 12,
2005.
Although the funding for CMHI was announced in May 2005, there was a 7 month delay
between approval and receipt of the funds. The CMHI position of National Manager was staffed
in advance of the receipt of resources (November 2005) to oversee the initiative from National
Headquarters. The first task for the initiative was to create generic job descriptions for each of
the CMHI positions (e.g., Clinical Social Worker – Discharge Planning, Clinical Social Worker
– Community, Nurse). The generic job descriptions took 10 months to complete (from December
2005 until September 2006). Staffing actions were not initiated until these were finalized. In the
interim, each region had an individual acting as a Regional Coordinator or manager of the
initiative. Positions were then finalized through regional competitive processes. Refer to Figure 4
for an overview of CMHI implementation milestones.
38
Figure 4: Overview of CMHI Implementation
August 2007
May 2005
April 2006
December 2006
* Quebec and Atlantic
Funding approved
Ontario Regional
Quebec Regional
Regions fully
Coordinator staffed
Coordinator staffed
for the
operational in the
‘Strengthening
community
Community Safety
December 2005
* Atlantic Region
Initiative’
September 2006
*Generic job
May 2007 accepted first referrals
* Generic job
classification and
* Prairie Region fully
classifications and
January 2008
descriptions for CMHI
operational in the
descriptions
finalized
Ontario
and Pacific
specific positions were
community
for CMHI positions
Regions
fully operational
initiated
* Prairie Region
* Staffing actions
in
the
community
*Selection of 16 CMHI
accepted first referrals
initiated
PO sites
*Funding received for
CMHI and could be
spent
May 2005
February 2006
Pacific Regional
coordinator staffed
November 2005
National Manager for
CMHI was staffed
November 2006
Atlantic Regional
Coordinator staffed
October 2007
Quebec Region
accepted first referrals
July 2007
Ontario and Pacific
Regions accepted first
referrals
June 2006
Prairie Regional
Coordinator staffed
39
Oct 2008
Regional Implementation
Implementation began at the same time across all regions, but different approaches were
used to recruit and hire staff that ultimately affected the implementation timeframes for each
region. Regional implementation timelines and challenges will be discussed below. For each
regional implementation description, there is a corresponding timeline providing documentation
on implementation milestones. The date that the first position was staffed at each site is reported
through the timeline staffing dates. 12
Atlantic Region. In the Atlantic Region, all community and institutional sites were staffed
in August 2007. The staffing process for Atlantic Region took 12 months from beginning to end
(September 2006 to August 2007). Staffing challenges were reported in the region but were
focused mainly on the length of time the staffing process took. The positions were advertised on
the Government of Canada’s website; many applications were received and no recruitment
challenges were reported. Refer to Figure 5 for further details regarding regional implementation
milestones.
12
There has been staff turnaround within the CDP and CMHS positions. The site implementation dates reported are
only for the first person in that position. There have been vacancies in some of the positions since it was initially
staffed. However, these vacancies are not reported
40
Figure 5: Atlantic Region CMHI Implementation Timeline
May 2005
Funding approved for the
‘Strengthening Community
Safety Initiative’
May 2005
September 2006
* Staffing actions
initiated
November 2005
National Manager
for CMHI was
staffed
November 2006
Atlantic Regional
Coordinator staffed
December 2005
* Selection of 16
CMHI PO sites
August 2007
Discharge Planner positions staffed at
RHQ, serving offenders at:
* Springhill;
* Dorchester;
* Westmorland;
* Nova; and
* Atlantic Institutions
October 2008
August 2007
*Atlantic Region accepted first
referrals
*Atlantic Region fully operational in the
community
*St John’s site operational
*Halifax site operational
*Moncton site operational
*Saint John site operational
Quebec Region. In the Quebec Region, all community sites were staffed by August 2007,
and their first referrals were accepted in October 2007. The staffing process for CMHI
community staff in Quebec Region took 7 months from beginning to end (March 2007 to August
2007). The staffing process for Clinical Discharge Planners (the institutional counterparts of the
initiative) was not completed until October 2008 (taking one year and seven months). The main
staffing challenges reported in the region were that there were few applicants to the positions,
many of the applicants were screened out, and lengthy delays were experienced for second
language evaluations. The region reported receiving limited human resource assistance in
staffing the positions. They advertised the positions on the Government of Canada’s website.
Refer to Figure 6 for further details regarding regional implementation milestones.
41
Figure 6: Quebec Region CMHI Implementation Timeline
May 2005
Funding approved for
the ‘Strengthening
Community Safety
Initiative’
August 2007
*Quebec Region fully
operational in the
community
*Quebec City site
operational
*St. Jerome site
operational
May 2006
Quebec Regional
Coordinator in
December 2005
position
Selection of 16
CMHI PO sites
October 2007
Quebec region
accepted first
referrals
October 2008
Discharge planner
position
staffed
at Granby
Parole Office *
May 2005
November 2005
National Manager for
CMHI was staffed
Oct 2008
March 2007
* Staffing actions
initiated
May 2008
September 2007
Discharge planner
Discharge planner position position staffed at
staffed at CCC Martineau*Regional Headquarters*
Regional Headquarters*
Ontario Region. In the Ontario Region, all community sites were staffed by January 2008
and the first referrals were accepted in July 2007. The staffing process for Ontario Region took
one year and five months from beginning to end (September 2006 to January 2008). Staffing
challenges were reported in the region, particularly pertaining to the length of time it required,
the lack of qualified applicants who applied, and difficulty using recruitment strategies other than
the Government of Canada’s website. Despite attempts, no national advertising for the positions
was initiated, and a process was initiated with Interchange Canada that was unsuccessful in
attracting any employees. Interchange Canada offers nation-wide employee exchanges within
federal provincial and private organizations. Refer to Figure 7 for further details regarding
regional implementation milestones.
42
Figure 7: Ontario Region CMHI Implementation Timeline
May 2005
Funding approved for the
Strengthening ‘Community
Safety Initiative’
December 2005
Selection of 16
CMHI PO sites
July 2007
Ontario region
accepted
first referrals
November 2007
Warkworth DP
position staffed
September 2007
RTC Discharge
Planner position
staffed
September 2006
*Staffing actions
initiated
May 2005
November 2005
National Manager
for CMHI was
staffed
January 2008
*Ontario Region
fully operational in
the community
*Kingston
(Portsmouth CCC)
site operational
October 2008
April 2006
Ontario
Regional
Coordinator
in position
June 2007
Hamilton site
operational
December 2007
Toronto (Keele)
site operational
Prairie Region. Prairies Region was the first region to hire staff, accept referrals, and
become fully operational in both the community and institutional sites (May 2007). The staffing
process took only 9 months (September 2006 to May 2007). Very few staffing challenges were
reported for this region. Additional Human Resource assistance was utilized and an extensive
national advertising campaign was generated, including advertisements in newspapers and
professional association websites. This advertising brought many prospective employees into the
competitive process that resulted in successful candidates for each of the positions. Refer to
Figure 8 for further details regarding regional implementation milestones.
43
Figure 8: Prairie Region CMHI Implementation Timeline
May 2005
Funding approved for
the ‘Strengthening
Community Safety
Initiative’
December 2005
* Selection of 16
CMHI PO sites
June 2006
Prairie Regional
Coordinator in
position
May 2007
*Prairie Region fully operational in the
community
*Prairie Region accepted first referrals
*Edmonton site operational
*Calgary site operational
*Winnipeg site operational
*Regina site operational
May 2005
October 2008
November 2005
National manager for
CMHI was staffed
September 2006
May 2007
* Staffing actions
*Discharge Planning Positions
initiated
staffed at Stony Mountain
*Regional Psychiatric Centre
*Saskatchewan Penitentiary
*Drumheller Institute
*Grierson Centre
*Bowden Institution
Pacific Region. In the Pacific Region, all community sites were staffed by January 2008,
and first referrals were accepted in July 2007. The staffing process for Pacific Region took one
year and five months from beginning to end (September 2006 to January 2008). Recruitment was
advertised in newspapers and with the boards of registration for nurses and social workers.
Staffing challenges were reported in the region, particularly around the length of time it required
to complete human resource tasks, and the lack of qualified applicants who applied. Refer to
Figure 9 for further details regarding regional implementation milestones.
44
Figure 9: Pacific Region CMHI Implementation Timeline
May 2005
Funding approved
for the
Strengthening
‘Community
Safety Initiative’
December 2005
Selection of 16
CMHI PO sites
September 2006
Staffing actions
initiated
August 2007
New Westminster
site operational
May 2005
November 2005
National Manager
for CMHI was staffed
January 2008
*Pacific Region
fully operational in
the community
*Vancouver site
operational
October 2008
February 2006
Pacific Regional
Coordinator in
position
July 2007
Pacific Region accepted first
referrals
*Vernon site operational
Discharge Planner positions
staffed at
*Fraser Valley
*Matsqui
*Mission
December 2007
Discharge Planner
positions staffed at
*Mountain & Kent
*Regional Treatment
Centre
Summary of Implementation Challenges
The CMHI encountered implementation challenges, particularly pertaining to staffing,
that caused lengthy delays in implementation. 13 Some regions took more than one year from the
time they initiated staffing actions until the positions were filled (see Table 8). From the approval
of the initiative in May 2005, it took between two years and two years and eight months to have
the community sites fully staffed. The Prairie Region can be viewed as a best practice for the
successful and timely implementation of CMHI. Not only did the region have the first site
staffed, but staffing all positions (community and institution) in this region took the least amount
of time. There was also a greater level of agreement among CSC staff survey respondents from
13
It was suggested that some regions faced challenges when trying to recruit health professionals (e.g., labour
shortages, difficulty attracting health care workers), and that wage disparities across regions and economic and
labour variations across the coutnry may have selectively affected particular regions (CMHI National Coordinator,
personal communication, December 8, 2008).
45
the Prairie Region that implementation had occurred according to schedule, and that positions
had been staffed in a timely manner (see Table 8). If the initiaitve were to expand or a similar
initiative were to be launched, it is possible that something could be gained by following some of
the practices implemented by the Prairie region (e.g., dedicated administrative support to assist
with human resources, wide advertisement of the positions, etc.). Implementation milestones
across regions and results from the staff surveys regarding implementation schedules and
timeliness are summarized in Table 8.
Table 8: Regional Implementation Timelines and Staff Survey Results
Region
First
position
staffed in
the
community
First
Referral
All
Community
sites staffed
Length of
time for
Community
staffing
process*
Elapsed
time from
CMHI
approval to
full
community
staffing
Staff
agreement that
implementation
occurred
according to
schedule (%)
Staff
agreement
that
positions
filled in
timely
manner (%)
Atlantic
August
2007
August
2007
August
2007
12 months
2 years 3
months
29%
42%
Quebec
August
2007
October
2007
August
2007
7 months
2 years 3
months
31%
29%
Ontario
June 2007
July 2007
January
2008
1 year and
5 months
2 years 8
months
27%
20%
Prairies
May 2007
May 2007
May 2007
9 months
2 years
49%
54%
Pacific
July 2007
July 2007
January
2008
1 year and
5 months
2 years 8
months
30%
20%
* Note: Length of time for staffing process was calculated using the dates staffing actions were initiated in the
region until all the sites in the community were staffed.
As previously described, the funding for the initiative was announced in May 2005 and it
was not until May 2007 that the initiative accepted its first referral for service, in the Prairie
Region. As noted, there were many operational milestones that were required prior to staffing
regional positions. This delay limited the amount of time to follow the treatment recipients’
progress in the community. The CSC RPP (2008a) specifies that recidivism results should be
reported: (1) while under CSC supervision; (2) within two years of the end of sentence; and (3)
within five years of the end of sentence. The potential follow-up time for this evaluation was
only 6 to 13 months after the offenders’ first referral to service. In many cases, the offenders
were still under community supervision and had not reached their warrant expiry dates. This
greatly limits the ability of this evaluation to examine long-term correctional outcomes (e.g.,
46
violent and non-violent recidivism) which would require several additional years of data in order
to fully evaluate.
RECOMMENDATION 1: To sustain and enhance mental health services provided in the
community, CSC should support the implementation of mental health services through the
development of a strategic staffing process and recruitment campaign.
CMHI Referrals
FINDING 5: Discharge planning referrals are not occurring in accordance with CMHI
guidelines regarding timeframes (i.e., nine months prior to anticipated release date).
FINDING 6: The most common reason for CMHI referral rejections occurred because
offenders did not meet inclusion criteria. Staff also suggested that some offenders in need of
services were not being referred. Examination of findings suggests that this may be due to a
lack of knowledge among CSC staff members regarding CMHI referral criteria, lack of
reliable tools to facilitate early identification of those in need of services, and/or a lack of
available services in the communities to which the offenders are being released.
Referral Criteria
Referral criteria for the CMHI included the diagnosis of a major mental disorder (e.g.,
schizophrenia, mood disorder, or other disorders), or moderate to severe impairment from
personality disorder, acquired brain injury/organic brain dysfunction, or developmental disability
or intellectual impairment. CSC staff members were asked to rate their familiarity with the
inclusion criteria of the CMHI given that the staff (mainly the offenders’ parole officers) make
the referrals to CMHI services. Slightly more than half (57%; n = 290) of CSC staff members
indicated that they were at least moderately familiar with the inclusion criteria for the CMHI, 14
and all (100%; n = 13) of the community service providers who responded to the survey question
indicated that they were at least moderately familiar with the inclusion criteria for offenders with
mental disorders.
14
The General Communication email sent to all CSC staff asked that “staff who have experience and knowledge in
the area of working with offenders with mental disorders” complete the survey. This invitation for participation does
not require staff respondents to be in a position to refer offenders for service in which case they would be explicitly
familiar with the referral criteria of the CMHI
47
Community Mental Health Specialist (CMHS) Referrals. Approximately one-half of CSC
staff respondents indicated that offenders were being referred to the CMHS prior to their release
(48%; n = 169). Approximately half of CSC staff members (43%; n = 132) also suggested that
the first contact that offenders had with the CMHS (i.e., the initial communication between the
CMHS and the offender) occurred in a timely manner. Among offenders accepted to receive
services, the majority were scheduled to begin receiving CMHS services within one month of
referral (75%; n = 143). Only 5% (n = 9) were waitlisted, with the majority of candidates on the
waitlist coming from Atlantic Region (n = 4) and Pacific Region (n = 4).
Clinical Discharge Planning (CDP) Referrals. Approximately half of CSC staff members
(48%) agreed that offenders with mental disorders were being referred to clinical discharge
planning services. It is also important to note that only about half (51%, n = 197) of CSC staff
agreed that the procedures to refer offenders for clinical discharge planning were clear. 15 Also,
staff members who indicated that the CDP procedures for referral were unclear were also likely
to disagree that offenders were being referred for CDP services (see Figure 10: Perceptions of
Clarity of CDP Referral Criteria by Perceptions of CDP Referral). Therefore, it is possible that
clarity and staff awareness of referral procedures may be impacting upon referrals for clinical
discharge planning services.
Proportion of Staff
Respondents (%)
Figure 10: Perceptions of Clarity of CDP Referral Criteria by Perceptions of CDP Referral
80
70
60
50
40
30
20
10
0
CDP referral criteria were
unclear
CDP referral criteria were
neither clear nor unclear
Disagree
Neither Agree
nor Disagree
Agree
CDP referral criteria were
clear
Are offenders being referred for CDP services?
15
Approximately one-third (29%) disagreed, and the remaining staff provided a neutral response
48
CMHI guidelines also suggest that discharge planning should be performed 9 months
prior to the offender’s anticipated release date (Champagne et al., 2008). The mean time from
CDP referral to anticipated release was 5.0 months nationally (CSC, 2008c). Quebec Region had
the shortest average period from referral to release (3.9 months) and the Prairie Region had the
longest period (5.6 months). Given these results, it appears that efforts should be made to
identify appropriate candidates for discharge planning earlier in their sentences to provide
sufficient time to complete the discharge plan, to create links to community services prior to
release and to ensure adherence to CMHI guidelines.
Referrals to CDP services must be completed by institutional parole officers. Whereas
mental health training has benefited community staff, the individuals who initiate CMHI services
(i.e., institutional parole officers) have not been targeted for mental health training. Furthermore,
institutional correctional officers and other case team members are two staff groups that have
considerable contact with OMDs in the institutions and could benefit from an enhanced
knowledge of mental health issues.
Percentage of Offenders Receiving Services Based on Referrals. According to referral
records, a total of 507 unique offenders were referred for CMHI services nationally from the first
reported referral in May 2007 (Prairies Region) to June 2008 (CSC, 2008c). 16 Table 9: Clinical
Discharge Planning and Community Mental Health Specialist Referrals and Acceptance Region
presents the referral and acceptance rates by region and by type of service (CDP and CMHS).
16
It should be noted that referral records included all offenders whose referral forms had been sent to NHQ for
inclusion in the referral dataset by June 2008. Those offenders who were referred prior to June 2008, but whose
referral forms had not yet been transferred to NHQ would not have been included in this analysis
49
Table 9: Clinical Discharge Planning and Community Mental Health Specialist Referrals
and Acceptance Region
CDP
Region
Referred
Accepted
Atlantic
55
Ontario
CMHS
Unknown
Referred
Accepted
38 (69%)
Not
Accepted
11 (20%)
Unknown
57 (75%)
Not
Accepted
12 (16%)
6 (11%)
76
9
8 (89%)
1 (11%)
0 (0%)
53
29 (55%)
17 (32%)
7 (13%)
Quebec
15
2 (13%)
1 (7%)
12 (80%)
14
6 (43%)
1 (7%)
7 (50%)
Prairies
125
95 (76%)
16 (13%)
14 (11%)
86
56 (65%)
14 (16%)
16 (19%)
Pacific
38
33 (87%)
5 (13%)
0 (0%)
59
42 (71%)
13 (22%)
4 (9%)
National
242
176
(73%)
34 (14%)
32 (13%)
288
190
(66%)
57 (20%)
41 (14%)
7 (9%)
Notes.
1)
Percentages may not total to 100 due to rounding.
2)
A total of 23 cases received both CDP and CMHS services and are counted in both the CDP and CMHS
groups. The total number of unique individuals referred to CDP and/or CMHS services was 507.
3)
Offenders not accepted for reasons such as not meeting inclusion criteria, offender refusal of services,
offenders UAL, and other reasons.
Two-hundred and forty-two offenders were referred for CDP services and 73% of these
were accepted for services. Two-hundred and eighty-eight offenders were referred for CMHS
services and 66% of this group were accepted for services. 17 Overall the majority of those
referred for CDP (86%) and CMHS (85%) were male, and approximately one-quarter to onethird of CDP (35%) and CMHS (23%) referrals were Aboriginal offenders. 18 Most frequently,
referrals were rejected from services because the offenders did not meet referral criteria (47% of
CDP rejections and 42% of the CMHS rejections) or because offenders refused to receive the
service (12% for CDP, n = 4; and 14% for CMHS, n = 8).
Percentage of Offenders who should be Referred for Services, Who are Not Referred.
Among community service provider respondents, the majority (64%; n = 7) agreed that the right
offenders were being identified as meeting criteria for the CMHI. Slightly more than half of CSC
staff (58%) agreed that the referral criteria for the CMHI were appropriate. However, many
respondents (68%; n =145) also indicated that there were at least several offenders who were
eligible for services who did not receive them. When asked to explain why these offenders did
17
18
Twenty-three offenders were referred to, and received both, CDP and CMHS services.
Additional information regarding referrals by region, race, and gender are presented in Appendix D
50
not receive services, the most frequently identified reasons were lack of services or offenders’
refusal of services. Some staff members also suggested that there was a lengthy waitlist and
indicated that the tools that were used to identify offenders who needed services were unreliable.
However, others indicated that referrals for services were not being made, or that offenders were
not being identified for the services, possibly due to perceptions that the eligibility criteria were
too restrictive. When asked to describe changes to the CMHI that might improve the correctional
outcomes of CMHI offenders, a few staff members (6%; n = 12) indicated that the inclusion
criteria were too restrictive or offenders who had not been diagnosed still presented with mental
health issues and could not access the services/resources that they needed
Currently, the only objective way to assess the number of CSC offenders in need of
CMHI services nationally is through examination of the OIA indicator “diagnosed as disordered
currently”. However, this does not appear to be an accurate indicator of the need for these
services as not all offenders with the OIA indicator meet the CMHI criteria 19 and not all
offenders who meet the criteria for the CMHI are identified with the OIA indicator at intake
(e.g., offenders who have moderate to severe impairment as a result of personality disorder,
acquired brain injury/organic dysfunction, or developmental disability or intellectual
impairment). Furthermore, according to guidelines, referral for CDP services should be initiated
at least 9-months prior to an offender’s scheduled release. Mental health status may have
changed between intake and referral to CDP services which would not be captured in the OIA
indicator at intake. Due to lack of an accurate indicator or identification tool administered to all
offenders to objectively identify those who should receive services, it is not possible to
accurately identify how many CSC offenders should be receiving CMHI services at this time.
RECOMMENDATION 2: Procedures or processes to improve early identification of
offenders’ mental disorder and treatment needs should be explored in order to enable
accurate identification of offenders with mental health needs, to better facilitate treatment
referrals, and to establish continuity of care from an earlier stage.
19
Note that when a sample of files of offenders with the OIA indicator were coded for research purposes by RPC
and CSC Health Services staff, it was found that not all offenders with the OIA indicator would have qualified as a
participant for the CMHI.
51
Coordination and Information Sharing
FINDING 7: Implementation challenges were reported related to coordination and
information sharing among institutional and community mental health and case
management teams
Evidence of information sharing was observed based on data collected through
community capacity building records gathered for the initiative. Results indicated that there were
388 internal (within CSC) capacity building contacts initiated for the purposes of information
sharing for CDP and CMHS services (CSC, 2008c). In addition, numerous consultations between
various CSC staff members (e.g., parole officers, psychologists, health care staff, etc.) and CDP
or CMHS service providers were recorded for the purpose of case reviews ad discussions. A total
of 2,439 consultations were recorded between April 2007 and April 2008. Furthermore, all
(100%) of the offenders interviewed indicated that their Parole Officers and CMHS staff work
together to ensure that all of their mental health and correctional needs are met in a balanced
way.
However, some implementation challenges, particularly with respect to coordination and
communication (e.g., information sharing) between institutional and community staff (mental
health and case management teams), were reported by CSC staff members. Implementation
challenges were reported by the majority of staff with respect to coordination/information
sharing amongst the institutional mental health team, the community mental health team, and the
case management team in the context of CDP and CMHI services (see Table 10: Implementation
Challenges with respect to CDP and CMHS).
52
Table 10: Implementation Challenges with respect to CDP and CMHS
Implementation challenges with respect to CDP:
Coordination/information sharing with the
institutional mental health team (IMHT)
Coordination/information sharing with the
institutional case management team (e.g.,
institutional parole officer)
Coordination/information sharing with the
community case management team (e.g.,
community parole officer)
Implementation challenges with respect to CMHS
Coordination/information sharing with the
community mental health team
Coordination/information sharing with the
community case management team (e.g.,
community parole officer)
n
No
Maybe
Yes
128
41 (32%)
11 (9%)
76 (59%)
129
37 (29%)
20 (16%)
72 (56%)
121
31 (26%)
18 (15%)
72 (60%)
n
No
Maybe
Yes
136
50 (37%)
17 (13%)
69 (51%)
137
52 (38%)
19 (14%)
66 (48%)
Issues related to information sharing and communication were also raised by respondents
at several points throughout the CSC staff survey. For example, some respondents indicated that
offenders were not being referred to community-based services for mental health interventions
due to a lack of communication/consultation with CMHI staff. When asked if there was anything
about the CMHI that could be changed to improve the correctional outcomes for offenders
participating in the initiative, a number of staff members suggested improved communication,
information-sharing, and collaboration between institutional staff and community staff (e.g.,
correctional and mental health staff). Increased communication and collaboration among the
parties involved in offender case management was also described as a best practice in the
implementation of the CMHI.
RECOMMENDATION 3CSC should explore and develop mechanisms to increase
information-sharing across institutional and community mental health and case
management teams.
53
Location of CMHI Sites
FINDING 8: Existing CMHI sites appear to be well-placed to serve offenders with mental
health needs as demonstrated by the number of offenders with mental health needs at
existing CMHI sites. However, there are several CSC sites with significant proportions of
of offenders with mental health needs that have not been identified for CMHI services.
As shown in Table 11, the regions with the highest national percentage of OMDs as
identified by the OIA indicator ‘diagnosed as disordered currently’, are the Prairies and Ontario
Regions, with over one-quarter of all offenders in each of these regions. In addition, the highest
proportion of Aboriginal OMDs is being supervised in the Prairie Region. Quebec Region has
the smallest percentage of offenders with a current mental disorder which is consistent with the
previous finding upon which the CMHI site selection was based.
Table 11: Percentage of Offenders with Women and Aboriginal Sub-population Offenders
with Current Mental Disorder by Region
Region
Prairies
Ontario
Atlantic
Pacific
Quebec
All offenders
25%
25%
19%
18%
14%
Women offenders
15%
17%
13%
8%
11%
Aboriginal offenders
37%
15%
5%
25%
7%
Regional Geographic Analysis of Offenders with Mental Health Needs
Two sets of maps were created for each region to illustrate: (1) the percentage of all
federal offenders who received CMHI services at each office until June 2008; and (2) the
percentage of all federal offenders supervised at each office who had identified mental health
needs (as per the OIA indicator “diagnosed as disordered currently”) between August 2007 and
June 2008.
The maps below illustrate the locations of CSC’s Parole Offices and Community
Correctional Centres across each region. . The colour of the markers indicates the presence of a
54
CCC/CRF with or without CMHI services (red), or a parole office with or without CMHI
services (blue). The dot within the markers indicates whether the CCC/CRF or parole office has
(white) or does not have (black) CMHI services. Maps are presented by region, with the first
map for each region displaying the percentage of all federal offenders at each office who were
‘diagnosed as disordered currently’ according to the OIA indicator, and the second map
identifying the proportion of offenders at each site who received CDP and CMHS services,
respectively. 20 Note that offenders reported in the CDP group received these services at an
institution prior to their release and the maps indicate their community locations after release.
Also note that some CDP offenders were released to non-CMHI sites. As discussed in the
limitations section, relying on the OIA indicator as a proxy measure for those who would meet
the referral criteria for participation in the CMHI may not be an entirely accurate representation
of those requiring services as it relies solely on the OIA indicator “diagnosed as disordered
currently” and does not take into account the degree or type of mental disorders.
As illustrated in the following maps, with a few exceptions, CMHI sites appear to be in
the most appropriate locations for the majority of sites. A regional analysis is provided below. 21
The tables in the following sections detail the CMHI parole offices, and the corresponding CCC,
that together comprise the CMHI sites.
Atlantic Region
The CMHI sites in this region appear to be located at the most appropriate offices, given
the percentage of offenders with identified mental health needs supervised at each of these sites
(refer to Table 12). The site with the highest proportion of OMDs during this period was
Moncton Parole Office (4%) and there were correspondingly high proportions of CDP and
CMHS offenders supervised through this site (9% and 8%, respectively).
20
Note that OMDs may have received services through contracts at some of these sites.
The tables in the following sections detail the CMHI parole offices, with the corresponding CCCs identified
below, which together comprise the CMHI site
21
55
Table 12: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Atlantic Region
CMHI Site
Identified Need
CDP
CMHS
(N = 957)
(N =109)
(N =227)
Moncton
3.6%
9.2%
7.5%
Saint John PO
1.6%
2.8%
4.0%
Parrtown CCC
1.7%
3.7%
3.1%
Halifax PO
2.2%
1.8%
3.1%
Carlton CCC
1.0%
0.9%
2.6%
St John’s PO
1.6%
0.9%
4.0%
Newfoundland CCC
1.3%
0.9%
4.0%
Note: 5 offenders received both CDP and CMHS services through the Moncton Parole Office; 1 offender received
both CDP and CMHS services through the Saint John Parole Office; and 2 offenders received both CDP and CMHS
services in the Halifax area through the Halifax Parole Office and Carlton CCC.
56
Figure 11: Offenders with Identified Mental Health Needs in Atlantic Region Offices
1.
2.
3.
Percentage (%) next to each office indicates
the percentage of offenders supervised at
each office who are identified by Offender
Intake Assessment indicator “current mental
disorder”.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
57
Figure 12: Offenders Receiving CMHI Services in Atlantic Region Offices
1.
2.
3.
Percentages (%, %) next to each office
indicate the percentage of offenders
supervised at each office who are receiving
Discharge Planning and CMHS Specialist
Services, respectively.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
58
Quebec Region
Martineau CCC supervises the greatest proportion of offenders in need of CMHI services
(3%; refer to Table 13) than any other office in Quebec and approximately 2% of the CMHS
offenders are supervised by this site (although it is technically not a CMHI designated site). In
addition, it appears that the greater Montreal area has a relatively substantial percentage of
offenders with a current mental disorder. In comparison to the Martineau CCC, parole offices in
Montreal have similar proportions of offenders with a current mental disorder (Ville-Marie with
2% and Maisonneuve with 2%). In light of these findings, considerations to add a CMHI site to
service OMDs in the greater Montreal area (e.g., through expansion of the CMHI or relocation of
existing services) may be warranted.
Table 13: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Quebec Region
CMHI Site
Identified Need
CDP
CMHS
(N = 957)
(N = 109)
(N = 227)
Quebec PO
1.0%
0%
0%
Marcel Caron CCC
0.7%
0%
0.9%
Laurentian PO
0.3%
0%
0%
Laferriere CCC
0.3%
0%
2.6%
Martineau CCC*
2.9%
0.9%
1.8%
Note: * Martineau CCC was not designated as a CMHI site because this site had existing resources devoted to the
provision of community mental health services prior to the implementation of the CMHI. No locations were
identified in Quebec where offenders received both CDP and CMHS services during this time-period.
59
Figure 13: Offenders with Identified Mental Health Needs in Quebec Region Offices
1.
2.
3.
Percentage (%) next to each office indicates
the percentage of offenders supervised at
each office who are identified by Offender
Intake Assessment indicator “current mental
disorder”.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
60
Figure 14: Offenders Receiving CMHI Services in Quebec Region Offices
1.
2.
3.
Percentages (%, %) next to each office
indicate the percentage of offenders
supervised at each office who are receiving
Discharge Planning and CMHS Specialist
Services, respectively.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
61
Ontario Region
Among the CMHI sites in the Ontario Region, the Hamilton Parole Office and CCC,
Toronto Team Supervision Unit and Keele CCC, and Kingston Parole Office and Portsmouth
CCC supervise the highest proportion of OMDs in this region (refer to Table 14 and the Ontario
Region map). These three sites therefore appear to be appropriately designated as CMHI sites.
The Ottawa Parole Office, a non-CMHI site, also supervised a relatively substantial proportion
of offenders with mental health needs (3%) during this time, suggesting that Ottawa may warrant
future considerations for CMHI services.
Table 14: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Ontario Region
CMHI Site
Identified Need
CDP
CMHS
(N = 957)
(N = 109)
(N = 227)
Hamilton PO
2.8%
2.8%
5.7%
Hamilton CCC
1.1%
0%
2.6%
Toronto Team
0.9%
0.9%
0%
Keele CCC
2.9%
0.9%
5.7%
Kingston PO
1.1%
0.9%
0%
Portsmouth CCC
2.0%
0%
5.7%
Note: 1 offender received both CDP and CMHS services through the Toronto Team Supervision Unit and Keele
Community Centre; and 1 offender received both CDP and CMHS services through the Kingston Parole Office and
Portsmouth Community Centre.
62
Figure 15: Offenders with Identified Mental Health Needs in Ontario Region Offices
1.
2.
3.
Percentage (%) next to each office indicates
the percentage of offenders supervised at
each office who are identified by Offender
Intake Assessment indicator “current mental
disorder”.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
63
Figure 16: Offenders Receiving CMHI Services in Ontario Region Offices
1.
2.
3.
Percentages (%, %) next to each office
indicate the percentage of offenders
supervised at each office who are receiving
Discharge Planning and CMHS Specialist
Services, respectively.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
64
Prairie Region
CMHI sites in the Prairie Region are placed in appropriate locations, given the
percentages of offenders with identified mental health needs supervised by these offices (refer to
Table 15). One other area with a relatively high percentage of offenders with mental health needs
was Saskatoon, which had approximately 2% of OMDs with identified need. In addition, 5% of
all federal offenders receiving CDP services were being supervised in Saskatoon, but no CMHS
service was available in this location. Ideally, offenders would receive both CDP and CMHS
services. Given the high proportion of offenders receiving CDP services in Saskatoon, this site
may be one that should be considered as a potential future CMHI site where CMHS services
could be delivered.
Table 15: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Prairies Region
CMHI Site
Identified Need
CDP
CMHS
(N = 957)
(N = 109)
(N = 227)
Edmonton Urban PO
6.9%
6.4%
2.6%
Calgary Urban PO
4.1%
3.7%
4.8%
Winnipeg PO
3.5%
12.8%
10.1%
Osborne CCC
0.5%
0%
2.2%
Regina PO
1.1%
2.8%
0.9%
Oskana CCC
1.4%
2.7%
4.4%
Note: 1 offender received both CDP and CMHS services in the Edmonton area through the Edmonton Parole Office;
3 offenders received both CDP and CMHS services through the Calgary Urban Parole Office; and 7 offenders
received both CDP and CMHS services in the Winnipeg area through the Winnipeg Area Parole Office.
65
Figure 17: Offenders with Identified Mental Health Needs in Prairies Region Offices
1.
2.
3.
Percentage (%) next to each office indicates
the percentage of offenders supervised at
each office who are identified by Offender
Intake Assessment indicator “current mental
disorder”.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
66
Figure 18: Offenders Receiving CMHI Services in Prairies Region Offices
1.
2.
3.
Percentages (%, %) next to each office
indicate the percentage of offenders
supervised at each office who are receiving
Discharge Planning and CMHS Specialist
Services, respectively.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
67
Pacific Region
New Westminster and Vancouver sites are well placed given the percentage of offenders
with identified mental health needs at those sites (refer to Table 16). Approximately 5% of
offenders with mental health needs were supervised out of the New Westminster Parole Office
and relatively high proportions of CDP and CMHS offenders were supervised out of this office
(6% and 13%, respectively. Vernon was selected because it was central to Kamloops and
Kelowna and the CMHS staff could cover offenders being supervised in each of these three
offices. The three offices combined contain only 3% of offenders with a current mental disorder
(with 1% in Vernon, 1% in Kamloops and 1% in Kelowna). If the initiative were to expand into
another site, there appears to also be a need for services in Victoria as well, with 2% of offenders
identified with mental health needs.
Table 16: National percentages of offenders with identified mental health needs and
offenders receiving CMHI services in the Pacific Region
CMHI Site
New Westminster
Vancouver
Belkin Enhanced Unit
CRF
Vernon
Kelowna
Kamloops
Identified Need
(N = 957)
5.2%
3.2%
1.4%
CDP
(N = 109)
6.4%
4.6%
2.8%
CMHS
(N = 227)
12.8%
3.5%
0%
0.8%
1%
1%
0%
1.8%
0%
0.9%
3.5%
0.9%
Note: 2 offenders received both CDP and CMHS services through the New Westminster Parole Office.
68
Figure 19: Offenders with Identified Mental Health Needs in Pacific Region Offices
1.
2.
3.
Percentage (%) next to each office indicates
the percentage of offenders supervised at
each office who are identified by Offender
Intake Assessment indicator “current mental
disorder”.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
69
Figure 20: Offenders Receiving CMHI Services in Pacific Region Offices
1.
2.
3.
Percentages (%, %) next to each office
indicate the percentage of offenders
supervised at each office who are receiving
Discharge Planning and CMHS Specialist
Services, respectively.
Current as of August 31 2008.
Mapping: Facilities Branch, CSC
70
RECOMMENDATION 4: Several sites that are not presently included in the CMHI that
have large proportions of offenders with mental health needs should be considered for
CMHI services, through reallocation or expansion of CMHI services.
CMHI Budget and Expenditures
FINDING 9: Implementation delays have led to several instances of re-profiling and lapses
of CMHI funding. Financial data for the CMHI have not always been coded consistently
utilizing the appropriate cost-centres in IMRS
As a result of several factors (i.e., late receipt of funding for the first year of the initiative,
delays in staffing), CMHI funding has been re-profiled several times. Overall, this resulted in a
smaller than intended budget in the first two years of the initiative (2005/06 and 2006/07), and
increased budgets in the last 3 years of the initiative, from 2007/08 to 2009/10. In total, after all
three instances of re-profiling, just over $1.5 million was re-profiled to the CMHI budgets for
each of the fiscal years 2007/08, 2008/09, and 2009/10. Thus, from the original budgets of $6.4
million per year, the budgets for the first two years of the initiative have decreased significantly
($1.4, and $3.1 million), and the budgets have increased to just over $8 million for each of the
last three years of the initiative (refer to Table 17).
Table 17: Re-profiling of CMHI Funding (in thousands)
Budget
2005/2006
2006/2007
2007/2008
2008/2009
2009/2010
Original Budget
3,420
6,420
6,420
6,420
6,420
1st Re-profile
(2,000)
2,000
2nd Re-profile
(3,300)
1,100
1,100
1,100
3rd Re-profile
0
(1,989)
755
655
579
Total Revised
1,420
3,131
8,275
8,175
8,099
Budget
Note: Budget includes salary, operating, employee benefit plan, common services, and accommodation.
Total
29,100
29,100
CMHI budget and expenditures for fiscal years 2005/06, 2006/07, 2007/08, including
salary, operating, employee benefit plan, common services, and accommodations, are shown in
Table 18. Overall, the percentage of the CMHI budget spent in each year ranged from 51%
(2007/08) to 84% (2006/07). Total expenditures to the end of fiscal year 2007/08 represent 61%
71
of the CMHI budget with close to $5 million in lapsed spending (including all salary, operating,
employee benefits, common services, accommodations). CSC Health Services and Financial
staff have suggested that it is possible that financial expenditures for the CMHI may have been
inaccurately coded in IMRS (i.e., incorrectly coded to some other initiative or project).
Therefore, expenditures may have been somewhat greater than actually reported in IMRS.
However, it was not possible to identify and objectively verify any such coding errors/omissions.
Finally, it should be noted that the CMHI was not fully implemented until part way through
2007/08, so it is expected that CMHI expenditures relative to budgeted amounts will increase in
2008/09 when the initiative will have been fully implemented in all regions for a full fiscal year.
Table 18: Budgeted and Actual CMHI Spending for All Canada (in thousands)22
2005/06
2006/07
2007/08
Total
Revised Budget (after re-profiling)
$1,420
$3,131
$8,275
$12,826
Actual Expenditures
$965
$2,634
$4,237
$7,836
% of Budget Spent
68%
84%
51%
61%
Lapsed $
$455
$497
$4,038
$4,990
Note: These amounts include salary, operating, employee benefit plan, common services, and accommodations.
CMHI Expenditures by Cost Centre
When the CMHI was initiated, a general category was created in IMRS to track CMHI
expenditures, labelled “Mental Health Community Strategy”. Over time, additional cost centres
were created in IMRS to more accurately track CMHI expenditures according to major spending
areas, including: (1) discharge planning services; (2) communality mental health specialists; (3)
mental health training; (4) regional mental health contracts; (5) adjunctive services; (6)
evaluation and research; and (7) management and coordination. The general category of Mental
Health Community Strategy was closed during fiscal year 2007/08. Since that time, all CMHI
related spending is required to be coded according to the seven major categories of spending
listed above.
National CMHI expenditures (operating and salary only) for 2007/08, broken down by
each of the major spending areas, are shown in Figure 21. Overall the majority of expenditures
were designated for service contracts and management/coordination, followed by CMHS and
22
Source: Financial Information provided from IMRS by CSC Comptroller’s Branch
72
CDP services. This pattern of expenditures likely reflects the fact that CMHS and CDP services
were not fully implemented for the full year, and it would be expected that expenditures in these
areas (CMHS and CDP, and potentially other areas as well) would rise in subsequent years.
Figure 21: CMHI National Expenditures (Operating and Salary) for 2007/08
$1,000,000
$800,000
$600,000
$400,000
$200,000
$0
MHCS
CDP
CMHS
Train
Contracts Adjunct Research Coord
210 - SALARIES
240 - Operating
Note: MHCS = Mental Health Community Strategy; CDP = Discharge planning services; CMHS = Community MH
specialists; Train = Mental Health Training; Contract = Regional MH contracts; Adjunct = Adjunctive services;
Research = Evaluation and Research; Coord = Management and Coordination
CMHI expenditures by cost centre for each of the regions for 2007/08 are shown in
Figure 22. Overall, expenditures were higher in the Prairies, followed by Atlantic Region, which
were among the first regions to be fully operational in the community in 2007. A review of the
graphs indicates that not all regions appeared to be coding financial data in the same manner. For
example, the “Mental Health Community Strategy” financial code was still in use by two of the
regions (Ontario, Prairies). 23 Additionally, it seems possible that the Ontario Region was
utilizing the Mental Health Community Strategy category to report expenditures for CDP and
CMHS services as well, since the Ontario Region was offering CDP and CMHS services in
2007/08, but no expenses were recorded for those categories.
23
Note that, although not shown in the graphs, the financial code of “Mental Health Community Strategy” was still
in use by NHQ as well during 2007/08.
73
Figure 22: CMHI Expenditures by Cost Centre and Region for 2007/08
Atlantic
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0
MHCS
CDP
CMHS
Train
210 - SALARIES
Contract
Adjunct
Research
Coord
Research
Coord
Research
Coord
240 - Operating
Quebec
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0
MHCS
CDP
CMHS
Train
210 - SALARIES
Contract
Adjunct
240 - Operating
Ontario
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0
MHCS
CDP
CMHS
Train
210 - SALARIES
74
Contract
Adjunct
240 - Operating
Prairies
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0
MHCS
CDP
CMHS
Train
210 - SALARIES
Contract
Adjunct
Research
Coord
Research
Coord
240 - Operating
Pacific
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0
MHCS
CDP
CMHS
Train
210 - SALARIES
Contracts
Adjunct
240 - Operating
Note: MHCS = Mental Health Community Strategy; CDP = Discharge planning services; CMHS = Community MH
Specialists; Train = Mental Health Training; Contract = Regional MH contracts; Adjunct = Adjunctive services
Research = Evaluation and Research; Coord = Management and Coordination
RECOMMENDATION 5: CSC should ensure accurate, standardized coding of CMHI
expenditures in financial databases to ensure that expenditures are adequately recorded
and monitored and so the cost-effectiveness of the CMHI can be adequately assessed at
some future time.
75
Evaluation Objective 3: Success
Evaluation Objective: The extent to which the CMHI is delivering the expected outputs,
outcomes and objectives in relation to resources used.
Impact of Community Mental Health Training
FINDING 10: Mental health training was provided to 830 individuals in the community
and 352 CSC institutional staff members who worked with individuals with mental
disorders. Among institutional staff, trainees were primarily CSC nurses. The training was
effective in improving community personnel’s mental health knowledge and self-perceived
competency to work with offenders with mental disorders.
Receipt of Training
Community Personnel who Received Mental Health Training. In a 1.5 year period
(January 2007 to June 2008), a total of 830 community personnel participated in the national two
day mental health training (refer to Table 19). Two-thirds (66%) of community personnel who
received the training were CSC community staff members. 24 The remainder were primarily CRF
staff members who worked with community-based agencies on contract to provide services for
CSC offenders. Seventy-two percent of community trainees received the generic training
package while 20% received the women offenders’ training package, and the remaining 8%
received the train the trainers’ package.
24
For CSC staff, mental health training attendance records up until the end of 2007/08 were cross-referenced with
HRMS to verify accuracy by HS staff
76
Table 19: Number of community personnel who received the national mental health
training packages
Training Package
Generic
Train the Trainer
Women Offenders
Total
Frequency (%)
Non-CSC Staff
140 (50%)
2 (1%)
139 (49%)
281 (100%)
CSC Community Staff
460 (84%)
60 (11%)
29 (5%)
549 (100%)
Total
600 (72%)
62 (8 %)
168 (20%)
830 (100.0%)
Note. Data were derived from mental health training attendance records that had been cross-referenced with entries
in the Human Resources Management System (HRMS) to verify accuracy. Percentages may not total 100% due to
rounding.
Institutional Staff Members who Received Mental Health Training. According to
attendance records maintained by Health Services, a total of 352 institutional staff members
received mental health training (303 nurses, 19 correctional officers, and 30 institutional parole
officers). Most of the nurses (271/303) received CMHI mental health training in FY 2008/09, 25
while all of the other institutional staff received training in 2007/08. Although some institutional
staff did receive training, few of the staff members who are responsible for referring OMDs for
CDP services (i.e., institutional parole officers) received mental health training from the CMHI.
Earlier, it was noted that referrals to CDP services must be completed by institutional
parole officers. Whereas mental health training has benefited community staff, the individuals
who initiate the CDP service (i.e., institutional parole officers) have not been targeted for mental
health training. Furthermore, institutional correctional officers and other case management team
members have considerable contact with OMDs in the institutions, and could therefore benefit
from an enhanced knowledge of mental health issues.
Training Evaluations
In general, participants rated the mental health training favorably. Participants were asked
to complete a 12 item mental health training evaluation form, of which 9 items corresponded to
each of the 9 modules (i.e., introduction, myths and realities, what is a mental disorder, types of
mental disorders, cognitive disorders and FASD, risk and mental disorder, effective strategies,
resources, and legislative requirements). For each item, participants were asked to rate the
25
Note that at the time the mental health training summary report was completed, data for FY 2008/09 had not been
verified for accuracy against HRMS records
77
usefulness of the specific item on a 7 point scale from 1 (not useful) to 7 (very useful).
Participants provided an average rating of 6.22 (SD = 0.88, n = 516) for the overall training. A
rating of six was not defined but the closest anchored marker was 7 ‘very useful’. For each of the
9 modules, the mean ratings were positive, ranging from 5.57 (legislation) to 6.27 (mental
disorders). The average rating of the usefulness of the participant manual was 6.21 (SD = 0.96).
Participants were also asked to identify areas in which they wished to receive follow-up
training. The most common areas identified were risk management/effective strategies/skills
training (n = 81), medications/interventions (n = 59), mental disorders (symptomology and
DSM; n = 52), resources (n = 45), and FASD (n = 31). Furthermore, participants provided
suggestions to improve the training, and most frequently suggested the provision of additional
time for training (n = 69) and more information/details during training (n = 61). 26
Training Impact: Pre- and Post-Training Mental Health Knowledge Quiz
Across the three training packages (i.e., generic, TtT, and women offenders), participants
showed a 58.6% improvement on scores on the mental health knowledge quiz after training
(refer to Table 20). Participants were given a 10 item mental health knowledge quiz before and
after training to assess their knowledge in areas addressed in training. Total scores could range
from 0 to 17. The average scores before and after training were 8.63 (SD = 3.47) and 13.69
(2.84), respectively, with TtT participants showing the least improvement. This is to be expected
as these individuals had mental health backgrounds prior to training and had high average scores
at baseline.
Table 20: Average Pre- and Post-Training Mental Health Quiz Scores
Training Package
Total (n = 616)
Generic (n = 420)
Train the Trainer (n = 60)
Women Offenders (n = 136)
M (SD)
Pre-Training
Post-Training
8.63 (3.47)
13.69 (2.84)
8.17 (3.41)
13.28 (2.93)
11.35 (2.54)
14.60 (1.86)
8.88 (3.44)
14.55 (2.64)
Note. *** p < .001.
26
Results provided by Health Services training summary report
78
t (df)
% Improvement
-39.15*** (615)
-33.35*** (416)
-9.65*** (59)
-19.67** (135)
58.63%
62.55%
28.63%
63.96%
Generally, when there was opportunity for improvement (i.e., the recipients did not
receive a perfect score at pre-training), the majority of participants improved on their knowledge
rating. Training recipients demonstrated increased knowledge in the areas of symptoms, recovery
versus medical models of mental health, side effects of psychotropic medications, and effective
strategies for working with offenders with FASD (refer to Table A in Appendix E).
Self perceived competency ratings
Participants’ self-perceived competency ratings improved significantly after training. 27
Each participant was asked to rate eight items on a 7 point scale from 1 (strongly disagree) to 7
(strongly agree). The total mean post-training score was 42.36 (SD = 9.37) whereas the pretraining score on the competency ratings was 32.35 (SD = 9.23), which corresponds to an
average improvement of 31%. Significant improvements in ratings were observed on each of the
eight items (see Appendix E). Mean scores on each item ranged from 3.29 to 4.91 at pre-training
and 5.04 to 5.59 at post-training.
In addition, CSC staff members who responded to the evaluation survey were asked to
rate their competence to work with OMDs (using the same questions from the self-perceived
competency scale administered prior to and after mental health training). Responses of CSC staff
members who received the training were compared to those who did not. Just under half of all
the staff survey respondents indicated that they received training (199/480 or 42%). 28 Results
from the CSC staff survey administered for the present evaluation indicated that CSC staff
members who participated in the mental health training rated their competence to work with
offenders with mental disorders significantly higher than CSC staff members who did not receive
training (refer to Table 21). This suggests the training had a positive impact, even in the longer
term, not just directly after training was received.
27
The results presented in this paragraph were obtained from ratings completed before and immediately after
training, t(569) = -22.42, p < .001
28
It was hypothesized that these results may have been due to a disproportionate number of CSC staff members
who, by the nature of their profession, had pre-existing training in mental health issues within the group of staff who
indicated that they had received mental health training as part of the CMHI. These analyses were analyzed a second
time excluding all CMHI staff, psychologists, and nurses. The pattern of results was the same in that CSC staff
members who participated in mental health training as part of the CMHI provided significantly higher rating on their
competence to work with OMDs than their counterparts who did not participate in training
79
Table 21: Self-Perceived Competence in Working with Offenders with Mental Disorders:
Results from the CSC Staff survey 29
I have the knowledge to work effectively
with offenders with mental disorders
Received mental
health awareness
training under the
CMHI
No
Yes
No
Yes
N
Mean
t (df)
266
198
262
197
3.30 (1.31)
4.12 (0.92)
3.43 (1.28)
4.05 (0.92)
-7.49*** (462)
I have the skills and abilities to work
-5.81*** (457)
effectively with offenders with mental
disorders
I have the skills to recognize symptoms
No
267
3.67 (1.18)
-5.79*** (464)
suggestive of the need for intervention by a Yes
199
4.23 (0.79)
mental health professional
I am able to support offenders with mental
No
264
3.63 (1.21)
-6.09*** (459)
disorders by consulting and collaborating
Yes
197
4.24 (0.86)
with mental health professionals,
community resources, and families
Notes. All survey respondents were asked whether they participated in mental health training as part of the CMHI
initiative and then asked to rate each of the statements listed in the table.
*** p < .001.
RECOMMENDATION 6: Additional mental health training should be provided to
institutional staff members, including parole officers and other case management team
members in order to assist in identifying OMDs and providing early referrals for CMHI
services.
Receipt of DPS and CMHS Services
FINDING 11: Offenders referred to, and accepted for, CMHI services, including discharge
planning and community mental health specialist services, are receiving these services.
However, data regarding their termination from these services may not always be
consistently recorded in CMHI database.
Funding for the CMHI initiative provided three new categories of services: clinical
discharge planning in the institutions, community mental health specialists in 16 selected parole
offices/CCCs, and specialized mental health contracts in the community. This section focuses on
the overall number of recipients of CDP and CMHS services and the perceptions of offenders,
29
Respondents were asked to rate their agreement with the statements on a scale from “strongly disagree” (1) to
“strongly agree” (7)
80
CSC staff members, and community service providers with respect to the availability and
accessibility of clinical discharge planning and community mental health specialist interventions.
Accessibility of mental health contracts will be explored in the following section.
Clinical Discharge Planning Services
A total of 176 offenders were accepted for clinical discharge planning services nationally
from the start of the initiative until June 2008 (CSC, 2008c). The largest number of offenders
accepted for discharge planning came from the Prairies Region, followed by Atlantic, Pacific,
Quebec, and the fewest coming from the Ontario Region. Of these accepted referrals, 38% were
Aboriginal offenders and 85% were male (see Table 22).
Table 22: Total CDP Accepted Referrals by Region, Race, and Gender
Region
Atlantic
Ontario
Quebec
Prairies
Pacific
Total
Total CDP(n)
38
8
2
95
33
176
Aboriginal (n)
2
1
0
49
14
66 (38%)
Male(n)
29
8
2
82
28
149 (85%)
Almost half of offenders interviewed (47%; n = 14) reported having received CDP
services in the institution prior to their release. 30 Offenders who received CDP services generally
reported positive experiences with the service. All of those who reported receiving discharge
planning services (100%; n = 14) reported that the discharge planning had been helpful in their
transition from the institution to the community and most noted that they had a good working
relationship with their discharge planner (86%; n = 12). The majority of the offenders indicated
that their discharge planners were knowledgeable about their needs (79%; n = 11) and
encouraged them to take an active role in their discharge planning (86%; n = 11). However,
30
Note that official records gathered by CMHI staff show that there was only a small number of offenders who had
received both CMHS and CDP services (n = 23). It seems unlikely that the level of receipt of discharge planning
services among the small sample of offenders interviewed would be as high as was found in this evaluation.
Therefore it is possible that some of the offenders interviewed misunderstood the question and they did not receive
CDP services but perhaps had some pre-release discussions with their institutional parole officers. For this reason,
the results presented regarding offender perceptions of discharge planning services should be interpreted with some
caution.
81
implementation challenges such as clarity of referral criteria and timely staffing of positions
(discussed in detail in the implementation section earlier) may have affected the early availability
and accessibility of this service.
Community Mental Health Specialist Services
A total of 190 offenders were accepted for community mental health specialist services
nationally from the start of the initiative until June 2008 (CSC, 2008c). The largest number of
accepted referrals for community mental health specialist services came from the Atlantic
Region, followed by Prairie Region, Pacific Region, Ontario Region and the fewest came from
Quebec Region. Of these accepted referrals, 24% were Aboriginal offenders and 85% were male
(see Table 23).
Table 23: Total CMHS Accepted Referrals by Region, Race, and Gender
Region
Atlantic
Ontario
Quebec
Prairies
Pacific
Total
Total CMHS (n)
57
29
6
56
42
190
Aboriginal (n)
2
6
0
27
10
45 (24%)
Male (n)
43
28
6
50
35
162 (85%)
Offenders who were interviewed generally reported positive experiences with the CMHS
services. Of those interviewed, half reported meeting with CMHS staff once per week (52%;
16/31). All of the offenders (100%; 28/28) indicated that they felt that their social worker or
nurse has been helpful in their reintegration into the community. All but one offender (97%;
29/30) indicated that their social worker or nurse was available to them when needed, and the
majority (90%; 26/29) indicated that the CMHS staff encouraged them to take an active role in
their treatment planning. Most offenders also indicated that the CMHS staff members were
knowledgeable about their mental health needs (94%; 29/31).
One area that may require improvement is the timeliness of offenders’ first contact with
CMHS staff, as almost half (48%; n = 14) of the offenders indicated that they had their first
contact with CMHS staff as soon as they were released, while almost the same proportion of
offenders indicated otherwise (44%; n = 13). However, it is possible that offenders may have
82
been released prior to the implementation of the CMHI in these regions. Therefore, delays in first
contact may have been a function of early implementation challenges, but will be something to
review again at a later date once all regions have been fully operational for a sufficient period of
time.
Limitations
One of the challenges related to the identification of treatment recipients is that the
treatment recipient database, utilized for evaluation purposes, was generated with the receipt of a
completed referral for service form. According to the referral procedure, the clinical discharge
planner or community mental health specialist reviews the referral forms (completed by the
parole officer) and determines whether an offender is accepted for treatment or not. A copy of
the referral form is then stored on the offender’s file and an electronic copy is provided to Health
Services, NHQ, for evaluation purposes. Acceptance to treatment was based on two criteria. The
offender must meet the criteria and they must voluntarily agree to participate. If the offender was
referred but refused to participate in the services, their refusal would be noted on the referral
form and they would not be included in the treatment group. However, if the offender received
services and was terminated (either by the service provider or himself/herself), this information
may not have always been consistently recorded. Therefore, even if an offender was referred to
and originally accepted to participate in CMHI services, it is possible that they may not have
received these services, or they may not have received these services for any significant period of
time. It was not possible to differentiate offenders with respect to the length of service provision.
RECOMMENDATION 7: Offenders accepted for CMHI services should be tracked to
ensure that treatment has been provided and to monitor the length of time that offenders
receive services
Community-Based Contract Services
FINDING 12: The number of CMHI service contracts and number of offenders receiving
services have increased over time. Contract services are being delivered in a timely manner
and few offenders referred for services were waitlisted or not provided with the services.
83
The number of offenders receiving contract services each year is increasing. The most
frequent service received was psychiatric care. Very few offenders were on a waitlist and, of the
offenders interviewed, the vast majority indicated that they received services in a timely manner
and that the service providers were knowledgeable about their needs.
Over a two year period, 42 community contracts were implemented, 31 four of which have
since been terminated (CSC, 2008c; refer to Table 24). A total of 973 service requests were
made, indicating that offenders were referred either to more than one contracted
agency/individual, or they had multiple referrals to the same contracted service (CSC, 2008c).
The types of contracted services provided fell into 5 categories: (1) psychiatric services (57%; n
= 556); (2) leisure/ daily living support (34%; n = 335); (3) addictions (4%; n = 43); (4)
employment (2%; n = 24); and (5) women specific services (2%; n = 15).
Table 24: Community Contracted Services and Utilization
a
2006/07
Apr Sept
3
20
2006/07 Oct
- Mar
2007/08 Apr
- Sept
F2007/08
Oct - Mar
Total
Number of Contracts
20
26
39
n/a
Number of services requested
175
394
384
973
Types of Services
Addictions
0
11
16
16
43 (4.4%)
Employment
0
24
0
0
24 (2.5%)
Leisure/Daily Living
0
66
122
147
335 (34.4%)
Psychiatric Services
11
74
256
215
556 (57.1%)
Women Specific Services
9
0
0
6
15 (1.5%)
Notes.
1)
a Contracts in place during more than one reporting time period were counted in each of the subsequent
reporting periods.
2)
n/a = cannot be summed due to overlap between time periods
Of the contract services that were requested (n = 973), the majority of these requests have
been completed (68%, n = 662). The majority of completions were from the Pacific region (43%,
n = 283), followed by the Prairies (22%, n = 143) and Ontario regions (14%, n = 95). Atlantic
region constituted 13% (n = 84) of the completions and Quebec 9% (n = 57.) A significant
31
Re-profiled funding that was not utilized in previous years has been used to pay for contract services. Once the
CMHI is fully implemented, contract services will not be able to be maintained at the same level within the current
level of funding (CMHI National Coordinator, Personal Communication, December 8, 2008)
84
percentage of the sample had missing data (i.e., their status was not recorded at the end of the
reporting period), so it was unclear whether they completed their contract service or not (15%; n
= 150). Few offenders were waitlisted (1%; n = 7) or were not provided with services (4%; n =
36) and 12% had contract services terminated (voluntarily n = 19 or involuntarily n = 99). The
most common reason for not providing services was that the offenders were not eligible for the
services.
Despite these results indicating that few offenders were on waitlists, not all staff
respondents indicated that services had been provided in a timely manner. When asked if
offenders were receiving services from the community service providers in a timely manner,
only 42% (n = 119) of staff surveyed agreed that they were, 27% (n = 78) stated they were not
and 31% neither agreed nor disagreed. It is unclear why there is a discrepancy between staff
opinions and the implementation report findings. However, based on the relatively large
percentage of respondents who neither agreed nor disagreed (31%), it is possible that staff
members simply did not have enough information to reliably report on this question.
Alternatively, it is possible that staff respondents may have been referring more broadly to any
services provided in the community, rather than only those services provided by community
agencies under contract with CSC through the CMHI.
The majority of offenders interviewed reported that they had received services through a
community service provider under contract (61%; n = 20). The most frequent need addressed by
contract services was mental health follow-up (90%; n = 18). Most also indicated they had
received access to these services in a timely manner (85%; n = 17). The majority of respondents
agreed that the contracted community service providers were knowledgeable about their needs
(85%; n = 17) and all respondents indicated that they were treated respectfully (100%; n = 20).
All 14 of the community service providers indicated that they were at least moderately
able to meet the needs of offenders under the CMHI, with 36% (n = 5) indicating that they were
able to completely meet the needs of CMHI federal offenders. The majority of the community
service providers (85%; n = 11) indicated that their organizations had existing contracts for
services with CSC prior to the implementation of the CMHI, but most (64%; n = 7) also
indicated that there had been changes to the services that they provide as a result of the
85
implementation of the CMHI. 32 Specifically, most of the community service providers indicated
a slight (20%) to substantial (60%) increase in the variety of services available to CSC federal
offenders. However, respondents generally indicated that the CMHI had little impact on the
number of beds available to CSC federal offenders (100%, n = 4), the number of days between
referral and admission (80%, n = 4), and the number of CSC offenders on waitlists (68%, n = 4).
Most of the CSC staff survey respondents agreed that since the implementation of the
CMHI, there had been an increase in the availability of community mental health interventions
(such as counselling and assessment, 65%), resources/supports for CSC (63%), and offender
participation in community correctional services delivered by CSC or community partners
(61%). 33 Over half of CSC staff members (55%) agreed that offenders were attending mental
health interventions/services to which they were referred. Staff members suggested that
offenders might not attend mental health interventions because they refused to participate in
services/did not indicate that they needed the services or that the services/supports were not
available in the community. Two thirds of CSC staff members agreed that difficulties accessing
community-based services are being identified (66%) but only one-quarter (24%) agreed that
they were being resolved. The majority of the community service providers (92%), however,
indicated that their agencies had the capacity to provide services to additional federal offenders.
Community Capacity Building
FINDING 13: Community capacity building efforts have increased over time and servicebuilding contacts have generally focused on the areas of highest need or importance
according to CMHI referrals.
Table 25 shows the number of contacts for community capacity building for CDP and
CMHS services from April 2007 to April 2008. Nearly 1,800 contacts have been made by CDP
and CMHS staff members and other organizations during this time period, of which 60% (n =
1,057) were for information sharing purposes, and 40% (n = 698) were for service building
activities. The total number of contacts for information sharing purposes increased across
32
Note that these comments should be interpreted with some caution as they are based on a small number of
respondents from a small number of community service organizations
33
Most of the remaining respondents indicated there had been no change
86
2007/08 but the number of contacts for service building purposes decreased from the third to the
fourth quarters (CSC, 2008c).
Table 25: National Community Capacity Building for CDP and CMHS Services by
Quarter 34
Community Capacity Building
Apr-Jun
2007
Jul- Sep
2007
a
Oct-Dec
2007
Jan-Mar
2008
FY
2007/08
Total
1755
1057
Total Number of Contacts
50
478
649
578
Information Sharing with
36
199
375
447
Organizations
CSC Internal
14
68
139
167
388
Psychiatric/Psychological Services
9
22
53
31
115
Housing
0
16
44
49
109
Non-government organizations (e.g.,
6
14
12
24
56
Elizabeth Fry)
Correctional (CRF/Provincial)
0
8
18
25
51
Mental Health Information and
1
4
17
19
41
Referral
Employment
0
12
9
16
37
Addictions
1
6
10
17
34
b
Other
5
49
73
99
226
Service Building Activities with
14
279
274
131
698
Organizations
Psychiatric/Psychological services
3
54
66
35
158
Housing
1
35
24
17
77
Mental Health information/referral
2
27
33
6
68
Non-government organizations (e.g.,
3
13
29
11
56
Elizabeth Fry)
Addictions
0
31
19
3
53
Employment
1
24
18
10
53
c
Other
4
95
85
49
233
Notes.
1)
This table only includes services for which there were 40 or more contacts in the total period.
2)
a Excludes 47 entries on the Community Capacity Building records that were not appropriate capacity
building activities. Examples of such activities included attending CSC's new employee orientation, delivering a
two-day mental health training package, and meetings with offenders to complete assessments.
3)
b Includes categories that had small frequencies such as Aboriginal culture-specific services,
provincial/municipal government agency, and education.
4)
c Includes categories such as physical health, CSC (internal), and Aboriginal culture-specific services.
Three of the most frequent categories of service building contacts were for psychiatric/
psychological, housing, and mental health information/referral services. Consistent with the
34
Source: CSC (2008c).
87
pattern of service building contacts, mental health follow-up was identified as the most
frequently anticipated need among OMDs referred to CMHI services (see Figure 23; CSC,
2008c, p. 18).
Figure 23: Percentage of CMHI Accepted Offenders Identified with Anticipated Discharge
Needs at Referral
100
Clinical Discharge Planning (n = 176)
Community Mental Health Specialists (n = 190)
90
80
70
%
60
50
40
30
20
10
Other
Language Consid.
Transp. Considerations
Legal Considerations
Other Tx Follow-Up
Sub. Abuse Follow-Up
Phys. Hlth Follow-Up
Ment. Hlth Follow-Up
Cultural/Ethnic
Spiritual/Religious
Community Support
Family Supports/Dyna.
Leisure Activities
Occ./Employ.
Education
Financial Resources
Identification
Housing
Destination
0
Notes:
1)
a Anticipated need areas are not nationally representative as the numbers differ across regions
2)
Data presented in this figure were collected from referral forms completed by institutional and community
parole officers which include information about release, inclusion criteria, and anticipated needs areas.
Furthermore, the overwhelming majority (98%; n = 355) of CSC staff members surveyed
indicated that mental health follow-up was considerably to very important in the reintegration of
OMDs from the institution to the community. Similarly, 95% of staff members rated housing
needs to be considerably to very important. Finally, the majority of staff (97% to 99%) rated
88
financial, occupation/employment, and substance abuse needs/follow-up to be moderately to
very important for CMHI offenders.
To summarize, the results on contracts and community capacity building efforts (i.e.,
contacts) suggest that the capacity to provide community-based services is not problematic.
Rather, other difficulties such as staff awareness of available services in the community and
provision of services after warrant expiry may require further examination (the latter issue is
discussed in the next section). For instance, the majority of CSC staff members indicated that the
CMHI contributed to an increase in advocacy for community services by CDP and CMHS staff
(72%), and community capacity building (69%). In addition, the majority of the offenders (85%;
n = 17) agreed that the services that they had received from the community service providers
helped in their successful integration into the community while one individual (5%) disagreed.
All but one offender (97%; n = 29) indicated that the services that they received through the
CMHI helped them to live successfully in the community. Moreover, a majority of the offenders
indicated that they were very to extremely satisfied with the CDP services, CMHS services,
services provided by community-based service providers, and the CMHI overall (64% to 90%).
Furthermore, community capacity building efforts have focused on the areas of greatest need
according to needs recorded on referral forms. Finally, as discussed in the section on availability
and accessibility of CMHI services, from April 2006 to March 2008, contract services were
provided to 84% to 100% of all the offenders who requested services and the most frequent
reason for refusal of services was that the offender was not eligible for the services.
Continuity of Services
FINDING 14: Stakeholders generally reported enhanced continuity of care and services,
although some concern was reported regarding continuity of care after warrant expiry.
Continuity of services from the institution to community was rated positively by the
offenders based on their responses to an adaptation of the ACSS-MH (Adair et al., 2004). 35
Overall, offenders scored an average of 154 (SD = 17.1) which corresponds to an overall positive
rating (see Table 26). Offenders also scored positively on system fragmentation (offenders’
35
Refer to Appendix E for a description of the scale and scoring methodology
89
perceptions of continuity across the services; for example: “I have to deal with a confusing
number of agencies and programs”), relationship base (the extent to which the offender perceives
a consistent and dependable relationship with his/her treatment providers as being important; for
example: “I can count on my social worker/nurse to help me when I am in need”), and
responsive treatment subscales (extent to which services are provided to address the offender’s
needs; for example: “After release from the institution, I had to wait a long time before I received
mental health services”). These findings are consistent with ratings by CSC staff members and
offenders with respect to continuity of services. The majority of CSC staff members indicated
that the CMHI increased the continuity of services from the institution to the community (prior
to Warrant Expiry Date [WED]; 73%). Also, approximately half of staff respondents agreed that
continuity of care of mental health services after warrant expiry had also increased (51%).
Table 26: Offender Perception of the Continuity of Services as Rated Using the Alberta
Continuity of Services Scale for Mental Health
Mean (SD)
System Fragmentation
Relationship Base
Responsive Treatment
Total
Observed Range of
Scores
62 to 105
32 to 45
24 to 40
124 to 190
84 (10.2)
39 (4.1)
31 (4.5)
154 (17.1)
Possible Range of
Scores
21 to 105
9 to 45
8 to 40
38 to 190
The majority of offenders indicated that their discharge planner helped to establish
contact with community service providers prior to their release (85%). In addition, most
offenders reported that CMHS staff assisted them in accessing community resources and services
that they required (81%) and followed up after referring them to services to ensure that they were
receiving the services (93%). CSC staff members also indicated that there was an increase in
linkage to community mental health services while the offender is under CSC community
supervision (71%). Finally, the majority of CSC staff members (73%) reported that the CMHI
had contributed to an increase in comprehensive integration planning.
Community-Based Services after Warrant Expiry
One particular area that may require additional attention is the provision of communitybased services after offenders have completed their sentences (i.e., after WED). As noted by
90
Champagne and colleagues (2008), “a lack of substantive support for OMDs in the community
increases the likelihood that they will return to the criminal justice system through repeated
arrests and incarceration or be admitted and re-admitted to psychiatric hospitals” and “effective
mental health treatment can significantly contribute to CSC’s goal of ensuring safer
communities” (p. 3). Concerns about public safety do not cease at warrant expiry. One of the
service delivery gaps identified in an evaluation of the Texas Mental Health Initiative (Arrigona,
Prescott, Brown & Hook, 2003) was that the initiative lacked transitional services to facilitate
continuity of services after offenders were terminated from the Mental Health Initiative. Of the
1,507 adult probationers who were terminated from the Mental Health Initiative, only 38% had
continued involvement with mental health services at a 60 day follow-up. Arrigona and
colleagues suggested that the model be modified to include a gradual transition from the
intensive supervision and mental health services to program termination in order to increase the
likelihood that the successes and improvements achieved through the offender’s participation in
the initiative are sustained beyond termination.
According to the Correctional Service of Canada Community Mental Health Initiative
Clinical Discharge Planning and Community Integration Service Guidelines, CMHSs are
responsible for initiating “appropriate referrals to address immediate and longer term community
integration needs after the OMDs’ WED” (Champagne et al., 2008, p. 25). Furthermore,
“CMHSs encourage OMDs to maintain post-termination contact with them after completion of
sentence in the community, at their discretion, in order to support them for a transitional period
of time” (p. 26). Half of CSC staff members (51%) indicated that the CMHI has contributed to
an increase in continuity of mental health services after warrant expiry but a large proportion
also indicated that there has been no change (43%). Less than one-fifth (18%) of CSC staff
respondents indicated that they were aware of mechanisms/procedures in place for CMHS staff
members to facilitate the continuity of services for offenders after warrant expiry although the
majority of CSC staff respondents indicated that such mechanisms/procedures should be in place
(91%).
Staff members who indicated that they were aware of existing mechanisms most
frequently identified contact with, or referral to, non-governmental community-based service
providers (45%) and government agencies/departments (e.g., provincial health, social services;
15%). Several staff members also suggested that continuity of care could be facilitated after
91
sentence completion, by developing partnerships, MOUs, agreements, and engaging in
information sharing with service providers (government or non-government) to provide services
beyond WED. Overall, the most commonly identified strategies to facilitate continuity of care
after WED included referring offenders to service providers after WED or arranging
appointments/case conferences with agencies involved in post-WED care, and CSC/CMHI staff
providing follow-up for at least a short-term or temporary basis following warrant expiry.
The majority of offenders reported considerable to complete agreement with the
statement that they had all of the necessary services in place at the end of their sentence (71%).
Approximately one-fifth (18%) of the offenders indicated ‘a little’ to ‘moderate’ agreement and
the remainder (11%) indicated not at all. 36 When asked to explain their responses, offenders most
frequently indicated that the needed services are already in place (21%), although some also
reported that they were concerned about having access to services after warrant expiry (15%).
The majority of community service providers (77%) surveyed indicated that CSC federal
offenders are eligible to access services from their agency beyond WED although half of the
community providers (50%) indicated that there are changes to the services provided after WED.
Although there was a general perception of increased continuity of care for offenders
through the CMHI, the importance of extending continuity of care up to and beyond warrant
expiry cannot be overemphasized. The Kirby Report stresses the importance of this by
recommending that CSC take responsibility for ensuring continuity of care post-release (Kirby,
2006). Health care in Canada is typically a provincial responsibility unless offenders are residing
in CSC facilities (including CCCs; see review of policy in the policy and legislation section).
Once the offenders have reached warrant expiry, CSC no longer has responsibility for this care.
However, given the increased priority the government has placed on providing better care for
mentally disordered people and offenders, offender needs at warrant expiry should be
considered, in terms of services that may be arranged prior to WED to provide continuity of
services after WED. Given the general transfer of responsibility to the province following WED,
CSC may wish to develop additional links with provincial governments to facilitate continuity of
care after warrant expiry.
36
It may be important to note that the majority (73%; n = 24) of the offenders who were interviewed had been
released for 1 year or less at the time of the interview
92
RECOMMENDATION 8: CSC should continue to support and enhance the level of
services available to offenders with mental disorders in the community. Further, CSC
should explore the development of additional partnerships/links with organizations (such
as provincial governments and non-governmental organizations) to facilitate continuity of
care following warrant expiry.
Offender Quality of Life
FINDING 15: Stakeholders generally reported that the CMHI contributed to an improved
quality of life for offenders. However, the CMHI standardized assessment of quality of life
was not administered to offenders per CMHI guidelines. As a result, findings pertaining to
this assessment were inconclusive due to small sample sizes.
Administration guidelines (as reported in the Additional Measures for the Community
Mental Health Initiative – Resource Manual) indicate that the Quality of Life Scale is to be
administered within the first month of release, at the third month of release, and every 6 months
thereafter. QoL data were available for 36 CMHS offenders 37 for the first time period (i.e., Time
1; refer to Table 27, adapted from CSC, 2008d, p. 27).
Table 27: Quality of Life Scores for the CMHS Group within the First Month of Release
Domain
Mean (SD)
(n = 36)
5.3 (0.9)
5.0 (1.3)
4.9 (1.3)
4.8 (1.3)
4.7 (1.3)
4.7 (1.4)
4.5 (1.3)
4.8 (1.6)
3.6 (1.6)
Legal and Safety a
Activities
Social Relations a
General Life Satisfaction
Work a
Living
Health
Family a
Finances
Notes:
1) Missing data for CMHS in family (n = 32), social relations (n = 35), work (n =20) and legal and safety (n = 34).
37
Data were reported for ten CDP offenders at Time 1, five of whom also received CMHS services. According to
the guidelines, the Quality of Life scale should be administered to offenders in the community. It is unclear why
Quality of Life scale was administered to the other five CDP offenders who did not receive CMHS services.
However, only data for the CMHS offenders, who were supposed to complete the Quality of Life scale as per the
CMHI guidelines, are presented here
93
2) In order to assist in interpretation of mean scores presented in the table, the scale is rated from 1 to 7 where: 1 =
terrible; 2 = unhappy; 3 = mostly dissatisfied; 4 = mixed; 5 = mostly satisfied; 6 = pleased; 7 = delighted.
At the 3-month interval (i.e., Time 2), data were available for only 16 CMHS offenders
and at the 6 month interval (i.e., Time 3) there were too few data to analyse (data were available
for 4 offenders only). There were no significant differences in scores between these two time
periods although the small number of cases at Time 2 precluded any interpretation of the impact
of the CMHI on quality of life. For the most part, average scores ranged from 4 to 5, indicating
that in general offender perceptions of quality of life were “mixed”, or “mostly satisfied”. Given
the small samples and missing data, however, these results should be interpreted with caution.
Although the results from the QoL Scale were inconclusive, key stakeholders reported
that the CMHI has contributed to improved quality of life for OMDs. The majority of community
service providers (85%) indicated that the CMHI has contributed to an increase in the quality of
life for OMDs. In addition, the majority of offenders (81%) indicated that the CMHI has
increased their quality of life (substantially, 67%) while one individual (3%) indicated that the
CMHI has resulted in a substantial decrease in his/her quality of life. Furthermore, the majority
of CSC staff members (68%) indicated that the CMHI had contributed to an increase in OMDs’
quality of life while they were supervised in the community and just under half of the staff (47%)
indicated an increase in quality of life after warrant expiry. Almost half of the staff members
(46%) indicated that there has been no change to OMDs’ quality of life after warrant expiry. This
may be related to the finding that only 18% of CSC staff respondents indicated that they were
aware of mechanisms/procedures in place for CMHS staff members to facilitate the continuity of
care services for offenders after warrant expiry. When asked whether or not they agreed that
offenders served through the initiative experienced a reduction in symptomology, almost half
(46%; n = 116) neither agreed nor disagreed, while 42% (n =104) agreed and 11% (n = 28)
disagreed.
Overall, survey and interview responses suggest that staff and offenders believe offender
quality of life has been enhanced as a result of participation in CMHI. It will be important to
collect additional data on the QoL Scale to increase sample sizes and review overall quality of
life over longer time periods.
94
RECOMMENDATION 9: CSC should review the Quality of Life Scale administration
guidelines to ensure that guidelines for administration are practical and develop
procedures to ensure that CMHI staff engage offenders in completing the assessment of
quality of life as per the guidelines.
Impact of CMHI on Reintegration to the Community
FINDING 16: The majority of offenders received either clinical discharge planning (CDP)
or community mental health specialist (CMHS) services, but not both. Offenders receiving
CMHS services were less likely to be suspended or revoked than the comparison group,
after statistically controlling for pre-existing group differences. There was no evidence to
suggest that the CDP group differed from the comparison group with respect to these
outcomes. These preliminary findings should be interpreted with caution due to small
sample sizes and short follow-up times.
Three groups were included in correctional outcome analyses: (1) offenders who were
accepted for CDP services, (2) those accepted for CMHS services, and (3) a comparison group.
The demographic variables, criminal history, and risk information for these three groups are
summarized earlier in the report (refer to Table 4). Generally, offenders in the CDP group had a
lower reintegration potential and a higher number of prior convictions (M = 26.4, SD = 17.5)
than the other two groups at release (significantly higher number of prior convictions than the
CMHS group and marginally higher than the control group), which were quite similar in profile.
Release information for offenders in these three groups is presented in Table 28 (CSC,
2008d, p. 16). Within each group, the majority of the offenders were released on statutory
release. None of the offenders in the CMHS group were released at warrant expiry, although
11.3% and 13.7% of the CDP and comparison groups were released at warrant expiry,
respectively.
95
Table 28: Release Types for the CDP, CMHS, and CMHI Comparison Groups
Frequency n (%)
CMHS
(n = 79)
CDP
(n = 53)
Comparison Group
(n = 95)
1
First Release Type
a
b
Day or Full Parole
8(15.1%)
27(34.2%)
25(26.3%)
Statutory Release
35(66.0%)
47(59.5%)
52(54.7%)
Warrant Expiry
6(11.3%)
-13(13.7%)
Long Term Supervision
0(0%)
5(6.3%)
3(3.2%)
2
Resided in CRF/CCC
17(39.5%)
31(39.2%)
42(52.5%)
Not Yet Released
4(7.5%)
-2(2.1%)
Notes:
1)
1 1st releases are based on: 1) CDP group – 1st release following most recent referral to CDP, 2) CMHS
group – closest release to referral date,3) CMHI-Comp – 1st release following 2003-2005 eligibility.
2)
2 Percentages of those who resided in a CRF/CCC are reported out of the total number of offenders in that
group on supervised release (i.e., the total n for that group minus the number of offenders released at warrant expiry
or not yet released: 17/43 for CDP, 31/79 for CMHS and 42/80 for CMHI-Comparison Group.
3)
CMHS services are not provided to offenders released at WED because CSC does not have jurisdiction
over offenders beyond their warrant expiry dates.
4)
Post-hoc comparisons between pairs of groups were completed, where the overall test was significant, to
determine whether there were any differences among the three groups. Statistically significant differences between
the groups are identified with an a, b at p < .05.
Suspensions and Revocations
Preliminary recidivism outcomes for the CDP, CMHS, and comparison groups were
assessed. It is important to note that caution is needed in interpreting the results due to
methodological limitations such as short follow-up periods for the CDP and CMHS groups and
small sample sizes as well as pre-existing group differences in reintegration potential (a proximal
measure of risk and need). Suspension and revocation outcomes for the three groups are
presented in Figure 24 (see Appendix F for additional statistics).
96
Percentage (%)
Figure 24: Suspension and Revocation Rates for CDP, CMHS, and Comparison Groups at
the 6-Month Follow-Up
90
80
70
60
50
40
30
20
10
0
CDP (n=20)
CMHS (n =61)
Comparison (n=68)
Suspension
Revocation
Correctional Outcomes (Prior to WED)
Note: The values in parentheses represent the number of offenders who had at least 6-months of follow up for each
group.
It is important to note that there were pre-existing differences between the groups on a
number of demographic and risk-related variables and therefore the results in Figure 24 may be
misleading. In addition, there were variable follow-up periods for each of the groups, with an
average of 6.4 months for CDP, 8.4 months (CMHS), and 14.0 months for the CMHI
Comparison Group (CSC, 2008d). In order to control for follow-up time and any potential preexisting differences between the treatment and comparison groups, Cox regression analyses were
conducted.
Survival Analysis
Pre-existing differences between the groups, particularly when the groups differ on
variables that are related to risk of recidivism, may lead to difficulties in interpreting results, as
any difference in recidivism between groups may be due to these pre-existing factors rather than
the treatment (in this case, CMHI services). As such, Cox regression analysis was used to
examine differences in survival rates after statistically controlling for pre-existing differences in
age at release, reintegration potential, and functional impairment.
97
Two sets of Cox regression analyses were conducted to examine whether the likelihood
of being suspended and revoked differ between three treatment groups (i.e., CDP, CMHS, and
comparison) after controlling for age at release, functional impairment, and reintegration
potential. For each analysis, age at release, functional impairment, and reintegration potential
were entered into block 1, group was entered into block 2, and time at risk 38 was entered as the
dependent variable. Offenders who “survived” were those who did not receive a suspension (or
revocation) whereas offenders who “failed” were those who were suspended (or revoked).
Suspension. After controlling for pre-existing differences in age at release, functional
impairment, and reintegration potential, there was a significant group effect on survival (refer to
Figure 25). Specifically, the CMHS group was 34% less likely to be suspended than the
comparison group (refer to Table e in Appendix F) and the CMHS group was 42% less likely to
be suspended than the CDP group (refer to Table f in Appendix F). There was no significant
difference between the CDP and comparison groups.
38
For suspensions, time at risk was the time between release into the community and date of suspension. For
revocations, time at risk was the time between release and the date of revocation.
98
Figure 25: Survival Function for the CDP, CMHS, and Comparison Groups (Suspensions)
Note. Results indicate that CMHS group was suspended at a significantly lower rate than the CDP and CMHS
groups. A point on the lines represents the proportion of offenders who have not been suspended at that point in
time. Time 0 represents release date where 100% of the three groups have “survived” (i.e., not suspended). Note that
results shown in the graph after 6 months should be interpreted with caution, as not all treatment group members
were followed-up past that time.
Revocation. After controlling for pre-existing differences in age at release, functional
impairment, and reintegration potential, there was a significant group effect on survival when
examining likelihood of revocation of release (refer to Figure 26). Specifically, the CMHS group
was 59% less likely to have their release revoked than the comparison group (refer to Table g in
Appendix F), and the CMHS group was 60% less likely to be revoked than the CDP group (refer
to Table h in Appendix F). There was no significant difference between the CDP and comparison
groups on likelihood of revocation.
99
Figure 26: Survival Function for the CDP, CMHS, and Comparison Groups (Revocations)
Note. Results indicate that CMHS group was revoked at a significantly lower rate than the CDP and comparison
groups. A point on the lines represents the proportion of offenders whose release has not been revoked at that point
in time. Time 0 represents release date where 100% of the three groups have “survived” (i.e., not revoked). Note that
results shown in the graph after 6 months should be interpreted with caution, as not all treatment group members
were followed-up past that time.
Although caution is needed due to methodological limitations (e.g., short follow-up,
small sample sizes), preliminary results suggest that CMHS is related to a reduction in rates of
suspension and revocations whereas there is no evidence to suggest that CDP has an effect on
these two outcomes when compared to the comparison group. The fact that the CDP group was
also found to be different from the comparison group with respect to a number of factors (e.g.,
level of functioning, reintegration potential) should also be taken into account when interpreting
these analyses. That, combined with the short follow-up times, indicates that it will be important
100
for these analyses to be conducted again in several years following full implementation and
greater offender participation in the initiative.
Continuity of care in the community has frequently been identified as an important factor
in the safe reintegration of offenders into the community. Whereas discharge planning may help
to identify needs, it may not be sufficient if these plans are not followed through or implemented
in the community. For those CDP offenders who did not receive CMHS services, there is no
readily available information regarding any types of services that CDP offenders may have
received in the community upon release. As of June 2008, only 23 offenders in CMHI databases
had received both CDP and CMHS services. There may be various reasons for this, including the
fact that CDP offenders may be released to non-CMHS sites, or that late implementation of
discharge planning services or community specialist services may have resulted in a lack of
continuity in services. Furthermore, results presented earlier indicated that discharge planning
was not occurring within the suggested timelines (5 months rather than 9 months prior to
anticipated release date). The delay in delivery of CDP services may have reduced the time
available to coordinate community services for CDP offenders, ultimately having a negative
impact on post-release outcomes. Although preliminary, the results thus far related to community
outcomes for CDP offenders suggest that it will be important to ensure continuity of services for
CDP offenders following release from CSC institutions, either through the provision of CMHS
services (if CDP offenders are released to CMHS sites), or through links to other community
services (if CDP offenders are not released to CMHS sites).
RECOMMENDATION 10: CSC should review the possible reasons for lack of continuity
from CDP services to CMHS services. Based on this review, CSC should develop strategies
and procedures to better impact community reintegration for CDP offenders.
Evaluation Objective 4: Cost-Effectiveness
Cost-effectiveness determines the relationship between the amount spent and the results achieved
relative to alternative design and delivery approaches.
101
FINDING 17: Although the CMHI has demonstrated several positive short-term outcomes,
limitations related to financial coding and the short implementation period precluded the
ability to conduct a reliable cost-effectiveness analysis at this stage of the CMHI.
In order to conduct cost-effectiveness analysis, cost-savings associated with decreased
recidivism (i.e., reduced institutional costs because an offender is maintained in the community)
would be compared to the program costs to determine overall dollar return on investment. For
example, results indicated that CMHS participants were less likely than the comparison group to
be revoked. Thus, the likelihood of remaining in the community without returning (technical
revocation) would be converted to the number of days participants successfully remained in the
community versus the comparison group in order to determine the cost savings due to CMHS
participation. Specifically, the CMHS and CMHI comparison group would be compared, where
calculations considered the daily cost to incarcerate an inmate, offset by the extended daily cost
of supervising an offender in the community. Finally, cost savings (positive or negative) would
be compared to the unit costs of delivering the CMHI, to calculate the overall dollar return per
dollar invested (e.g., each $1.00 spent results in a return of $x).
However, there are several challenges associated with conducting a cost-effectiveness
analysis at this stage of the CMHI implementation. In order to effectively conduct a costeffectiveness analysis, a minimum of one full year of initiative implementation with associated
financial data for that year would be necessary, as well as an adequate follow-up time (generally
two years), to assess outcomes in the community. Currently the CMHI has only been fully
operational for part of 2007/08, so a full year of implementation and associated financial data do
not exist.
Furthermore, to conduct the cost-effectiveness analysis, the average length of time that
treatment groups remain in the community longer than comparison groups would be assessed to
determine the costs saved (i.e., because supervision costs less than institutionalization). Given
the late implementation of the initiative, there are limited follow-up data. Specifically, only 20
CDP offenders and 61 CMHS offenders had six months of follow-up data related to the outcome
analysis (i.e., suspensions, revocations), making any analyses conducted regarding community
outcomes preliminary only. Such a short follow-up period would result in a truncated average
time spent in the community which would impact upon the ability to detect differences between
the groups with respect to survival time, and ultimately the ability to accurately determine any
102
potential cost savings of the initiative. At least several years of follow-up data should be
available in order to adequately conduct a cost-effectiveness analysis of this nature.
In addition, it was noted in the previous section that the financial coding for the CMHI
has varied somewhat over time and across regions, with some regions utilizing the specific
financial codes to record financial expenditures for different types of treatment services (CDP
and CMHS), and other regions appearing to utilize the more generic “Mental Health Community
Strategy” to code this financial information.
The impact of these challenges, particularly the length of follow-up, on cost-effectiveness
will become apparent after considering the following information. Given the current concerns
regarding the length of follow-up time for outcome analysis, a different approach to costeffectiveness analysis was taken, to determine the number of days that CMHS participants would
need to remain in the community to offset program costs. In order to do so, it was necessary to
provide estimates of program costs, the average daily cost of maintaining an offender in an
institution, and the average daily cost of managing an offender in the community. Furthermore,
since initial effectiveness was demonstrated by the CMHS group (in that the CMHS group was
less likely to be suspended or revoked than the CMHI comparison group), the CMHS group was
chosen to illustrate the hypothetical cost-analysis below.
The average cost of providing CMHS services in fiscal year 2007/08 was determined
based on national CMHI expenditures (see Table 29).
Table 29: National CMHI Operating and Salary Costs for 2007/08
Actual Expenditure
Mental Health Community
Strategy
CDP
CMHS
Training
Contracts
Adjunctive Services
Evaluation and Research
Management and Coordination
Total
210 - Salaries
$84,020
240 - Operating
$48,408
$383,909
$700,161
$0
$0
$0
$115,794
$608,328
$1,892,212
$32,341
$48,819
$87,192
$876,779
$10,222
$1,521
$222,263
$1,327,545
103
In order to calculate CMHS program costs, all national CMHS costs were included (but
CDP costs – the other main treatment group - were excluded). 39 Valuation and research costs
were excluded as they were not considered to be annual, fixed, ongoing costs for the initiative.
Half of the dollar amount of all the other cost-centres (mental health community strategy,
training, contracts, adjunctive services, management and coordination) was included in the
CMHS program cost calculations (The remaining half of the cost for each of these cost-centres
was presumed to be associated with the other main treatment group – CDP services). 40 The total
cost associated with CMHS, based on these assumptions, is $1,717,586. This total estimated
value for CMHS services was then divided by the 79 CMHS treatment participants included in
the outcome analysis to obtain the CMHS cost per person which was approximately $21,742.
The daily savings associated with supervising an offender in the community is the
difference between the average daily cost of maintaining an offender in an institution ($241.28)
and the average daily cost of managing an offender in the community ($63.30), which equals
$177.98. 41
In order to simply achieve cost-neutrality, CMHS participants would need to remain in
the community approximately 122 days or approximately 4 months longer than the comparison
39
Note that there were two main treatment groups at the current time. Results have indicated that most offenders
received either CDP or CMHS services. Aside from any costs directly attributed to either of these cost centres, other
peripheral costs (e.g., management and coordination, training, etc.) might be presumed to be associated with either
of these services. Therefore, half of these other costs were assumed to be associated with the cost of CMHS services
(and included in the costs calculated here related to CMHS treatment outcomes), and the remaining costs were
assumed to be associated with CDP services, and excluded from this analysis on CMHS outcomes.
40
Note that there may be a number of limitations with this estimate of the CMHS cost analysis, including the fact
that the CMHS services were not operational for a full year, the fact that financial data were not always coded
consistently, and the fact that there may be other treatment groups/effects that may emerge after longer
implementation. For example, there are a number of offenders who were receiving contract services. Currently, 5%
of offenders who received contract services where CDP recipients, and 29% of those who received contract services
were CMHS recipients. Given that most regions had contract services in place prior to the initiation of CDP and
CMHS services, it is unclear whether these contract services will be utilized primarily by CMHS and CDP groups in
the future (and costs should be attributed to these two treatment groups), or whether there may be other groups of
offenders who might receive only contract services. If the latter is the case, it is possible that there may be a
treatment effect attributed solely to the use of contract services, in which case financial costs associated with
contract services should not be included in these CMHS service costs. However, this is something that cannot be
determined at this time, and as such, cost calculations from CMHS services were calculated based on the two
treatment groups that have been established and assessed to date, but could potentially be somewhat overestimated.
In future years, following more extensive implementation time and more consistent financial coding, better
estimates of CMHS costs should be possible.
41
Note that these costs were reported based on the costs of maintaining an offender in 2005/06 as reported in the
Corrections and Conditional Release Statistical Overview; Annual Report, 2007. The Annual Report for 2008 was
not available at the time that this report was written, but more current financial data regarding the cost of
maintaining an offender will need to be obtained when the cost effectiveness analysis of this program is conducted
in the future.
104
group (program cost per offender divided by the daily cost-saving or $21,742/$177.98; refer to
Table 30). In order to achieve a 50% return (e.g., $1.50 for every $1.00 spent), CMHS
participants would need to remain in the community 183 days or approximately 6 months longer
than the comparison group (122 days x 1.5).
Table 30: Cost-Savings Analyses for CMHS Participants
Return on CMHS Dollar
Investment
Program Cost
(B)
Daily Savings
(difference between
costs of maintaining an
offender in an institution
and in the community)
(C)
Number of days that
CMHS group would
need to remain in the
community beyond the
comparison group
(A*B/C)
(A)
$1.00
$21,742
$177.98
122 days
$1.50
$21,742
$177.98
183 days
These results, although entirely achievable, demonstrate the limitations of trying to
conduct a cost-effectiveness analysis at this stage of the CMHI implementation, when only
approximately 6 months of follow-up data are available (i.e., even if there were significant cost
savings, it is unlikely that they could be detected with such a truncated follow-up time in the
community). 42
The CMHI has demonstrated several benefits even at this early stage of implementation,
including positive impacts on staff awareness and competency related to CMHI training,
increased capacity building and access to services for offenders with mental health needs in the
community, and reductions in suspensions and revocations for CMHS participants. However,
given the current state of implementation (and resulting short follow-up period for long-term
impacts), as well as issues related to recording of financial data, it is premature to conduct costeffectiveness analysis at this time. It would be recommended to conduct this analysis after at
least 2 more years, assuming that financial data are accurately recorded in the future.
42
At the time of this evaluation, with 6 months of follow-up, a cost-effectiveness analysis cannot adequately be
conducted. Results based on the data available to date indicates that the average number of days between release and
revocation for the CMHS and comparison groups were 127 and 109 days, indicating that the CMHS group stayed in
the community an average of 18 days longer than the comparison group.
105
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110
Appendices
111
Appendix A: Community Mental Health Initiative Evaluation Matrix
Evaluation Objective: Continued Relevance
The extent to which the Initiative remains consistent with departmental and government-wide priorities, and realistically addresses actual needs.
Evaluation Question
Performance Indicator
Source
Responsibility
1. What role does the
● Alignment of the Initiative to
● Comparison of PAA, Corporate
● Evaluation Branch
enhancement of CSC’s
CSC’s Program Activity
Priorities, Corporate Risk Profile,
community mental health strategy
Architecture (PAA) and Corporate
and Initiative objectives
● Literature review
play in accommodating and rePriorities
integrating offenders into the
community?
2. Does the strategy support the
● Key documents (e.g., 2007
● Evaluation Branch
● Document review to identify
public policy objectives of the
Speech from the Throne, CCRA,
government support for the
government?
Corporate Priorities, Corporate
initiative
Risk Profile, Out of the Shadows
at Last – the Kirby Report,
Government of Canada’s mental
health strategy, Government of
Canada budgets, World Health
Organization documentation,
CMHI key documents, CSC Panel
Review)
3. Is there a need for the Initiative
● Number of offenders who have
● Documents (e.g., OIA, referrals
● Evaluation Branch
to continue?
benefited from the Initiative
for services, preliminary literature
● Number and profile of offenders
on intake screening tool pilot
with mental health issues
projects)
● Review of Changing Offender
Profile literature
4. Is the CMHI consistent with
● Comparison of costs between
● Review of relevant literature
● Evaluation Branch
other jurisdictions’ practices?
CSC and other jurisdictions who
● Review of Roundtable
provide specific resources to
jurisdictions practices and
community released offenders
provincial jurisdictions
with mental disorders
Evaluation Objective: Implementation
The extent to which the Initiative was organized or delivered in such a way that goals and objectives can be achieved. This involves appropriate
and logical linkages between activities, outputs, outcomes and long-term outcomes.
112
Evaluation Question
1. Is the Initiative being delivered
as designed?
2. Are there any operational
constraints or implementation
challenges that limit the ability of
the Initiative to achieve the
objectives or expected results and
outcomes?
3. Are the most appropriate
offenders being identified and
included in the Initiative?
4. Are the parole offices selected
under the CMHI receiving the
majority of offenders with mental
Performance Indicator
● A review of national
implementation challenges and
best practices (i.e. staffing,
funding, etc.)
● Key informant survey responses
suggesting implementation issues
and timeliness of service delivery
● Establish implementation
timeline with challenges and best
practices identified with NHQ
Health Services management
● RPC Implementation Report
reviews implementation dates,
outputs, and timeliness of
intervention
● Staff that can provide details on
the achievements of the initiative
(i.e. discharge planning,
community care plans, contracted
services, and the timeliness of
intervention)
● Establish implementation
timeline with challenges and best
practices identified with NHQ
Health Services management
● Percentage of offenders who
meet criteria for Initiative services
targeted by the Initiative
● Percentage of offenders who
meet criteria for Initiative services
not targeted by the Initiative
● Perceptions of stakeholders
regarding appropriate
identification (i.e., are the referral
criteria appropriate)
● The 16 community sites
selected had the highest
percentages of offenders with the
Source
● Review of RPC Implementation
Report
● Review of Regional
Implementation Model
● Key informant survey
● Consultation with NHQ Health
Services management
Responsibility
●Regional Psychiatric
Center/Health Services
● Evaluation Branch
● Review of RPC Implementation
Report
● Key informant survey
● Consultation with NHQ Health
Services management
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
● Review of RPC PreImplementation and
Implementation Reports
● Survey of key informants
● Interviews with offenders
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
● Geographical mapping of all
offenders with mental disorders on
community release
● Evaluation Branch
113
disorders on release?
5. Have the funds been spent as
planned?
OIA indicator “diagnosed as
disordered currently”
● Examination of community
released offenders with mental
disorders in relation to where
services are provided (i.e.
offenders who received discharge
planning services but were not
released to CMHI parole offices)
● Establish implementation
timeline with challenges and best
practices identified with NHQ
Health Services management
● Financial documents and files,
including the Regional
Implementation Model and
Integrated Financial and Material
Management System (IFMMS) to
identify any gaps, lapses, or
reallocation in funding
● Key stakeholder perceptions of
reasons for gaps, lapses, or
reallocation in funding
● Perceptions of senior
management and stakeholders
involved in the implementation of
the initiative
● Review of financial documents
and files
● Key informant interviews
● Evaluation Branch
Evaluation Objective: Success
The extent to which the Initiative is the delivering the expected outputs, outcomes and objectives in relation to resources used.
Evaluation Question
Performance Indicator
Source
Responsibility
Efficiency
1. To what extent has the CMHI
● Review of RPC Implementation
● Discharge plans have been
● Evaluation Branch
been successful in achieving the
created for all offenders who meet and Post-Implementation Reports
following expected outputs in an
● HS staff training report
criteria and performed in a timely
efficient and timely manner: (1)
● Key informant interviews with
manner
training; (2) discharge planning;
staff and community contracts
● Number and types of contracts
(3) services in the community?
with community agencies to
provide services for offenders and
performed in a timely manner
● Number of CMHI staff hired is
equal to number of positions
originally allocated
114
● Mental health awareness
training has been conducted in all
designated CMHS parole offices
(number of staff trained, increased
confidence to work with OMD
following training)
● Key informant interviews
regarding improved confidence to
work with OMD following staff
training
Effectiveness
1. To what extent is there an
increased awareness amongst
staff of mental health issues?
2. To what extent is there an
increased availability of services
and offenders’ access to these
services?
3. To what extent has there been
an increased community capacity
to deal with the needs of offenders
with serious mental disorders?
4. To what extent has the Initiative
resulted in improved immediate
and intermediate correctional
outcomes?
● Staff report increased
awareness of mental health issues
following training and an
increased ability/self-efficacy in
managing the needs of OMDs in
the community
● Number of contracts and
agreements established with
community agencies as a result of
the Initiative
● Number of community capacity
building records submitted as a
result of the Initiative
● Perceptions of offenders, staff,
and stakeholders as to the ability
to address offender needs
● Number of community capacity
building records submitted as a
result of the Initiative
● Perceptions of offenders, staff,
and stakeholders as to the ability
to address offender needs
● Decrease in revocation and
recidivism rates
● Decrease in offenders UAL
● Increased length of time on
community release
● Pre/Post training questionnaires
with staff members
● Key informant survey results of
those who participated in the
training
● Health Services
● Evaluation Branch
● Survey of staff and community
stakeholder informants
● Interviews with offenders
● Review of RPC Implementation
and Post-Implementation Reports
● Alberta Continuity Services
Scale for Mental Health
administered after the interview
with the Evaluation team
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
● Review of RPC Implementation
and Post-Implementation Reports
● Survey of staff and community
stakeholder informants
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
● Review of RPC Implementation
and Post-Implementation Reports
● OMS, CPIC
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
115
5. Has the Initiative resulted in
improved quality of life for
offenders with mental disorders?
● Increase in discretionary
releases (only applicable for those
that received discharge planning
service)
● Perceptions of offenders and
staff as to whether or not the
initiative has improved offenders’
quality of life
● Quality of Life instrument used
at three-month intervals postrelease to assess the offender’s
self perceived quality of life and
after the interview
● Survey of key informants
● Interviews with offenders
● Quality of Life Scale repeated
measures data from the RPC
Post-Implementation Report
● Quality of Life Scale
administered after interview with
Evaluation team
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
Evaluation Objective: CostEffectiveness
The extent to which the initiative
demonstrates value for money.
Evaluation Question
1. What evidence exists that the
Initiative produces value for
money?
Performance Indicator
Source
● Success of funded activities
● Review of RPC Implementation
● Cost-savings of providing
and Post-Implementation Reports
● Review of financial data to
services to offenders through the
examine costs of the Initiative
Initiative compared to the cost of
● Cost of Maintaining Offenders
incarcerating these offenders in
(COMO) database
either regular institutions or
RPC/RTC
2. Is CSC providing cost effective
● Comparison of costs between
● Review of relevant literature
interventions in relation to other
CSC and other jurisdictions who
● Review of Roundtable
jurisdictions (i.e., the provinces,
provide specific resources to
jurisdictions practices and
other countries)?
community released offenders
provincial jurisdictions
with mental disorders
Evaluation Objective: Unintended Findings
The extent to which the Initiative created any unintended positive and/or negative outcomes
Evaluation Question
Performance Indicator
Source
1. Have there been any other
● Views of senior management,
● Survey of staff and community
impacts or effects resulting from
staff, offenders, community
stakeholders
● Interviews with offenders
the initiative?
stakeholders regarding any
unintended impacts
Review of documents and files
116
Responsibility
● Regional Psychiatric
Center/Health Services
● Evaluation Branch
● Evaluation Branch
Responsibility
● Evaluation Branch
117
Appendix B: CSC's Community Mental Health Initiative Logic Model
Activities
Output
Staff
training
Hiring of mental health
staff for community sites
• Standardized national mental
health training package.
• Qualified trainers in each region.
• Trained front-line staff at
identified sites.
• Community Mental Health
Nurses and Clinical Social
Workers hired
• Community care plans developed
for targeted offenders
Discharge
Planning
Establishing contracts and agreements for
enhanced services for community OMDs
• Discharge Planners
hired
• Discharge plans
developed for
targeted offenders
• Contracts and
agreements
established
Immediate
Staff has increased awareness
Standardized
Offenders are accessing
Increased availability of services and support for offenders
Outcomes
of mental health issues
provision of services
available services
with mental disorders being released and in the community
Intermediate
Outcomes
Ultimate
Outcomes
Improved services for offenders
Improved correctional outcomes for
Improved quality of life for
with mental disorders
offenders with mental disorders
offenders with mental disorders
The Community Mental Health Initiative contributes to the safe accommodation and reintegration of offenders into
Canadian communities by providing them with reasonable access to mental health care.
118
Appendix C: Themes from Open-Ended Questions Survey and Interview Questions
General Notes:
• This Appendix provides information regarding themes from open-ended survey questions. Responses to dichotomous (yes-no)
and rating scale questions are reported in the text of the document.
• Percentages were calculated using total number of respondents who had the opportunity to respond to the question.
• Note that total percentages may not sum to 100% since multiple themes were noted by individual respondents.
• Note that only responses to questions where clear themes emerged relevant to the evaluation questions are listed here. In some
cases, few responses were generated by interviewees or survey respondents, or no clear themes emerged based on the
responses that were generated. Thus, some questions may not be shown here due to lack of clear emerging themes.
Themes from Staff Surveys
Design and Implementation
If there were offenders who did not receive services (if you responded 2-4 in Question B2), why not (please indicate all that
apply)? Other response.
Theme
Staff (n = 49)
Referrals for services were not being made/offenders not identified for services
18 (36.7%)
Referrals were made but services were not available (e.g., no staff in position)
9 (18.4%)
Staff members are unclear of roles and responsibilities of CMHI staff/unfamiliar with services offered through CMHI (e.g., had
not received sufficient information about the CMHI to utilize the service)
5 (10.2%)
Please explain why you feel offenders are not attending mental health interventions/services to which they were referred
Staff (n = 25)
Theme
119
Offenders don’t want services, don’t think they need them, or refuse to participate in treatment
11 (44.0%)
Lack of supports/services in the community
5 (20.0%)
Please explain why you feel offenders are not being referred to community-based services for mental health interventions
Staff (n = 43)
Theme
Lack of services/resources in place for offenders
12 (27.9%)
Staff are unfamiliar with/not aware of the services of the CMHI
6 (14.0%)
Lack of communication/consultation with CMHI staff
4 (9.3%)
CMHI service is not available at the site/position not staffed so referrals cannot were not made
4 (9.3%)
Offenders not being identified/inclusion criteria excludes offenders who are not diagnosed
3 (7.0%)
According to the guidelines, referral to discharge planners should occur within 9 months of offender’s scheduled release. If
you indicated that that 9- month target is not appropriate, please explain why.
Staff (n = 71)
Theme
Timeframe too short (Total):
38 (55.5%)
a) General statement that timeframe is too short (k=11)
b) Need more time to address/meet the needs (k=10)
c) Waitlists for programs may be long (k=3)
d) Need more time to build rapport (k=4)
Timeframe too long (Total)
22 (31.0%)
a) General statement that timeframe is too long (k=9)
b) Offenders’ needs change over time (k=7)
c) Services cannot be arranged so far in advance/opportunities or availability of services may change (k=6)
Process should begin at institutional intake
8 (11.3%)
120
How many months prior to release should referral for clinical discharge planning be initiated?
Staff (n = 71)
Theme
0 – 4 months
18 (25.4%)
5 – 9 months
14 (19.7%)
10 -14 months
20 (28.2%)
15 or more months (max of 2 years)
9 (12.7%)
According to the guidelines, referral to community mental health specialists by Community Parole Officers should occur
within 24 hours of the offender’s release. If you feel this timeframe is not appropriate, please explain why.
Staff (n = 133)
Theme
More work needs to be completed prior to release/referral should occur prior to release
49 (36.8%)
More time is needed for PO to complete the necessary work (e.g., to ensure continuum of care, improve integration, build
rapport; insufficient time)
Staff scheduling conflicts that do not permit referral within the timeframe (e.g., releases on Friday/pre-weekend; PO away)
36 (27.1%)
General comment indicating timeline is unrealistic or unreasonable
10 (7.5%)
Shortage of services; backlogs/waitlists for services or appointments
9 (6.8%)
14 (10.5%)
When should referrals to the community mental health specialists occur (e.g., 1 week prior to release, at release, within 1 week
of release)?
Staff (n = 133)
Theme
Prior to release
59 (44.4%)
1 week before (k=25)
From 1 to 4 weeks (k=17)
Over 4 weeks (k = 5)
Non-specific (k= 12)
Within 1 week after release
27 (20.3%)
Between 1 week after release and 1 month
11 (8.3%)
121
If you are aware of mechanisms/procedures in place for Community Mental Health Specialists to facilitate the continuity of
care/services for offenders after sentence completion (i.e., after WED), please describe them and indicate whether they are
adequate
Staff (n = 65)
Theme
Contact with/refer to non-governmental community-based providers (e.g., Canadian Mental Health Association, psychiatrists,
hospitals) before WED to ensure services will be available after WED
Contact/refer to government agencies/departments (e.g., provincial health, Social Services)
29 (44.6%)
10 (15.4%)
Please describe any suggestions that you have to facilitate continuity of care/services after sentence completion
Staff (n = 218)
Theme
Refer offenders to service providers who can provide services after WED (e.g., provincial mental health) or arrange
appointments/case conferences with agencies involved in post-WED care
CSC/CMHI staff provide follow-up for a short-term/long-term/temporary basis or as needed
46 (21.1%)
Pre-WED planning (non-specific)
12 (5.5%)
Develop partnerships/MOU/agreement/information sharing with service providers (government or non-government) to provide
services beyond WED
11 (5.0%)
19 (8.7%)
Unintended Outcomes
Is there anything about the Community Mental Health Initiative that you feel could be changed to improve the correctional
outcomes for offenders participating in the initiative? If yes, briefly describe.
Staff (n = 212)
Theme
Staffing issues:
a)
General comment to increase staff (k=9)
b)
Hire more discharge planners (k=9)
c)
Hire more community mental health specialists (i.e., nurses and clinical social workers) (k=8)
d)
Hire more psychologists/psychiatrists (k=7)
e)
Improve recruitment and retention of qualified personnel (e.g., permanent positions rather than contract; competitive
salary) (k=13)
122
46 (21.7%)
Improve communication, information-sharing, and collaboration between institutional staff and community staff (e.g.,
correctional and mental health staff)
Increase services
a)
Increase funding/resources (non-specific) (k=19)
b)
Expand CMHI services into other/rural areas (k=12)
Provide/increase general mental health training to CSC staff members (e.g., so that staff members can recognize mental
health symptoms; reduce stigma; increase awareness)
Develop partnerships/establish contracts with community mental health care providers and other service agencies
43 (20.3%)
Provide training/information session/workshops about the CMHI (e.g., CMHI staff roles and responsibilities)
18 (8.5%)
Inclusion criteria is too restrictive; OMDs without diagnoses but nonetheless require mental health services cannot access the
needed services/resources
There is a need for post-WED planning to ensure that offenders have access to services beyond WED
12 (5.7%)
More timely referrals/earlier referrals to discharge planning services
12 (5.7%)
Changes to reporting practices (e.g., reduce paperwork, reduce repetition in reports)
7 (3.3%)
31 (14.6%)
29 (13.7%)
23 (10.8%)
12 (5.7%)
Please describe lessons learned and best practices in the implementation of the Community Mental Health Initiative
Staff (n = 526)
Theme
Increase communication and collaboration among the parties involved in offender case management
32 (6.1%)
Staffing was a challenging process (e.g., timely staffing, clear roles and job descriptions)
15 (2.9%)
Services for special populations (e.g., women and Aboriginal offenders and offenders with FASD) and in rural areas need to
be improved/increased
Discharge planning needs to start early in the process and should include community staff
13 (2.5%)
Provide training/workshops about the CMHI (e.g., services provided, roles and responsibilities)
11 (2.1%)
Training and education on mental health issues is important/needs to be provided to staff
11 (2.1%)
Need to build community capacity/networks
9 (1.7%)
Consult with frontline staff on program design
6 (1.1%)
Too much paperwork; paperwork is repetitive/takes time away from provision of services; revise reporting format to facilitate
case management/communication
Importance of providing follow up
6 (1.1%)
Develop relationship with offender (e.g., advocacy, rapport)
5 (1.0%)
123
12 (2.3%)
6 (1.1%)
Is there anything else you would like to add?
Staff (n = 526)
Theme
Information sharing/communication among stakeholders involved in the management of offenders with mental disorders
(e.g., POs, IMHT, CMHI, service providers); case conference/team approach
Mental health education/training for CSC staff (k=17)
a)
Correctional officers (k=1)
b)
Other institutional staff (k=1)
c)
Cross-training (k=4)
Increase funding/resources in the community (including Community Mental Health Specialists); increase community
capacity/collaboration with community service providers
Program needs to be continued/funded/expanded/increased to other sites
24 (4.6%)
Difficulties in staffing (e.g., positions not staffed, delay, permanent positions)
13 (2.5%)
Increase mental health resources and services in the institutions
13(2.5%)
Training/workshop on the CMHI (e.g., services provided, roles and responsibilities, procedures)
9 (1.7%)
124
23 (4.4%)
19 (3.6%)
18 (3.4%)
Themes from Offender Interviews
Overall Experience
In your opinion, do you think the services you have received within the Community Mental Health Initiative have helped you
to be able to live successfully in the community?
Theme
Offenders (n=33)
Negative
---
---
Positive
Staff help me to gain access to specific services (e.g., housing, counselling, programs)
4 (12.1%)
Staff provide support/monitoring (non-specific)
9 (27.3%)
What was the most helpful aspect of the Community Mental Health Initiative?
Theme
Offenders (n=33)
Staff provided support (non-specific)
18 (54.5%)
Staff members helped me get access to medication/medication information
7 (21.2%)
Staff members helped me obtain basic necessities (e.g., housing, transportation, identification)
6 (18.2%)
Overall, to what extent do you feel that you have all the needed services in place for you once you reach the end of your
sentence?
Theme
Offenders (n=33)
Needed services are in place
7 (21.2%)
Concerned about having access to services after warrant expiry (WED)
5 (15.2%)
125
Would you recommend the services you have received within the Community Mental Health Initiative to a friend?
Theme
Offenders (n=33)
Yes
Can be beneficial/helpful (non-specific)
15 (45.5%)
CMHI facilitates access to services (e.g., faster, less stressful)
5 (15.2%)
126
Themes from Community-Based Service Provider Surveys
Relevance
Specify other need addresses by your organization
Theme
Personal support (e.g., provide assistance in personal management skills and personal care)
Community
Service Providers
(n = 6)
4 (67%)
Design and Implementation
Explain why you feel the right offenders are not being identified
Theme
Criteria for inclusion/requirement of diagnosis excludes offenders who still require help
Community
Service Providers
(n = 3)
3 (100%)
Describe strategies that may be useful in overcoming these implementation challenges
Theme
Increase communication between case management staff and community service providers (e.g., include providers in case
management meetings)
127
Community
Service Providers
(n = 14)
4 (29%)
Success
Describe the process involved in continuing services to federal offenders after WED
Theme
Community
Service Providers
(n = 10)
6 (60%)
Request as needed/apply
Refer to other service providers
2 (20%)
Describe changes to services provided to federal offenders after they have completed their community supervision
Theme
Community
Service Providers
(n = 5)
3 (60%)
CSC does not fund services beyond WED
Unintended Outcomes
Describe changes to the CMHI that could improve correctional outcomes of offenders
Theme
Community
Service Providers
(n = 14)
4 (29%)
Increase funding/services
Ensure services are available after WED
2 (14%)
Describe changes to CMHI that could improve the mental health outcomes of CMHI offenders
Theme
Community
Service Providers
(n = 14)
128
Increase funding/services
3 (21%)
Increase participation of community service provider in case management meetings
2 (14%)
Describe lessons learned and best practices in the implementation of the CMHI
Theme
Community
Service Providers
(n = 14)
6 (43%)
Team approach to managing these offenders
129
Appendix D: Referral Profiles from RPC Implementation Report #2
Table D1: Profile of all offenders referred for CDP service by Region
Demographic Variables
Age at Referral – Years
% (n) Gender – Male
% (n) Race – Aboriginal
% (n) Missing
Criminal History & Risk Variables
% (n) Alerts/Flags/Needs – Yes
% (n) Missing
Reintegration Potential
% (n) High
% (n) Medium
% (n) Low
% (n) Missing Data
Type of Offence
% (n) Schedule I
Provincial
% (n) Schedule II
Provincial
% (n) Other
% (n) Dangerous Offender or Lifer
Mean Sentence Length – Years
Offender Security Level
% (n) Maximum
% (n) Medium
National
(N = 242)
Atlantic
(N = 55)
Ontario
(N = 9)
Pacific
(N = 38)
Prairies
(N = 125)
Quebec
(N = 15)
33.8
86 (208)
35 (85)
1 (3)
33.2
75 (41)
9 (5)
2 (1)
40.7
100 (9)
11 (1)
0
36.2
87 (33)
40 (15)
0
32.3
89 (111)
50 (63)
2 (2)
37.4
93 (14)
7 (1)
0
71 (172)
13 (32)
76 (42)
9 (5)
100 (9)
0
53 (20)
11 (4)
74 (92)
16 (20)
60 (9)
20 (3)
10 (25)
31 (74)
48 (115)
12 (28)
20 (11)
38 (21)
35 (19)
7 (4)
0
56 (5)
33 (3)
11 (1)
3 (1)
26 (10)
61 (23)
11 (4)
9 (11)
29 (36)
50 (62)
13 (16)
13 (2)
13 (2)
53 (8)
20 (3)
66 (159)
0.4 (1)
7 (16)
0.4 (1)
27 (65)
14 (34)
3.9
62 (34)
2 (1)
11 (6)
2 (1)
24 (13)
0
3.9
67 (6)
0
0
0
33 (3)
0
3.7
68 (26)
0
3 (1)
0
29 (11)
0
4.3
66 (82)
0
6 (8)
0
28 (35)
27 (34)
3.8
73 (11)
0
7(1)
0
20 (3)
0
3.7
23 (55)
54 (130)
26 (14)
53 (29)
0
100 (9)
50 (19)
50 (19)
15 (19)
52 (65)
20 (3)
53 (8)
130
% (n) Minimum
% (n) Missing Data
CMHI Referral Criteria
% (n) Major Mental Disorders (MMD)*
% (n) Schizophrenia/Other Psychotic Disorder
% (n) Mood Disorders
% (n) Other (e.g., PTSD, OCD)
% (n) PD with Functional Impairment
% (n) Acquired Brain Injury/Organic Brain Dysfunction
% (n) Developmental Disability/Intellectual Impairment
% (n) History of Substance Abuse
13 (31)
11 (26)
18 (10)
4 (2)
0
0
0
0
16 (20)
17 (21)
7 (1)
20 (3)
62 (149)
18 (44)
36 (86)
19 (46)
18 (44)
16 (39)
9 (21)
69 (166)
67 (37)
7 (4)
27 (15)
42 (23)
27 (15)
9 (5)
11 (6)
55 (30)
78 (7)
22 (2)
56 (5)
0
11 (1)
0
11 (1)
67 (6)
66 (25)
13 (5)
53 (20)
13 (5)
50 (19)
21 (8)
5 (2)
79 (30)
63 (79)
26 (33)
36 (45)
14 (18)
6 (8)
21 (26)
10 (12)
79 (99)
7 (1)
0
7 (1)
0
7 (1)
0
0
7 (1)
*Note: The categories of MMD do not add up to 100% due to co-morbidity.
131
Table D2: Profile of all offenders referred for CMHS services by region
Demographic Variables
Age at Referral – Years
% (n) Gender – Male
% (n) Race – Aboriginal
Criminal History & Risk Variables
% (n) Alerts/Flags/Needs – Yes
% (n) Missing
Reintegration Potential
% (n) High
% (n) Medium
% (n) Low
% (n) Missing Data
Type of Offence
% (n) Schedule I
Provincial
% (n) Schedule II
% (n) Other
% (n) Missing Data
% (n) Dangerous Offender or Lifer
Mean Sentence Length – Years
Offender Security Level
% (n) Maximum
% (n) Medium
% (n) Minimum
% (n) Provincial
% (n) Missing Data
CMHI Referral Criteria
% (n) Major Mental Disorders (MMD)
% (n) Schizophrenia/Other Psychotic Disorder
National
(N = 288)
Atlantic
(N = 76)
Ontario
(N = 53)
Pacific
(N = 59)
Prairies
(N = 86)
Quebec
(N = 14)
36.5
85 (246)
23 (66)
35.6
78 (59)
3 (2)
40.2
98 (52)
25 (13)
36.5
85 (50)
29 (17)
34.7
85 (73)
40 (34)
38.0
86 (12)
0
71 (203)
9 (25)
68 (52)
8 (6)
81 (43)
13 (7)
78 (46)
2 (1)
59 (51)
9 (8)
79 (11)
21 (3)
17 (49)
41 (117)
36 (103)
7 (19)
22 (17)
42 (32)
30 (23)
5 (4)
4 (2)
23 (12)
74 (39)
0
17 (10)
51 (30)
29 (17)
3 (2)
22 (19)
42 (36)
22 (19)
14 (12)
7 (1)
50 (7)
36 (5)
7 (1)
63 (182)
1 (3)
7 (19)
28 (80)
1 (4)
8 (24)
5.1
63 (48)
0
5 (4)
32 (24)
0
0
3.8
77 (41)
0
0
23 (12)
0
0
3.6
54 (32)
5 (3)
8 (5)
32 (19)
0
12 (7)
6.9
56 (48)
0
11 (9)
29 (25)
5 (4)
19 (16)
5.6
93 (13)
0
7 (1)
0
0
7 (1)
6.3
12 (35)
61 (175)
19 (55)
1 (3)
7 (20)
18 (14)
50 (38)
26 (20)
1 (1)
4 (3)
19 (10)
70 (37)
8 (4)
0
4 (2)
10 (6)
64 (38)
15 (9)
3 (2)
7 (4)
5 (4)
61 (52)
22 (19)
0
13 (11)
7 (1)
71 (10)
21 (3)
0
0
60 (174)
18 (51)
70 (53)
5 (4)
47 (25)
25 (13)
61 (36)
24 (14)
59 (51)
19 (16)
64 (9)
29 (4)
132
% (n) Mood Disorders
% (n) Other (e.g., PTSD,OCD)
% (n) PD with Functional Impairment
% (n) Missing Data
% (n) Acquired Brain Injury/Organic Brain Dysfunction
% (n) Developmental Disability/ Intellectual Impairment
% (n) History of Substance Abuse
29 (84)
21 (60)
15 (42)
0.3 (1)
15 (43)
10 (29)
74 (213)
133
41 (31)
34 (26)
17 (13)
0
12 (9)
13 (10)
80 (61)
19 (10)
6 (3)
15 (8)
0
8 (4)
17 (9)
62 (33)
31 (18)
14 (8)
12 (7)
0
25 (15)
7 (4)
78 (46)
26 (22)
24 (21)
15 (13)
0
17 (15)
7 (6)
76 (65)
21 (3)
14 (2)
7 (1)
7 (1)
0
0
57 (8)
Table D3: Number, status and timeliness of CMHI referrals for CDP services by race and gender
Total # Referrals
Clinical Discharge Planning (CDP)
# Referrals
% (n) Accepted
% (n) Commence 1 Month*
% (n) Waitlist
% (n) Missing Data
% (n) Not Accepted
% (n) Does Not Meet Criteria
% (n) Offender Refused
% (n) Resources Available at Destination
% (n) Short Turnaround
% (n) Supports Available in Community
% (n) Remanded to Custody on Release
% (n) Missing Data
Mean Time to Anticipated Release When Referred – Months (n)
Total
Aboriginal
530
151
By Race
NonAboriginal
376
242
73 (176)
80 (141)
14 (25)
6 (10)
14 (34)
47 (16)
12 (4)
3 (1)
32 (11)
3 (1)
3 (1)
13 (32)
5.0 (239)
85
78 (66)
79 (52)
18 (12)
3 (2)
12 (10)
60 (6)
20 (2)
0
10 (1)
0
10 (1)
11 (9)
5.6 (84)
154
70 (108)
81 (88)
11 (12)
7 (8)
15 (23)
39 (9)
9 (2)
4 (1)
43 (10)
4 (1)
0
15 (23)
4.7 (152)
By Gender
Missing
Data
3
3
67 (2)
50 (1)
50 (1)
0
33 (1)
100 (1)
0
0
0
0
0
0
4.9 (3)
*Includes categories ‘commence as soon as possible’, ‘commenced’, and ‘plan to commence within one month’.
134
Male
Female
454
76
208
72 (149)
78 (116)
16 (24)
6 (9)
15 (31)
52 (16)
13 (4)
3 (1)
26 (8)
3 (1)
3 (1)
14 (28)
5.3 (205)
34
79 (27)
93 (25)
4 (1)
4 (1)
9 (3)
0
0
0
100 (3)
0
0
12 (4)
3.6 (34)
Table D4: Number and status of CMHI referrals for CMHS services by race and gender
By Race
Community Mental Health Specialist (CMHS) Services
# Referrals
% (n) Accepted
% (n) Commence 1 Month
% (n) Waitlist
% (n) Offender UAL
% (n) Missing Data
% (n) Not Accepted
% (n) Does not Meet Criteria
% (n) Offender Refused Services
% (n) Offender UAL
% (n) Other
% (n) Missing Data
% (n) Pending
% (n) Missing Data
By Gender
Total
Aboriginal
NonAboriginal
Male
Female
288
66 (190)
75 (143)
5 (9)
0.5 (1)
20 (37)
20 (57)
42 (24)
14 (8)
7 (4)
33 (19)
4 (2)
0.3 (1)
14 (40)
66
68 (45)
71 (32)
2 (1)
2 (1)
24 (11)
24 (16)
31 (5)
25 (4)
19 (3)
25 (4)
0
0
8 (5)
222
65 (145)
77 (111)
6 (8)
0
18 (26)
18 (41)
46 (19)
10 (4)
2 (1)
37 (15)
5 (2)
0.5 (1)
16 (35)
246
66 (162)
74 (120)
5 (8)
1 (1)
20 (33)
21 (51)
45 (23)
16 (8)
4 (2)
33 (17)
2 (1)
0.4 (1)
13 (32)
42
67 (28)
82 (23)
4 (1)
0
14 (4)
14 (6)
17 (1)
0
33 (2)
33 (2)
17 (1)
0
19 (8)
135
Appendix E: Mental Health Training and Results
Table a: Percentage of participants with relative improvement from the post-quiz relative
to the pre-quiz.
Axis I of the DSM IV is used to classify which
area of conditions? (1 point)
List three positive symptoms of
Schizophrenia. (3 points)
In general, offenders with mental disorders
are more violent than offenders without
mental disorders. (1 point)
Identify how the Recovery Model is different
from the Medical Model. (1 point)
List two treatments for Bi Polar Disorder. (2
points)
In North America, mental disorders are
categorized in a manual called the
____________. (1 point)
A fear of abandonment, impulsiveness, and
reactive mood are key characteristics of
which personality disorder? (1 point)
Name three key potential side effects of
psychotropic medications. (3 points)
Name three effective strategies for working
with an offender with FASD. (3 points)
Suicide rates for offenders are similar to
those of the general population. (1 points)
Total Score
Same score on
post
(Improvement
Possible)
4.87% (n = 30)
Same score on
post
(Improvement
Not Possible)
69.48% (n = 428)
19.8% (n = 122)
4.55% (n = 28)
16.23% (n = 100)
76.3% (n = 470)
1.95% (n = 12)
81.01% (n = 499)
14.0% (n = 86)
16.23% (n = 100)
25.97% (n = 160)
55.5% (n = 342)
2.27% (n = 14)
58.76% (n = 362)
33.2% (n = 204)
3.41% (n = 21)
71.75% (n = 442)
24.7% (n = 152)
7.80% (n = 48)
65.20% (n = 401)
23.1% (n = 142)
8.12% (n = 50)
28.08% (n = 173)
55.5% (n = 342)
10.88% (n = 67)
18.83% (n = 116)
65.8% (n = 405)
1.79% (n = 11)
76.62% (n = 472)
17.2% (n = 106)
3.73% (n = 23)
0.16% (n = 1)
93.18% (n = 574)
Better score on
post
Note: The percentage of participants who received a lower score on the post-quiz relative to the pre-quiz was also
calculated. The following values correspond to each question respectively: 5.4% (n= 29), 2.8% (n= 16), 3.0% (n=
16), 2.0% (n= 11), 6.5% (n= 35), 0.2% (n= 1), 3.9% (n= 21), 8.9% (n= 48), 5.0% (n= 27), 3.7% (n= 20). It should be
noted that there may be several explanations for lower post-quiz scores including the stringent scoring criteria used
to maintain consistency in data; the marking scheme was derived from the selection of responses within the
participant manual and is not all inclusive. The tests were marked by non-clinical staff at NHQ (and not the trainers),
who would not be aware of other “correct” responses discussed during training but not included within the scoring
guide.
136
Table b: Average pre-and post-training self perceived competency ratings
Question
I have the knowledge to work effectively
with offenders with mental disorders.
I have the skills and abilities to work
effectively with offenders with mental
disorders.
I am confident that my approach to working
with offenders with mental disorders is
based on “realities” of mental disorders
rather than “myths”.
I have the received the necessary training
to prepare me to work in my position with
offenders with mental disorders.
I am informed about legislation and CSC
initiatives that impact my ability to work with
offenders with mental disorders.
I am aware of specific considerations for
working with special populations (women
offenders, Aboriginal offenders).
I have the skills to recognize symptoms
suggestive of the need for intervention by a
mental health professional.
I am able to support offenders with mental
disorders by consulting and collaborating
with mental health professionals,
community resources, and families.
Training Package
Pre mean
score
All (n = 588)
Generic (n = 396)
Women's (n = 133)
TtT (n = 59)
All (n = 587)
Generic (n= 395)
Women's (n = 133)
TtT (n = 59)
All (n = 585)
Generic (n = 394)
Women's (n = 132)
TtT (n = 59)
All (n = 586)
Generic (n = 394)
Women's (n = 133)
TtT (n = 59)
All (n = 579)
Generic (n = 388)
Women's (n = 132)
TtT (n = 59)
All (n = 583)
Generic (n = 393)
Women's (n = 132)
TtT (n = 58)
All (n = 585)
Generic (n = 393)
Women's (n = 133)
TtT (n = 59)
All (n = 582)
Generic (n = 390)
Women's (n = 133)
TtT (n = 59)
3.74
3.60
3.77
4.54
3.92
3.79
3.99
4.64
4.36
4.24
4.45
5.00
3.29
3.13
3.41
4.10
3.45
3.37
3.33
4.25
4.17
4.07
4.35
4.47
4.46
4.29
4.71
4.97
4.91
4.81
4.98
5.46
*p < .01, ** p < .001
137
Post
mean
score
5.13
5.01
5.20
5.76
5.04
4.94
5.08
5.59
5.56
5.41
5.75
6.12
5.09
4.98
5.14
5.73
5.27
5.30
5.10
5.42
5.15
5.03
5.47
5.28
5.47
5.32
5.66
6.03
5.59
5.47
5.70
6.12
Difference
1.39**
1.41**
1.43**
1.22**
1.12**
1.15**
1.08**
0.95**
1.20**
1.17**
1.30**
1.12**
1.80**
1.85**
1.74**
1.63**
1.82**
1.93**
1.77**
1.17**
0.98**
0.96**
1.12**
0.81*
1.01**
1.03**
0.95**
1.07**
0.67**
0.66**
0.72**
0.66*
Appendix F: Recidivism - Additional Data and Analyses
Descriptive Statistics
Table a: Suspension and Revocation Summary Statistics
Suspensions and Revocations
Length of Supervised Follow-Up Time
(months)a
Time to 1st Suspension (months) b
Time to 1st Revocation (months) b
CDP
(n =53)
CMHS
(n = 79)
6.4 (2.9)*
Mean (SD)
8.4 (3.8)*
0.9 (1.1)
3.8 (1.5)
Number of offenders released to community
supervision a
Suspended
Revoked
Revocation without Chrg/Off c
Revocation with Chrg/Off c
Comparison
Group
(n =95)
14.0 (9.9)
2.4 (3.3)
5.5 (3.6)
43
2.5 (2.2)
5.1 (1.8)
n (%)
79
31 (72.1%)
20 (46.5%)
14 (70.0%)
6 (30.0%)
46 (58.2%)
19 (24.1%)
14 (73.7%)
5 (26.3%)
58 (72.5%)
45 (56.2%)
34 (75.6%)
11 (24.4%)
80
Notes:
1)
Table reproduced from CSC (2008, October), Community Mental Health Initiative (CMHI) Outcome
Evaluations: Preliminary Post-Implementation Report, p. 19.
2)
a Outcome follow up is based on: (1) CDP group – 1st release following most recent referral to CDP, (2)
CMHS group – closest release to referral date, if the release is prior to the referral date, the referral date is used,(3)
CMHI-Comp – 1st release following 1st eligibility date between 2003 and 2005.
3)
b Mean for time to first suspension and revocation is based on the number of individuals suspended or
revoked.
4)
c Percentage calculated based on the number of offenders revoked.
Table b: Correctional Outcomes for the CDP, CMHS and CMHI Comparison Groups by
Gender
Suspensions and
Revocations
Supervised Follow-Up
Time (months) ‡
Time to 1st Suspension
(months)†
Time to 1st Revocation
(months)†
CDP
Accepted Referrals
(n =53)
Male
Female
(n= 42)
(n =11)
6.1(3.0)
7.9(2.2)
CMHS
Accepted Referrals
(n = 79)
Male
Female
(n =64)
(n =15)
8.5(3.9)
7.9(3.6)
0.9(1.1)
1.3(1.0)
2.5(2.4)
2.7(1.4)
2.6(3.5)
1.1(1.1)
3.7(1.6)
4.2(0.7)
5.0(1.9)
5.8(0.9)
5.5(3.8)
5.3(1.7)
138
CMHI Comparison
Group
(n =95)
Male
Female
(n =85)
(n =10)
14.4(10.4)
11.3(5.1)
Number (%)
# on Any Supervised
Release during FollowUp‡:
Suspended
35
8
64
15
71
9
26(74.3%)
5(62.5%)
38(59.4%)
8(53.3%)
50(70.4%)
8(88.9%)
Revoked
18(51.4%)
2(25.0%)
16(25.0%)
3(20.0%)
39(54.9%)
6(66.7%)
12(66.7%)
2(100%)
12(75.0%)
2(66.7%)
29(74.4%)
5(83.3%)
6(33.3%)
0(0%)
4(25.0%)
1(33.3%)
10(25.6%)
1(16.7%)
Revocation without
Chrg/Off††
Revocation with
Chrg/Off††
Notes:
1)
Table reproduced from Table 3 of CSC (2008, October), Community Mental Health Initiative (CMHI)
outcome evaluations: Preliminary post-implementation report
2)
‡Outcome follow-up is based on: 1) CDP group – 1st release following most recent referral to CDP, 2)
CMHS group – closest release to referral date, if the release is prior to the referral date, the referral date is used, 3)
CMHI-Comp – 1st release following 1st eligibility date between 2003 and 2005. †Mean for time to first suspension
and revocation is based on the number of individuals suspended or revoked. ††Percentage calculated based on the
number of offenders revoked.
Table c: Correctional Outcomes for the CDP, CMHS and CMHI Comparison Groups by
Race
CDP
Accepted Referrals
(n =53)
Suspensions and
Revocations
Supervised Follow-Up
Time (months) ‡
Time to 1st Suspension
(months) †
Time to 1st Revocation
(months) †
NonAboriginal
(n=30)
5.8(3.0)
Aboriginal
(n=23)
CMHS
Accepted Referrals
(n = 79)
Aboriginal
(n=18)
7.1(2.6)
NonAboriginal
(n=61)
8.4(3.8)
1.2(1.4)
0.7(0.7)
4.0(1.6)
3.7(1.6)
CMHI Comparison
Group
(n =95)
8.4(4.0)
NonAboriginal
(n=79)
13.7(8.5)
Aboriginal
(n=16)
16.3(16.8)
2.7(2.1)
2.1(2.6)
2.7(3.5)
1.0(1.3)
5.5(1.7)
4.4(2.0)
5.9(3.9)
3.7(1.6)
n (%)
# on Any Supervised
Release in Sentence‡:
Suspended
24
19
61
18
69
11
15(62.5%)
16(84.2%)
33(54.1%)
13(72.2%)
49(71.1%)
9(81.8%)
Revoked
8(33.3%)
12(63.2%)
13(21.3%)
6(33.3%)
36(52.2%)
9(81.8%)
5(62.5%)
9(75.0%)
9(69.2%)
5(83.3%)
28(77.8%)
6(66.7%)
3(37.5%)
3(25.0%)
4(30.8%)
1(16.7%)
8(22.2%)
3(33.3%)
Revocation without
Chrg/Off††
Revocation with
Chrg/Off††
Notes:
1)
Table reproduced from Table 3 of CSC (2008, October), Community Mental Health Initiative (CMHI)
outcome evaluations: Preliminary post-implementation report
139
2)
‡Outcome follow-up is based on: 1) CDP group – 1st release following most recent referral to CDP, 2)
CMHS group – closest release to referral date, if the release is prior to the referral date, the referral date is used, 3)
CMHI-Comp – 1st release following 1st eligibility date between 2003 and 2005. †Mean for time to first suspension
and revocation is based on the number of individuals suspended or revoked. ††Percentage calculated based on the
number of offenders revoked.
Table d: Mean Follow-up Times to Suspensions and Revocations for the Comparison, CDP,
and CMHS Groups (only offenders with 6-month or shorter follow-up)
N
Mean in Months (SD)
Comparison
50
1.31a (1.39)
CDP
31
0.93a (1.12)
CMHS
42
2.01b (1.55)
Comparison
30
3.59 (1.19)
CDP
18
3.40 (1.05)
CMHS
13
4.18 (1.17)
Suspension
Revocation
Notes:
1)
Post-hoc analyses using LSD.
2)
For suspensions, comparison vs. CMHS group: mean difference = -0.70, standard error = 0.29, p = .017;
CDP vs. CMHS group: mean difference = -1.08, standard error = 0.33, p = .001.
3)
For revocation, CDP vs. CMHS group: mean difference = -0.77, standard error = 0.42, p = .07.
Cox Regression Analyses
Suspension
Table e. Cox regression analysis to examine whether survival is a function of group
(CMHS, CDP, and comparison groups)
Block 1
Age at Release
Functional Impairment
Reintegration Potential
(high)
Reintegration Potential
(low vs. high)
Reintegration Potential
(medium vs. high)
Block 2
ß
SE
Wald
df
Sig.
Odds ratio
-0.044
0.059
-
0.009
0.040
-
21.516
2.216
-
1
1
2
.000
.137
-
0.957
1.061
-
1.118
0.292
14.642
1
.000
3.060
0.772
0.282
7.502
1
.006
2.165
140
Comparison
2
CDP vs. Comparison
0.143
0.229
0.391
1
.532
1.154
CMHS vs. Comparison
-0.409
0.202
4.085
1
.043
0.664
Note: The omnibus test of model coefficients found that group added significantly to the model after controlling for
age at release, functional impairment, and reintegration potential, -2 log likelihood = 1217.795, total model χ2 (6) =
58.151, p < .001. Change in χ2 (2) = 6.756, p = .034.
Table f. Cox regression analysis to examine whether survival is a function of group (CDP
and CMHS groups)
ß
Block 1
Age at Release
-0.057
Functional Impairment
0.062
Reintegration Potential
(high)
Reintegration Potential
1.228
(low)
Reintegration Potential
0.716
(medium)
Block 2
Group a
0.550
Note. a Group: 0 = CMHS and 1 = CDP
SE
Wald
df
Sig.
Odds ratio
0.013
0.051
-
19.047
1.490
-
1
1
2
.000
.222
-
0.945
1.064
-
0.379
10.486
1
.001
3.414
0.368
3.775
1
.052
2.046
0.239
5.300
1
.021
1.734
The odds ratio of 1.734 indicates that the CDP group is at a 1.734 odds of being
suspended compared to the CMHS group. This means that the odds of the CMHS group being
suspended compared to the CDP group is 0.577 (i.e., 1/1.734 = 0.577). Therefore, the CMHS
group is associated with a 42% (i.e., 1-0.577) reduction in odds of suspension compared to the
CDP group.
Revocation
Table g. Cox regression analysis to examine whether survival is a function of group
(CMHS, CDP, and comparison groups)
Block 1
Age at Release
Functional Impairment
Reintegration Potential
ß
SE
Wald
df
Sig.
Odds ratio
-0.031
0.014
-
0.012
0.051
-
6.491
0.072
-
1
1
2
.011
.788
-
0.970
1.014
-
141
(high)
Reintegration Potential
1.250
0.420
8.876
1
.003
3.490
(low)
Reintegration Potential
1.143
0.405
7.958
1
.005
3.137
(medium)
Block 2
Comparison
2
CDP vs. Comparison
0.009
0.278
0.001
1
.975
1.009
CMHS vs. Comparison
-0.903
0.278
10.530
1
.001
0.406
Note: The omnibus test of model coefficients found that group added significantly to the model after controlling for
age at release, functional impairment, and reintegration potential, -2 log likelihood = 763.301, total model χ2 (6) =
35.233, p < .001. Change in χ2 (2) = 13.379, p = .001.
Table h. Cox regression analysis to examine whether survival is a function of group (CDP
and CMHS)
ß
Block 1
Age at Release
-0.052
Functional Impairment
0.081
Reintegration Potential
(high)
Reintegration Potential
0.769
(low)
Reintegration Potential
0.889
(medium)
Block 2
Group a
0.907
Note. a Group: 0 = CMHS and 1 = CDP.
SE
Wald
df
Sig.
Odds ratio
0.019
0.075
-
7.098
1.144
-
1
1
2
.008
.285
-
0.950
1.084
-
0.580
1.760
1
.185
2.159
0.558
2.535
1
.111
2.432
0.333
7.394
1
.007
2.476
The odds ratio of 2.476 indicates that the CDP group is at a 2.476 odds of being revoked
compared to the CMHS group. This means that the odds of the CMHS group being revoked
compared to the CDP group is 0.404(i.e., 1/2.476 = 0.404). Therefore, the CMHS group is
associated with a 60% (i.e., 1-0.404) reduction in odds of revocation compared to the CDP
group.
142
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