FOR LHIN USE ONLY
PROPOSAL ID: _____________
HEALTH SYSTEM IMPROVEMENT PROPOSAL (H-SIP) FORM
Training
SECTION 1 –PROPOSAL DETAILS
PROPOSAL CEO APPROVED BY SUBMITTING HEALTH SERVICE PROVIDER
PROPOSAL TITLE
Dialectical Behaviour Therapies: Building a Continuum of Services
CONTACT INFORMATION
NAME: TIM SIMBOLI
E-MAIL: tsimboli@cmhaottawa.ca
PHONE NUMBER AND ADDRESS:
CANADIAN MENTAL HEALTH ASSOCIATION OTTAWA CARLETON BRANCH
301-1355 BANK STREET, OTTAWA, ON
K1H 8K7
613 737 7791 EXT 249 FAX 613 737 7644
LEGAL NAME OF HEALTH SERVICE PROVIDER: CANADIAN MENTAL HEALTH ASSOCIATION – OTTAWA
CARLETON BRANCH
DATE OF SUBMISSION: AUGUST 19, 2013
COMMUNITY OF CARE ALIGNED WITH PROPOSAL
EASTERN COUNTIES
NORTH LANARK & NORTH GRENVILLE
OTTAWA CENTRAL
OTTAWA EAST
OTTAWA WEST
RENFREW COUNTY
REGIONAL
If this proposal has been submitted to other LHINs, please indicate which LHINs below and the status of the
proposal.
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
1
SECTION 2 – NATURE OF REQUEST
SMALL CAPITAL REQUIRED TO SUSTAIN SERVICES (< $100,000) (EX. EQUIPMENT, RENOVATIONS)
CHANGE TO HSP SERVICES (INCLUDING VOLUNTARY INTEGRATION)*
ADMINISTRATIVE/OPERATIONAL EFFICIENCY (NOT SERVICE RELATED)
OTHER (PLEASE SPECIFY _______________________________________________________)
request for integration
SECTION 3 – DESCRIPTION OF REQUEST
DESCRIPTION OF PROPOSAL
Please provide a brief description of the project including a description of any proposed services. (Maximum 200
words)
Dialectical behavior therapy (DBT) is an evidence-based approach that can be delivered at both moderate and
high intensity levels, and has proven to be effective for people that can present particular challenges to the
mental health service system – in particular, for people with Borderline Personality Disorder (BPD) or
borderline traits (see Appendix A for a description of BPD symptoms). DBT involves group skills training,
individual therapy, telephone coaching and a therapist consultation team. Therapists receive DBT intensive
training through Behavioral Tech, which was founded by Marsha Linehan, the developer of DBT.
Currently, DBT services sited within the City of Ottawa (although open to all residents of Champlain) are
provided by CMHA Ottawa, The Ottawa Hospital, Montfort Hospital, and the Royal Ottawa Mental Health
Centre1. Services are typically provided in group settings, and the high intensity service option (DBT “Full”)
incorporate group sessions and frequent individual therapy sessions.
The target population for these services varies depending on service type and are summarized as part of the
attached DBT Services Continuum (see Appendix B). In short, this is a client group that are high users of
emergency department and inpatient services, place a heavy burden on service providers, experience
significant impacts in their functioning as a result of BPD symptoms, and for whom a specialized approach is
required to empower them in achieving sustainable change and improvement (see Appendix C for the
evidence base for DBT in treating patients with BPD). For example:
 High utilization of services:
 A two year study of people with BPD features showed that this group, as compared to a control
group, utilized more pharmacologic, psychological and medical treatment, even after controlling
for gender and Axis I and II pathology
(Bagge et al 2005)
 A comparison of inpatients with BPD and inpatients with other axis II diagnoses showed that
patients with BPD were 2- 4.5 times more likely to have received each of 12 types of treatment
1
Note that DBT services are offered by the ROMHC to people who are active patients.
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
2
(excluding electro-convulsive therapy), spend more time in individual therapy, spend more time
in inpatient units and take more medications over the course of their treatment
 >75% had individual therapy, previous hospitalizations and standing medications
 50- 60%: self-help groups, multiple psych hospitalizations, day hospital or residential
treatment
 35-45%: group, couple/family, intensive individual (>2x/week), intensive polypharmacy
(>3 meds) Zanarini et al 2001,
 Patients with BPD had greater likelihood of receiving each mode of treatment (individual, group,
family, day, hospitalization and all classes of medication) than patients with MDD OR 1.89 to 4.95.
Patient with BPD received more of these treatments than patients with MDD or other personality
disorders.
(Bender 2001)
 Poor service outcomes
o Gunderson et al 2004 (since updated)
 BPD plus Major Depressive Disorder (MDD) vs MDD alone have similar rates of
remission – 81% vs 91%.
 Time to remission is significantly different – 55.1 weeks (mean) for BPD + MDD vs 18.7
weeks for MDD alone
 BPD + MDD and MDD have similar rates of relapse – 72% and 63%, however time to
relapse is much shorter for BPD + MDD 48 weeks(mean) vs 106.8 weeks

o Zanarini et al 2004
 Rates of axis I disorders in patients whose BPD remitted also showed significant decline
 Rates of axis I disorders (Mood, anxiety, substance use disorders, eating disorders) in never
remitted BPD remained stable despite intensive treatment
 Sociodemographic profile:
o In a sample of treatment-seeking BPD patients in Mannheim, Germany, researchers found that
there were significant differences for patients in employment status and marital status as compared
to general population statistics, despite the fact that there were similar levels of education and
training across the two groups
o Researchers also found that this group of patients was young – with majority being aged 38 or less
– prime years for education, employment, and raising young children
 High impact on children and families:
o Compared to moms with depression or moms with no mental disorder
 BPD Moms are predisposed to frightened/frightening behaviours that are thought to
increase the likelihood of disorganized infant attachment (Main et al 1990, Schuengel et al
1999)
 BPD Moms are prone to relate to their infants with intense, inconsistent and often selforiented styles of engagement
 BPD Moms were more likely to exhibit fear/disorientation in response to their infant’s
attachment bids (Hobson et al 2009)
o Compared with children of moms with depression, cluster c or no disorder, children (ages 11-18)
of moms with BPD exhibited:
 Higher harm avoidance
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
3

Perceived their mother as being overly protective (mother gets overinvolved, mother
induces feeling of shame and guilt, mother acts very anxious, mother dictated what clothes
should be worn)
 Lower levels of self esteem
 Compared with children of moms with no disorder
 attention problems, behavioural problems (delinquency and aggression)
 Death wishes and suicidal ideas/plans
o Families with parental BPD more unstable and children more frequently exposed to parental
substance abuse, neglect and suicide attempts (Feldman, Zelkowitz, Weiss, Heyman, Vogel and
Paris 1995)
o Families with parental BPD report interactional styles with more conflict, less expression and less
cohesion (Moos and Moos 1986)
o BPD patients entering treatment perceived family relationships as extremely difficult, and overall
their scores for quality of relationships with partner, children and family unit were much worse
than is seen with depression. (Gerull, Meares, Stevenson, Korner and Newman 2008)
 High suicide risk:
o All suicides:
 9% adults – Kullgren et al 1986
 Up to 33% of adolescent suicides BPD Runeson and Beskow 1991
o Lifetime risk of suicide in BPD: 3-10% Paris and Zweig-Frank 2001
o Early all cause mortality 18.2% at mean age 50 yrs (expected in general population 4.5% women
7.5% men) Paris and Zweig-Frank 2001
An extensive community consultation was undertaken to better understand service needs and gaps for people
with BPD or BPD traits in the City of Ottawa (see Appendix 4 for a summary of findings): an adequately
resource continuum of DBT services, including consultation to partners, was identified as a key need. Service
providers have piloted various approaches to providing a range of DBT services. These partners have
developed expertise in providing the range of DBT services, and have also developed an intimate knowledge
and understanding of what is required to ensure there is sufficient capacity in each of the service types to meet
this population’s needs. Case studies shared throughout this HSIP provide examples of the significant,
positive impact DBT services have already had at a local level, empowering and supporting people as they
dramatically reduce their ER and inpatient utilization, and make tremendous, positive changes in their
educational, professional and personal lives.



Case Study – Ms. A
Presenting to The Ottawa Hospital in 1996, there were multiple diagnoses at admission,
including:
Axis I: dysthymia, major depressive disorder, social phobia, eating disorder NOS,
polysubstance dependence
Axis II: borderline personality disorder, avoidant personality disorder
Axis III: asthma, myofacial pain syndrome, environmental allergies
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
4
In Oct 2004 Ms A entered DBT-full treatment. The program, at that time, lasted 18 months.
Ms A received full DBT – including individual and group therapy and telephone consultation
from October 2004 to May 2006.
Following completion of DBT, Ms A was able to return to University part-time and then
eventually full time to complete her degree and her masters. In July 2011 she moved out of
the Ottawa area and obtained her first full time employment and continues in full time
employment at the time of this report.
March 1996 to Oct 2004
DBT
Oct 2004 to May 2006
May 2006 to July 2011
ER
visits
psych
26
1
ER
visits
medical
3
0
Inpatient
admissions
Inpatient
days
Outpatient
visits
29
1
360
5
46
129
3
0
3
13
75
While partners are committed to continuing to provide some of the funding required to serve clients, they
recognize that additional resources are required to have sufficient capacity to meet client needs. Partners
recognized that this HSIP represented an opportunity to come together as a group to define the DBT service
system, identify the resource requirements, clarify individual partner roles and areas of specialty, and set out a
process through which coordinated access to this service system would be developed.
Ensuring that the full continuum of DBT options is crucial to maximizing resources and efficiencies: the
continuum facilitates treatment staging, with lower intensity options designed to support people both as they
enter the system, and as they “graduate” from DBT full options. The figure and table below summarizes the
different areas of expertise that various providers have developed over time. In addition to the direct services
provided to patients, CMHA and TOH have piloted different approaches to support family physicians in
meeting patient needs, including providing a consultation clinic. Patients referred by family physicians do not
necessarily require the intensity of a “DBT Full” program, but have benefited from the less intensive group
options as well.
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
5
Moderate
Intensity
High
Intensity
Low
intensity
•Group/Working with Emotions – 12 weeks - TOH
•DBT Lite – 6 months - TOH
•Emotion regulation skills training – Women’s Mental Health/Meadowcreek ROMHC
•DBT Lite - Hopital Montfort
• DBT Full: Group and individual therapy – 12 months - TOH
• Group/DBT Modified – 24 weeks – CMHA
• DBT M-Individual – 48 weeks - CMHA
• Individual therapy - Family Services Ottawa in planning phase (in concert
with existing CMHA group and case management therapies)
• Group/DBT S – 24 weeks - CMHA
•Group/DBT Grad – open - TOH
•Group/DBT Aftercare – 48 weeks - CMHA
Service type
Entry Treatment Services:
Individual or Groups - Working
with emotions (TOH), Emotion
Management (ROHCG)
DBT Lite
DBT Full
DBT Case Management (includes
case management, group therapy,
individual therapy)
Description of needs
Anyone who presents at ER who
could benefit (TOH) – tends to be a
high risk group that would need
some individual support in addition
to the WWE group
ROH tends to be for individuals not
currently presenting at the
emergency room
People with BPD or People with
BPD Traits
People are moderately impaired and
symptoms are moderate in severity
People with BPD
People are highly impaired and
symptoms are high in severity
People with BPD
People are highly impaired, and
high severity symptoms, and are
usually experiencing other complex
issues e.g. homelessness
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
Provider
TOH
ROHCG
Groups – TOH, Montfort (provides
a group to 18-25 year olds)
Individual therapy provided by
community therapist
TOH – Groups and individual
therapy
CMHA – Case management
CMHA – Groups
Individual therapy – Family
Services Ottawa (planned)
6
TOH – Graduates group
CMHA – Group – pilot integrates
peer support component
FSO - will provide individual
therapy in the future
DBT Consultation
Consultation/outreach support to
TOH
other providers
CMHA
NOTE – 2/3 of people continue in therapy for one or more years after completing DBT Lite or DBT Full
DBT Follow-up
People with BPD who have already
completed DBT Full or DBT Case
Management
Under this HSIP:
 The Ottawa Hospital will provide the DBT “Full” Program and continue to offer the Working with
Emotions Group, DBT Lite Group and DBT Grad Group
 ROMHC will continue to provide Emotion Regulation Groups
 CMHA Ottawa will provide DBT Group and Individual Therapies, as well as consultation services to
CMHA staff. Clients of the CMHA Ottawa program will also have access to the range of CMHA
programs including the primary care nurse practitioner.
 Family Services Ottawa will provide DBT Individual Therapies and co-lead groups provided by
CMHA Ottawa
 Annual training and support will be provided to the Champlain Mental Health Crisis Line volunteers to
provide after-hours, time-limited support to clients of DBT services. The CMHCL requires this
additional training to ensure that the needs of this particular population group are supported in an
appropriate, efficient, and evidence-based manner.
 Additional funds are identified to address existing wait lists and build capacity for moderate intensity
groups (e.g. Working with emotions or similar group models)
This proposal further lays out a process to develop a coordinated access mechanism for the range of DBT
services for people with BPD or BPD traits, together with consideration of what other types of lower-intensity
or moderate-intensity groups, particularly those utilizing peer support, might be of benefit to this population.
The coordinated access mechanism will formalize the informal ways in which various services, including
primary care services, substance use services, and emergency room services can link patients for assessment
and referral to the most appropriate level of care. Providing a central way in which primary care providers can
access services, and ensuring that the DBT service continuum is integrated within the range of mental health
and addictions services, will be key goals of the coordinated access development.
PROPOSED BUDGET
Please complete the following tables with your proposed budget. Please identify any funding for this project obtained
from other sources (including previous LHIN funding received). Please identify any cost savings with a negative
number.
CAPITAL EXPENDITURES
Name/Sub Account
Description
Fiscal 2012/13
Annualized
Budget
N/A
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
7
N/A
Total – Capital Expenditures
ONE-TIME EXPENDITURES
Name/Sub Account
Description
Fiscal 2012/13
Annualized
Budget
Coordinated Access Development
Provides funding to facilitate the DBT
committee in reaching agreement on:
 How patients access assessment for
services
 Protocols and tools used in the assessment
process
 How referrals are made for specific DBT
services
 How wait lists for services will be
managed
 How other health services intersect with
the coordinated access
 How DBT services are situated within the
broader addictions and mental health
system
 The ways in which primary care providers
can refer clients for assessment and
services
 What additional service options are needed
to support people with BPD or BPD traits,
particularly considering groups that have
strong peer support elements e.g. Skills For
Safer Living, a model first developed by
St. Michael’s Hospital in Toronto
20,000
N/A
New staff training and education
Btech "foundation training" 5 day training,
available to clinicians who are joining an
established DBT team. Costs are
approximates, based on the training offered
this fall in Princeton New Jersey
27,200
N/A
BTech tuition 1400 US
Transportation $600
Food and accommodation: $1400
Total per clinician - $3400
4 clinicians (2.0FTE) CMHA, 2 clinicians
(1.0FTE) FSO, 2 clinicians TOH
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
8
Total – One-Time Expenditures
47,200
N/A
OPERATIONAL EXPENDITURES (FOR BASE FUNDING)
Name/Sub Account
Description
Fiscal 2013/14
26,000
Salaries – TOH - note - this
reflects the cost difference
in addition to other funding
sources for additional FTEs
as noted in table below
Psychiatry (0.2 FTE)
Psychology (0.2FTE) - see other funding
sources)
Social Work - includes on-call (0.6FTE)
Occupational Therapy (0.4FTE)
RN - includes on-call (0.6FTE)
Administrative Support (scheduling, data entry,
clerical) (0.4FTE)
Annualized
Budget
52,000
15,587
31,174
33,956
32,129
43,537
67,912
64,258
87,074
9,335
18,670
Research Assistant (program-wide)
25,000
50,000
Social Work (2FTE @ $94,315/FTE)
94,315
188,630
Provides 2 days/week physician time plus
additional 20 half days per year
60,000
120,000
Counseling (1FTE)
33,350
66,700
To provide after-hours on-call support to clients
of the DBT programs provided by TOH
5,000
5,000
Salaries – TOH – System
Resource
Salaries – CMHA Ottawa note - this reflects the cost
difference in addition to
other funding sources for
additional FTEs as noted in
table below
Sessional fees - CMHA to
support staff and clients in
CMHA and FSO DBT
programs
Salaries – Family Services
Ottawa
Training – Distress Centre
of Ottawa
General and administrative
expenses – CMHA Ottawa
General and administrative
expenses – Family Services
Ottawa
Program administration
expenses – CMHA Ottawa
Staff travel, cell phone, training, rent, computer
12,472
24,944
Staff travel, cell phone, training, rent, computer
6,236
12,472
Administrative infrastructure for program i.e.
book-keeping, data and LHIN reports
5,710
11,347
402,627
800,181
Total – Operating Expenditures - Salaries
OTHER FUNDING SOURCES FOR THIS PROJECT
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
9
Funding Sources
TOH (total of 1.35
FTE)
CMHA Ottawa (total
of 2.0 FTE)
Previous
fiscals
Description
Fiscal
2012/13
Annualized
Budget
Sessionals – Psychiatry 0.6FTE
20,000
20,000
20,000
Psychology
0.4 FTE
62,345
62,345
62,345
Social Work
0.2 FTE
22,638
22,638
22,638
Admin
0.1 FTE
6,223
6,223
6,223
Social Work
2.0 FTE
207,524
207,524
207,524
318,730
318,730
318,730
Total – Other Funding Sources
Note - additional program dollars exist via ROHCG and Hôpital Montfort Programs
Table does not reflect administrative infrastructure provided by organizations, nor does it reflect the range of
other programs clients have access to at CMHA e.g. nursing, concurrent disorders groups – CMHA contributes 6
hours psychiatry/month and 15 hours case manager time/week to the DBT program
Partners have agreed that student placements will be actively used in this program as a way in which to build
capacity with no additional funds required for the program. Note on psychology from TOH – provided as part
of annual global funding.
IS THIS REQUEST A PRIORITY FOR YOUR ORGANIZATION IN FISCAL 2012-13?
If yes, please describe why this issue is a priority for your organization and why it should be completed in
2012-13. If you have submitted more than one HSIP during the current fiscal, please identify which has
the highest priority.
DBT services typically serve people who have had high levels of service use, often with little success. The
experience of the TOH DBT full program has been consistent with the literature in finding that patients with BPD
benefit from access to appropriate services rather than defaulting to repeat Emergency room presentations and
inpatient admissions/readmissions. The wind up of this pilot program presents the system with an urgent need to
secure ongoing, stable funding to ensure that these individuals continue to have access to appropriate services.
Borderline personality disorder affects 1% of the population (Lenzenweger et al.2007). It accounts for 10% of
mental health outpatients and 20% of psychiatric inpatients (APA, 1994; NICE 2009). It is also often
associated to trauma. While BPD affects men and women equally in the clinical population women outnumber
men 3:1. (Links, Heslegrave & Van Reekum, 1998).
It results in significant morbidity, including significant problems in relationships, parenting and employment.
Individuals with BPD have repetitive self harm, and are at increased risk of many co-morbid disorders
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
10
including, depression, eating disorders, substance and alcohol dependence and anxiety disorders, anxiety
disorders and PTSD (Linehan, 1993).
DBT involves group skills training, individual therapy, telephone coaching and therapist consultation team. Our
therapists received DBT intensive training through Behavioral Tech, which was founded by Marsha Linehan,
the developer of DBT.
DBT is an empirically validated program for treatment of BPD that has been shown to reduce suicide and self
harm behaviors, improve treatment retention, reduce hospital ER visits and inpatient admissions, and improve
overall quality of life. It has the most extensive research supporting its effectiveness of any of the empirically
validated treatments for borderline personality disorder (Miller et al, 2007).
Case Study - Ms B
Ms B first presented to TOH in June 2006: she had a 12 day hospitalization due to depression
and suicide attempts. Prior to being admitted to TOH, she had a 2 month day hospital stay and
a 4 month inpatient admission overseas. She had returned to Ottawa following these treatments,
but was unable to return to work. Ms B had a history of depression since her teens, bulimia
nervosa since her 20’s and a 10 year history of repetitive self-harm (cutting). She was diagnosed
with BPD during this hospital admission and was referred to the TOH DBT program.
In September 2006,Ms B started the DBT-full program at TOH. She participated in the DBT
skills group at TOH and her individual counseling with a community psychologist who was
affiliated with the DBT program.
Following completion of the DBT program in April 2008, she returned to University and
completed an honors degree and her masters. She is now gainfully employed in another career,
is married and has a child. She has not had any further psychiatric admissions. She was seen in
outpatient psychiatry once per month from 2009- 2010 and then every three months. She has
also received treatment from the perinatal psychiatry program.
An extensive community consultation process was undertaken by Ottawa partners to better understand what
services are currently available to people with BPD, what’s working well, where service gaps exist, and what
services were of the highest priority. Incorporating partner survey and client/patient survey findings, together
with stakeholder meetings, a working group undertook a priority setting exercise, identifying three main
priorities for improving care for people with BPD in the Ottawa region: Improved access to services, Education
and Coordination of Services. Provision of DBT and DBT-lite was identified as the highest sub-priority within
the access to services priority. This in-depth consultation process presented partners with evidence-based
research that emphasizes: 1) Specialized treatment for BPD exists, 2) there is good evidence that it works, and
3) it may save money when compared to treatment as usual.
Participants also prioritized the importance of global system coordination, and the ability to match services to
an individual’s needs and severity of illness. This HSIP includes a request for one-time funding to create a
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
11
coordinated access approach to ensure clients access the right type of DBT service at the right time with the
right provider.
The Champlain LHIN has identified in the 2013-2016 Integrated Health Service Plan mental health and
addictions as a key result area. Over the next three years, the Champlain LHIN is committed to work with its
partners so that more people with mental health conditions and addictions have access to services: “For more
people with mental health and addictions to have access to services, a system that is responsive and efficient is
needed. We need a system so that people are not entering at multiple points, services are not duplicated, that
appropriate services are delivered when needed and with a quality that provides the best possible outcome”.
Specifically, the LHIN will be monitoring two indicators to assess the degree to which this area is being
impacted:
• Rate of repeat visits to hospital emergency rooms for mental health conditions and / or addictions
• Hospital readmission rates for mental health conditions and / or addictions within 30 days (unplanned
readmissions).
As noted in the indicators sections, these will be central to monitoring progress of the DBT range of services.
SECTION 4 – ALIGNMENT WITH LHIN PRIORITIES
Note – In 2011-12 the Champlain LHIN implemented an updated Decision-Making Framework as part of the proposal review
process. The following questions are directly related to the scoring metrics in this framework. Please reference sources where
appropriate.
ALIGNMENT WITH CHAMPLAIN LHIN PRIORITIES
Please describe how your proposed service change will help advance one or more priorities or goals in the
Champlain LHIN Integrated Health Services Plan and/or Annual Business Plan and/or Champlain eHealth
Strategic Plan and/or Decision Support Strategic Plan by completing the following table.
Note – Please see www.champlainlhin.on.ca for a copy of these reports.
Priority/Goal
People with BPD or BPD
traits
Impact of Project
Reduction in emergency room visits
People with BPD or BPD
traits
Reduction in hospital readmission
rates
Performance Measure
Number of ED visits and
repeat visits per year by
project clients
Number of hospital
readmissions post-discharge
by project clients
Source of Data
Patient registration
system at hospital
and client charts
Patient registration
system at hospital
and client charts
Case Study – Ms C
Ms C was referred to the DBT-full program by the TOH eating disorder program as she was
unable to complete the eating disorder program due to frequent suicide attempts. She had also
attempted the day hospital program but was unable to complete this program due to suicide
attempts. Ms C’s diagnoses included Bulimia Nervosa, PTSD, chronic depression and alcohol
use disorder in addition to BPD. She had chronic suicidal ideation since the age of 13.
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
12
From August 2010 to Nov 2011 Ms. C received full DBT at TOH. Treatment included
individual and group therapy and telephone consultation. Following the completion of DBT
treatment Ms C disclosed that she had continued to consume alcohol heavily throughout DBT
treatment. She was ready to engage in treatment for alcohol dependence which she did at a
local addiction program. Ms C continues to be seen once per month for out patient follow up
and twice per month for DBT graduate group. She has been able to remain abstinent from
alcohol. During the course of DBT, Ms C found out that she has ankylosing spondylitis and
has had some challenges managing this illness. Despite this she is attempting to return to work
with her former employer.
April 2008- Aug
2010
DBT Aug 2010 to
Nov 2011
Nov 2011 to June
2012
ER
visits
psych
31
ER
visits
medical
3
Inpatient
admissions
Inpatient
days
Outpatient
visits
12
20
59
Day
Hospital
Program
8
4
11
5
9
127
0
7
14
5
4
23
0
ALIGNMENT WITH HEALTH SERVICE PROVIDER MANDATE
Please provide a brief description on how this proposal is aligned with your role within the health system.
CMHA Ottawa
CMHA Ottawa works with individuals with serious mental illness (SMI), complex needs and co-occurring
substance use disorder who are homeless or vulnerably housed and fit the Intensive Case Management
Standards of Practice (Ministry of Health and Long term Care).
DBT involves group skills training, individual therapy, telephone coaching and therapist consultation team. Our
therapists received DBT intensive training through Behavioral Tech, which was founded by Marsha Linehan,
the developer of DBT.
This service has been extended to Mental Health Community Support Services (MHCSS) partners as agency
resources permit
DBT is an empirically validated program for treatment of BPD that has been shown to reduce suicide and self
harm behaviors, improve treatment retention, reduce hospital ER visits and inpatient admissions, and improve
overall quality of life. It has the most extensive research supporting its effectiveness of any of the empirically
validated treatments for borderline personality disorder (Miller et al, 2007).
Also see: http://www.nice.org.uk/nicemedia/live/12125/43045/43045.pdf
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
13
http://summaries.cochrane.org/CD005652/psychological-therapies-for-borderline-personality-disorder
The program works closely with CMHA’s concurrent disorder program as well as the cognitive restructuring
(CR) practitioners. All DBT practitioners are trained in motivational interviewing and CR, concurrent disorders
(CD), ASSIST ,SUICIDE care ,CPR, first aid and defibrillator training, all have undergone a mandatory 5 day
standardized case management training as well as NVCI( non-violent crisis intervention training) as well as
formal intensive DBT training. Practitioners have a minimum of 3 years working with the homeless ,are
masters prepared and can be registered with a professional college
Supervision: CMHA practitioners attend 2 separate clinical consultation teams1) internal with clinical support
from a DBT trained psychiatrist 1)external with a multi-disciplinary team of community and hospital based
practitioners .This participation in a weekly consultation team adheres to the fidelity of the treatment
Various recognized psychometric tools are used to screen ,assess and monitor participants :
DIB,OCAN &IAR, Self harm inventory, suicide risk assessment MCAS,AUS,DUS,BSL,OQ-45.2 ,CMHA
DBT screening tool.
Case management DBT knowledge base and staffing have been under significant development and the practice
has been validated: this model is highly effective and economical (Cochrane 2012) and see article by (Shelley
F. McMain and Paul S. Links 2012 featured in:ojp.psychiatryonline.org
The program is developing a peer led graduates group to provide ongoing support. There is an established DBT
–s group ( focus on substance use ). Expertise with the DD population is being developed in conjunction with
the CMHA Brokerage program . CMHA works with the Universities to provide placements for MSW students,
nursing students and counseling students.
Quality standards defined in the CMHA M-SAA (Multi-Service Accountability Agreement) with the Champlain
Local Health Integration Network are met (LHIN Program evaluation: CMHA has been working with Ottawa
University’s psychology department to facilitate a PhD student placement to evaluate the DBT program.
THE OTTAWA HOSPITAL
The Ottawa Hospital has played a leadership and facilitation role in developing a range of DBT services
available to the City of Ottawa, and broader Champlain LHIN area, for many years. In addition to working
in close partnership with CMHA Ottawa to ensure a continuum of DBT services are available to residents,
TOH provides a broad array of inpatient and outpatient mental health services to the community, in addition
to sponsoring key community services such as the Ottawa Mobile Crisis Team. As noted, DBT services can
play a crucial role in reducing ER visits and inpatient readmissions – both key indicators relating to health
system sustainability and quality of client outcomes.
TOH has allocated global funding towards DBT services for eight years through a mixture of psychiatry
(also funded through OHIP billing), psychology, social work and admin staffing. Together this team has
provided the following services:
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
14





Completed pilot - DBT Full: 2.5 hour DBT skills training group. Occurs weekly. Total time per group
3.5 hours – includes prep/debriefing/crisis assessments/notes. Duration 12 months
DBT Grad: Twice a month. 1.5 hour group. Total time 2 hours. Duration: open group
DBT Individual: 1-1.5 hours per week direct patient contact. Telephone coaching/notes require an
additional 0.5 hours (average) per week. Duration 12 months
DBT lite: 2.5 hour group. Total time required 3.5 – 4 hours. Prep/debrief/notes as for DBT full, but
more crisis assessment as patients in group have community therapists. Duration 6 months
Working with Emotions group (part of TOH Urgent Consultation Clinic/UCC) - DBT based skills
training group. Open to all UCC referrals. On average 1-3 patients in group with BPD. Group is 12
weeks.
Staff have contributed additional volunteer hours towards ensuring continuation of service provision,
including on-call support to existing patients. Extensive and rich patient data has been maintained through
the charting process.
FAMILY SERVICES OTTAWA
Family Services Mental Health Program
The Mental Health Program is a counselling program available to individuals living with a serious, long term
mental illness. Services are provided to an average of 250 clients per year. The age range of clients is 18 - 75.
The mental health challenges that clients are facing include mood disorders, Psychotic Disorders, Dissociative
Disorders, Eating Disorders, and Personality Disorders. Many of the clients have ‘traits’, or have a diagnosis of
Borderline Personality Disorder.
Counselling staff are very experienced in providing services to persons living with a mental illness. As a
program, the objective is to foster change through a focus on the issues and concerns that challenge the
individual from being able to have healthy relationships, live in the community, and participate in community
life. Approaches to providing counselling services are client-centered and recovery based; counselors integrate
the concepts of therapeutic change with practical skill based programming. Counselling services are grounded
in research based practices, and incorporate the newly emerging findings of neuroscience research and its
implications for practice interventions.
The program is well situated to provide individual therapy support for clients in DBT groups; this project will
assist in maximizing staff skills, with an additional clinical resource that will increase individual effectiveness
in providing services to individuals living with the challenges of BPD.
ROYAL OTTAWA HEALTH CARE GROUP
The ROHCG has a history in provision of DBT and Emotion Regulation type groups, both at their Brockville
site, and at their Ottawa site. There is recognition that clients can have co-morbid diagnoses with BPD or BPD
traits which can impact their prognosis unless properly treated. Currently, the Royal Ottawa Mental Health
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
15
Centre provides, for people who are active patients, an Emotion Regulation DBT skills training through a
combination of psychiatry, psychology and social work. These are provided as part of their overarching
Women’s Mental Health initiative funded through a private donation (not part of their annualized global
funding). In addition, the Youth mental health program has a Behaviour Tech trained DBT team, providing
DBT group skills training and concurrent DBT individual psychotherapy.
Although the ROHCG recognizes the need for additional development of the capacity of DBT services to reflect
client needs, the ROHCG will continue to support the endeavors of expanding DBT services and support this
HSIP as a first step in improving services.
IMPACT OF PROPOSAL ON THE CLIENT EXPERIENCE
Please describe how this proposal will improve continuity of care, safety, effectiveness, access to services, client
empowerment and/or client experience with the health system by completing the following table.
Nature of Impact
Increase access to services; reduction in
utilization of other clinical services




Performance Measure
Programs’ Wait list (as
monitored by project partners)
ER utilization
Inpatient Admissions
Patient satisfaction
Source of Data
Organizational data – wait list
Hospital data/patient registration system
Satisfaction surveys
HEALTH SYSTEM SUSTAINABILITY
Please describe the health care system efficiencies to be gained in quantitative terms on an annual basis (e.g. #
visits, # patients, monetary terms, impact on human resources over time).
Outputs/Outcomes
Reduction in repeat admissions
Reduction in inpatient admissions
Increased housing placement
Performance Measure
Repeat admissions post-discharge from
inpatient unit or ER
Admissions to inpatient units
# of clients who secure housing
# of clients who maintain housing (6+
months)
Increased stability and quality of life
Source of Data
Hospital data/patient registration system
Hospital data/patient registration system
CMHA client management system
Patient/client and clinician reporting
using OQ-45
Case Study - Mr. D
Mr. D was referred to the DBT-full program by the psychiatrist in the immunology program at TOH where
he was followed for treatment of HIV. He was referred for treatment of impulsive behaviours including
unprotected sex and problems managing anger.
He had previous diagnosis of THC and alcohol dependence and had received treatment through a local
addictions program with some success, but continued to use THC regularly. He had attended a local anger
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
16
management program following a domestic assault. Lastly he had been followed by a counselor at a local
family service agency for three years. At the start of DBT he identified his goals as: 1) being involved in a
monogamous, long term relationship with a partner who was aware of his HIV status, 2) improving
nutrition and exercise including quitting THC use and 3) maintaining full time employment.
Mr D received DBT- full – including individual therapy, group therapy and telephone consultation – at
TOH from Nov 2011 to Nov 2012. At the completion of the program he had been successful in all three of
his goals. He continues to receive outpatient follow up every 2-4 weeks at TOH.
INTEGRATION OF SERVICES
Please describe the extent to which this proposal would improve the coordination of health care among health
service providers to ensure continuity of care in the local health system and provision of care in the most
appropriate setting.
All partners are committed to developing a mechanism for coordinated access to the range of DBT services.
A working group will be struck with representatives from CMHA Ottawa, ROMHC, TOH, FSC, as well as
Client and family representatives to work through the following issues:
 The most appropriate model to facilitate coordinated access
 Address how regional access to services will be incorporated in the model
 Identify how language capacity and cultural competency will be built into the model
 Identify how information will be shared and data managed across partners
 Determine how partner communication, and system-level monitoring of the access will occur
 Ensure the full range of partner services are consulted e.g. eating disorders, substance use, based on
the client profile of people with BPD or BPD traits
The objectives of the coordinated access mechanism are to:
 Shorten the time from which a person is referred for assessment, to the point at which they are screened
(triaged) for level of need and service type needs,
 Improve differentiation of people to the services based on their needs,
 Maximize resources available by ensuring lower-intensity services are used as clinically appropriate and
as part of the person’s treatment staging
 Identify how the person will be supported prior to initiation of service
 Improve client satisfaction in accessing services,
 Improve retention rates from time of assessment to time of service initiation,
 Develop system referral protocols for the coordinated access mechanism for use by other mental health
services, addictions services, and allied health and social service sectors,
 Collect system level information about wait lists and where specific evidence-based service types or
approaches lack capacity or do not exist, and
 Increase the number of opportunities for cross-organization training and knowledge-building activities;
for example, cross-training.
As part of this process, the working group will also consider what additional groups might support people
with BPD or BPD traits: specifically, there is an emerging model first developed via St. Michael’s Hospital
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
17
in Toronto, and currently being implemented in a co-facilitation model with community mental health and
Peer Support organizations that requires further review and understanding.
ANALYSIS OF ALTERNATIVES
Please describe any other initiatives considered and why this option was chosen.
Partners have been engaged in discussions for years, developing the optimal range of DBT services and the most
appropriate partners to provide these services. The success of the TOH DBT-full pilot provided the impetus for the
development of this HSIP. This pilot is now complete, and the success of the pilot, consistent with the literature
on BPD, demonstrates that investment in this treatment for individuals with BPD benefits these individuals and
has impact at the ED and inpatient level.
Concurrently, partners recognize that the next phase of work must examine how best to coordinate the range of
available services, ensuring that clients have access to the most appropriate type of DBT services. They are fully
committed to developing a system access mechanism that helps clients be linked to the right service, with the right
provider, as determined by their needs.
INTEGRATION OF INNOVATIVE PRACTICES
Please describe how you have leveraged leading practices and/or innovation in your proposal.
Please refer to Appendix C, as well as Appendix D which presents a summary of the community
consultations that were undertaken in 2011.
ASSESSMENT OF RISK OR BARRIERS
Please describe any risks or barriers identified that may impact the implementation of this proposal by the HSP
(incl. financial, reputational, policy, legislative, etc)
Type of Risk or Barrier
Insufficient funding would limit the
capacity of services to meet the needs of
clients
Access to services and understanding
which client profile fits with which service
type could be challenging
Having sufficient resources in place to
properly measure the true impact of DBT
services on hospital utilization
Risk Level
Moderate
Moderate
Low
Mitigation Strategy
Unknown at this time – planning has included
discussion of how to use residents or students as
part of the overall program. There are also
opportunities to examine how overall system
capacity could be built through expansion of
training and consultation roles at TOH and
CMHA Ottawa
Creation of working group to develop a
mechanism for coordinated access to the range of
DBT services
Integration of a system research assistant to assist
in data collection and analysis to help in guiding
program development
IMPLEMENTATION TIMELINE
Please describe the major activities for the first year of the project. Please ensure that you indicate the expected
start date for service delivery (if applicable).
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
18
Activity
Lead agency/partnership agreement
Staff recruitment/hiring
Coordinated access working group
struck
Development of protocols – Distress
Centre of Ottawa and TOH for afterhours calls
Distress Centre of Ottawa Training
Staff training/orientation
New staff begin integrating in
existing DBT services and
individual client contacts
Begin running additional DBT
groups
Start Date
Completion Date
September 1
September 1
September 1
October 30
October 31
Ongoing
September 30
October 1
November 1
November 1
October 31
January 30, 2014
Beginning February 2014
SECTION 5 – TARGET POPULATION
Note – In 2011-12 the Champlain LHIN implemented an updated Decision-Making Framework as part of the proposal review
process. The following questions are directly related to the scoring metrics in this framework. Please reference sources where
appropriate.
POPULATION OF FOCUS
Please describe which LHIN population will benefit from this proposal. Please highlight the impact on any
populations where there is a known health status gap (i.e. Groups defined socially, economically, demographically,
culturally, linguistically or geographically). Please specifically highlight the impact on the francophone or
aboriginal populations. In determining the impact on the populations of focus, please consult the Health Equity
Impact Assessment and the Francophone Assessment tools available at www.champlainlhin.on.ca.
The DBT range of services, while focused in the City of Ottawa, are available to clients throughout Champlain.
Additionally, TOH and CMHA Ottawa provide training and consultation support throughout the region, and would
continue to do so in an expanded way if funding is received. The Montfort Hospital, which provides DBT services to
the francophone population, will be closely engaged in the implementation process. Partners also recognize the
opportunity to build close working relationships with Youth Services Bureau, recognizing that the younger population
presents particular challenges and opportunities with respect to DBT services.
IMPACT ON POPULATION HEALTH
Please describe any expected impacts on client health outcomes, quality of life, risk of adverse events, injury
prevention and/or health promotion by completing the following table.
Nature of Impact
Performance Measure
Source of Data
Partners have agreed that the Outcome Questionnaire-45 (OQ-45) will serve as the basis for measuring client
impacts at a health outcomes and quality of life level. The OQ-45 will be used to measure the impacts, over
time, on a number of indicators, including:
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
19






Interpersonal relationships
Suicidal and self-harming behaviours or actions (data will be augmented using the Self-Harm
Inventory as well)
Feelings of depression
Substance use
Social functioning
School and work functioning
COMMUNITY ENGAGEMENT ACTIVITIES
Please describe any community engagement activities you have conducted to date, or plan to conduct if this
proposal is approved. Please highlight any engagement with the francophone or aboriginal communities.
In addition to the extensive community consultation that was undertaken in 2011, HSIP partners propose the
establishment of a working group that would focus its activities on coordinated access. Partners would also
continue to meet to monitor the implementation and ongoing operations of the range of DBT services
available – some additional partners that will be engaged through this process (either through ongoing or
periodic participation) include:
 Youth Services Bureau
 Ottawa Mobile Crisis Team and Distress Centre of Ottawa
 Addictions Services – specifically the Ottawa Addictions Assessment and Referral Services
 Eating Disorders Program
 Wabano Health Services
 Ottawa Network for BPD (family members)
 Elizabeth Frye and John Howard
 Mental health and addictions services in the counties (Renfrew, Eastern, and Lanark)
Following acceptance of the HSIP, the existing DBT Committee membership will be refined to reflect
additional key partners. Below outlines audiences and communications strategies that will be utilized on an
ongoing basis.
Audience
To Whom? List recipients of
the information.


Information Needs
What? State what information will
be communicated.
Format & Timing
How? When? How often?
Explain method & frequency.
Clients and family
members

Service information

Partner websites

Coordinated access
mechanism

Service Brochure
Mental health and
Addictions service
providers

Ongoing reports on
implementation and
operations

Monthly – through the
Addictions and Mental
Health Network
Meeting
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
Responsible
Who? Identify who will
provide information.

DBT Committee

Lead identified
by DBT partners
20
Audience

Partner groups:

Aboriginal health
services

Mental health service
providers

Housing/homelessness
service providers

Primary Care
providers – including
Family Health Teams,
Family Health
Groups, Community
Health Centres and
the OMA

Emergency
Departments

Non-LHIN funded
services e.g. Ottawa
BPD Network,
Elizabeth Frye, John
Howard

Children and Youth
Services

Other

LHIN
Information Needs
Format & Timing
Responsible

Ongoing reports on
implementation and
operations of the DBT
services

Periodic

Lead from the
DBT Committee

Report on implementation
progress

Using LHIN identified
templates as required
on a quarterly basis

Lead agency
with support
from the DBT
Committee
SECTION 6 – CAPITAL FUNDING REQUESTS
In accordance with the Community Capital Projects Directive issued by the Ministry of Health and Long Term Care
on May 1, 2012, the Champlain LHIN must not fund or approve any projects without first obtaining approval from
the Ministry of Health and Long Term Care for the following:
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
21


All projects (including both leasehold and owner funded) with a value of over $100,000 (as
outlined in the Ministry’s Capital Planning Manual, 1996) and the provision set out in the
MOHLTC-LHIN Joint Review Framework for Early Capital Planning Stages Toolkit, November
9, 2012; or
Where the value is less than $100,000 and where there is space utilized for the provision of
primary care and/or allied health care services as part of the project, regardless of capital funding
source(s), including Own-Funds Capital Projects and projects funded by LHINs.
Please see www.champlainlhin.on.ca under the Health Service Providers section for more details on how
to submit requests for projects of this nature.
SECTION 7 – PREVIOUSLY FUNDED PROPOSALS
Note – This section may not be applicable for all proposals. Please contact your Champlain LHIN specialist with any
questions.
OUTCOMES FROM PREVIOUS PROJECT PHASES
If components of this proposal have received previous funding from the Champlain LHIN or other sources, please
describe the nature of this funding and the outcomes achieved. Please include a description of any funding
received for planning activities related to this proposal.
Note – It is not necessary to attach all project documents and reports that have previously been submitted to the Champlain
LHIN.
SECTION 8 – CHANGES TO SERVICES PROVIDED
Note – This section may not be applicable for small capital proposals. Please contact your Champlain LHIN specialist with any
questions.
CHANGES TO SERVICE TARGETS
Please complete the following table. Please consult the OHRS guidelines at www.mohltcfim.com if you are not
familiar with functional centre names and definitions for any new services.
OHRS
Functional
Center Code
725 10 76 12
725 10 76 12
725 10 76 12
725 10 76 12
725 10 76 12
OHRS
Functional
Centre Name
MH
Counseling
and treatment
MH Counseling
and treatment
MH Counseling
and treatment
MH Counseling
and treatment
MH
Service Activity
Service Activity
Fiscal
Unit
2013/14 (#
units)
Individual weekly
40
contacts
– CMHA
Group contacts –
12 group
DBT- M – CMHA
sessions
Group contacts
12 group
– DBT-S Group sessions
CMHA
Group contacts –
n/a
DBT-M – FSO
Counseling
40
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
Annualized
Budget (#
units)
640
Individuals Served
Fiscal
Annualized
2013/14 (#
Budget (#
clients)
clients)
4
16
24 group
sessions
48 group
sessions
8
8
8
8
24 group
sessions
320
0
8
4
8
22
Counseling
sessions – FSO
and Treatment
2013/14 figures - based on staff taking clients in Q4
FSO – based on individual counseling beginning in Q4 with weekly counseling sessions (total of 40 sessions per client per year in
order to account for cancelled appointments and vacation. Groups will be co-facilitated with CMHA but training time will take
place in 2013/14, allowing for beginning groups in 2014/15.
See below for increases through TOH.
Note – This information may be used to update existing Service Accountability Agreements if funding is provided for this
proposal.
CMHA Ottawa and FSO – Summary of Changes
Current Volumes
Additional Volumes
DBT-M
2 groups
16
1 group 8 – CMHA
1 group 8 - FSO
DBT-S
1 group
8
1 group 8
DBT-grad
1 group
8
1 group 8
Workers group
2
Workers only
2 Workers only
Focus group
1
Workers only
Individual
7 clients
16 – CMHA
Therapy
8 - FSO
Assessment: Case 36 /yr
50
workers
Assessment MD
20
Total Volumes
4 groups 32 clients
2 groups
2 groups
4 groups
1 group
31 clients
16 clients
16 clients
80
20
The Ottawa Hospital – Summary of Changes
DBT Full
DBT Therapy
Consults
Future Groups
2 running
concurrently
Individual
therapy runs
concurrent to
DBT Full
Current
Patients
Future
Patients
8
16
7
30
1 group run
twice per year
Open group
16
90
# Contacts/client
52 (weekly contact in
group for 1 year)
52 (weekly individual
therapy for clients in
DBT Full groups)
90
26 (weekly contact in
group for 6 months)
Total Client
Contacts
832 (i.e.52*16)
832
90
416
DBT lite Group
16
16
DBT Grad Group
8
16
DBT Grad Follow
Up
Open group
0
8
Total
5
69
162
Currently, there are about 70 patients serviced in three groups – this HSIP increases that to 162 per year
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
23
•Group/Working with Emotions – 12 weeks - TOH
•DBT Lite – 6 months - TOH
•Emotion regulation skills training – Women’s Mental Health/Meadowcreek ROMHC
•DBT Lite - Hopital Montfort
Moderate
Intensity
• DBT Full: Group and individual therapy – 12 months - TOH
• Group/DBT Modified – 24 weeks – CMHA
• DBT M-Individual – 48 weeks - CMHA
• Individual therapy - Family Services Ottawa (in concert with CMHA group
and case management therapies)
• Group/DBT S – 24 weeks - CMHA
High
Intensity
•Group/DBT Grad – open - TOH
•Group/DBT Aftercare – 48 weeks - CMHA
Low
intensity
CHANGES TO FTE
Please complete the following table. Please consult the OHRS guidelines at www.mohltcfim.com if you are not
familiar with functional centre names and definitions for any new services.
OHRS
Functional
Center Code
Ex. 7* 5 82 45
OHRS
Functional
Centre Name
Assisted Living
Services
725 10 76 12
Counselling
and
Treatment
Counselling
and
treatment
725 10 76
12w
Functional Center
Service
Fiscal
Activity Unit
2012/13 (#
FTE)
Inpatient /
0.75
Resident Days
Annualized
Budget (#
FTE)
1.5
Type of FTE
Description of FTE (ie. Admin,
RN, PSW, Physician, Case
Manager, etc)
PSW
2.0
188,630
Case manager
1.0
66,700
Social work/ psychotherapist
Note – This information may be used to update existing Service Accountability Agreements if funding is provided for this
proposal.
Additional Staffing Changes – The Ottawa Hospital:
Current Staffing Levels
Proposed Staffing
Psychiatry
0.6 FTE
0.8 FTE
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
Difference FTE
0.2 FTE
24
Psychology
Social Work
Occ Therapy
RN
Admin
Supplies
Social Work
RN
Total
0.4 FTE
0.2 FTE
0.0 FTE
0.0 FTE
0.1 FTE
0.6 FTE
0.6 FTE
0.6 FTE
0.6 FTE
0.4 FTE
0.2 FTE
0.4 FTE
0.6 FTE
0.6 FTE
0.3 FTE
On-Call 0.0 FTE
On-Call 0.0 FTE
1.35 FTE
0.2 FTE
0.2 FTE
4 FTE
0.2 FTE
0.2 FTE
2.65 FTE
OTHER PERFORMANCE METRICS
Please complete the following table to identify any other performance metrics that will be used to assess success of
this project.
Outputs/Outcomes
Performance Measure
Source of Data
Note – This information may be used to update existing Service Accountability Agreements if funding is provided for this
proposal.
The following is a DBT Checklist (already in use by CMHA Ottawa and TOH) that summarizes the range of tools used in
assessing client impact before, during, and after completion of DBT “Full” services
Baseline-Referral and Screening
TASK
Integrated Referral Form (beige one)
Multnomah Score (MCAS)
AUS rating
DUS
DBT Screening Form
Borderline Symptom List (BSL)
DBT Entry Interview
Self Harm Inventory
DBT program agreement
DBT Evaluation Consent Form
Case conference date
CSW (initial)
DBT (initial)












Middle
DBT questionnaire (BSL)
Self Harm Inventory
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012


25
Outcome Questionnaire (OQ-45.2)
Case Conference (if needed)



End of DBT
DBT Exit Interview
Borderline Symptom List (BSL)
Self Harm Inventory
Outcome Questionnaire (OQ-45.2)
Case Conference (if needed)
AUS
DUS
Multnomah Score (MCAS)









SECTION 9 – PROJECT COLLABORATION
COLLABORATION WITH CHAMPLAIN LHIN PARTNERS OR NETWORKS
Please describe any networks or partnerships that will be established or strengthened through this proposal and the
role each partner or network will play.
Partner/Network
Role
Involvement To-Date
CMHA Ottawa
Lead Agency
Key partner in planning and
delivery of DBT services
DBT Management
Committee
Provides oversight of
DBT services through a
formalized partnership
agreement
n/a individual partners
(TOH, FSO, ROMHC)
have been meeting formally
– may include additional
representation from Hôpital
Montfort, clients and
family, Youth Services
Bureau representatives
depending on feedback
received from those
partners
Expected Future Role
Lead agency in fund
administration and
administrative
oversight
Provide system-level
oversight of DBT
services
KNOWLEDGE TRANSFER
Please describe how results of this project will be communicated with other providers in order to share knowledge
with the broader region.
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
26
Delivery of DBT services and the organizations’ partnership will be promoted within the region through
communication activities and, where possible, at provincial, national and international conferences.
APPLICANT HSP CEO/ED:
As the lead participant in this proposal I support the project described above and believe that the performance
measures identified will help advance the priorities identified in the Champlain LHIN Integrated Health Services
Plan and/or Annual Business Plan and/or Champlain eHealth Strategic Plan and/or Decision Support Strategic
Plan.
_________________________________________
________________________ ___________________
TIM SIMBOLI
SIGNATURE
DATE
Executive Director, CMHA Ottawa
PLEASE HAVE AUTHORIZED PERSONNEL FROM ALL PARTNER AGENCIES ACKNOWLEDGE THEIR SUPPORT OF
THIS PROPOSAL.
PARTNER(S):
As a partner in this proposal I support the project described above and confirm my role as described in Section 8.
_________________________________________
________________________ ___________________
CHRIS CLEMENT
THE OTTAWA HOSPITAL
SIGNATURE
_________________________________________
________________________ ___________________
JAN CHRISTENSEN
EXECUTIVE DIRECTOR, FAMILY SERVICES OTTAWA
SIGNATURE
_________________________________________
________________________ ___________________
GEORGE WEBER
CEO, ROYAL OTTAWA HEALTH CARE GROUP
SIGNATURE
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
DATE
DATE
DATE
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Citations
Bagge, C.L., Stepp, S.D., Trull, T.J. (2005). Borderline Personality Disorder features and utilization of
treatment over two years. Journal of Personality Disorders. 19(4), 420-439
Barnow s, Spitzer C, Grabe HJ, Kessler C, Freyberger HJ. (2006) Individual characteristics, familial experience
and psychopathology in children of mothers with borderline personality disorder. J Am. Acad. Child Adolesc.
Psychiatry. 45 (8) 965-972
Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham
JM, Gunderson JG. (2001) Treatment utilization by patients with personality disorders. American Journal of
Psychiatry. 158(2) 295-302
Feldman, R., Zelkowitz, P., Weiss, M., Vogel, J., Heyman, M., & Paris, J. (1995). A comparison of the families
of mothers with borderline and nonborderline personality disorders. Comprehensive Psychiatry, 36, 157-163.
Gerull F, Meares R, Stevenson J, Korner A, Newman L. The beneficial effect on family life in treating
borderline personality. (2008) Psychiatry 71(1) 59-70.
Grilo CM, Stout RL, Markowitz JC, Sanislow CA, Ansell EB, Skodol AE, Bender DS, Pinto A, Shea T, Yen S,
Gunderson JG, Morey LC, Hopwood CJ, McGlashan TH. (2010) Personality Disorders predict relapse after
remission from a episode of major depressive disorder. A 6 year prospective study. J Clin Psychiatry 71 (12)
1629- 1635
Gunderson JG, Morey LC, Stout RL, Skodol AE, Shea MT, McGlashan TH, Zanarini MC, Grilo CM, Sanislow
CA, Yen S, Caversa MT, Bender DS. (2004) Major depressive disorder and borderline personality disorder
revisited: longitudinal interactions. J Clin Psychiatry. 65(8) 1049- 1056
Hobson RP, Patrick MPH, Hobson JA, Crandell L, Bronfman E, Lyons-Ruth K. (2009) How mothers with
borderline personality disorder relate to their year old infants. British Journal of Psychiatry. 195 (4) 325-330
Kullgren G, Renberg E, Jacobsson L. (1986) An empirical study of borderline personality disorder and
psychiatric suicides. Journal of Nervous and Mental Disease. 174(6) 328 -331.
Main M, Hesse E. (1990) Parents’ unresolved traumatic experiences are related to infant disorganized
attachment status: is frightened and/or frightening parental behaviour the linking mechanism? In Attachment in
the Preschool Years (eds M. Greenberg, D. Cicchetti, M. Cummings): 161–82. University of Chicago Press
Schuengel C, Bakermans-Kranenburg MJ, van IJzendoorn MH. (1999) Frightening maternal behavior linking
unresolved loss and disorganized infant attachment. J Consult Clin Psychol ; 67: 54– 63.
Moos R, Moos B (1986) The Family Environment Scale Manual (2nd ed). Pal Alto, CA: Consulting
Psychologists Press.
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Paris J, Zweig-Frank H.(2001) A 27 year follow up of patients with borderline personality disorder.
Comprehensive Psychiatry, 42(6) 482-487.
Runeson B, Beskow J. (1991) Borderline Personality Disorder in young Swedish suicides. Journal of Nervous
and Mental Disease. 179(3)153-156.
Zanarini, M.C., Frankenburg, F.R., Khera, G.S., Bleichmar, J.. (2001) Treatment Histories of Borderline
Inpatients. Comprehensive Psychiatry. 42 (2) , 144-150
Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. (2004) Axis I co-morbidity in inpatients with
borderline personality disorder: 6 year follow up and prediction of time to remission. Am J Psychiatry 161 (11).
2108- 2114
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Appendix A: BPD Symptoms
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked
impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of
the following:
 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.
 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between
extremes of idealization and devaluation.
 3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance
abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered
in Criterion 5.
 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability,
or anxiety usually lasting a few hours and only rarely more than a few days).
 7. chronic feelings of emptiness (or boredom)
 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights)
 9. transient, stress-related paranoid ideation or severe dissociative symptoms
In a Systematic enquiry of 50 dysphoric feelings compared to patients without BPD Zanarini 1998):
 BPD patients higher than non BPD on all 50 dysphoric feelings
 % of time spent feeling:
 Overwhelmed 61.7%
 Worthless 59.5%
 Very angry 52.6%
 Lonely 63.5%
 Misunderstood 51.8%
 Abandoned 44.6%
 Betrayed 35.9%
 Evil 23.5%
 Out of control 33.5%
 Like a small child 39.1%
 Like hurting or killing themselves 44% (
Co-morbidity:
The following table summarizes the incidence of co-morbidity between BPD and other mental illness.
“Overall” draws from Gunderson text, representing a compilation from several studies and includes inpatient
and outpatient samples. The “Inpatients” column is from Zanarini (2004), using data from McLean hospital:
290 consecutive inpatients between the ages of 18 and 35 SCID, DIB-R, Diagnostic Interview for personality
disorders. (Gunderson, Links 2008, Zanarini et al 2004)
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Overall
Inpatients (Zanarini 2004)
Depression
50%
86.6 %
Dysthymia
70%
44.8%
Bipolar II
11%
5.5%
Bipolar I
9%
0% (exclusion criteria)
ED (AN, BN)
25% (5%/20%)
53.8% (21.7%/24.1%)
PTSD
30%
58.3%
SUD
35%
62.1%
Alcohol only
25%
50.3%
Panic Disorder
45.2%
OCD
14.5%
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Appendix B: DBT Continuum of Services
All treatments are/have:
 Structured
 Weekly supervision, support for therapists
 Twice weekly sessions with patients
 Here and now focus
 Active therapist
 Emotion focus
 Psychoeducation about BPD
DBT Program Review
The Ottawa Hospital
Staffing
Psychiatry: 0.65 FTE
Psychology: 0.4 FTE
Social Work: 0.2 FTE
Admin: 0.1 FTE
Total: 1.35 FTE
Funding
$40K
$20K – SW
$7K – admin
$49K
Psychiatry via OHIP
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
The Canadian Mental Health Association



Coordinator: 0.2 FTE
Consultants: 0.2 FTE
Community Mental Health and
Dialectical Behavioural Therapy
Worker: 1 FTE
PLUS: (5)* 0.2 FTE = 1 FTE
 Admin: 0.1FTE
 Physical plant :rooms for all
CMHA groups ,Graduates group
from the Ottawa hospital and all
clinical consultation teams CMHA
and external group
Total: 2.5
Per Group



DBT Modified: 6 (2x 24 weeks)
DBT M- Individual: 8 (48weeks)
DBT S: 6 (2x24weeks)
DBT Aftercare: 8 (48weeks)
Royal Ottawa Mental Health Centre
Position:
Emotion Regulation:
0.1 FTE
social work (includes admin time)
0.1 FTE psychology (includes admin time)
Emotion Regulation DBT skills training:
0.1 FTE Psychiatry
0.1 FTE Social Work (includes admin
time)
Total: 0.4 FTE
Per Group
Emotion Regulation : 8-10
Emotion Regulation DBT skills training:
8
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Total unique patients: 32
Total unique patients: 16- 18
Number of Patients on
Average
Per Group
DBT Full:8 Patients/ Waitlist 30* (wait
list reflects list prior to pilot completion)
DBT Grad: 8*
DBT Individual: 7
DBT lite: 8
Per Group



DBT Modified: 6 (2x 24 weeks)
DBT M- Individual: 8 (48weeks)
DBT S: 6 (2x24weeks)
DBT Aftercare: 8 (48weeks)
Per Group
Emotion Regulation : 8-10
Emotion Regulation DBT skills training:
8
Total unique patients: 32
Total unique patients: 24
Description of Each Group
and Patient Population plus
Waitlist (# of patients and
length)
DBT Full: 2.5 hour DBT skills training
group. Occurs weekly. Total time per
group 3.5 hours – includes
prep/debriefing/crisis assessments/notes.
Duration 12 months
DBT Grad: Twice a month. 1.5 hour
group. Total time 2 hours. Duration: open
group
DBT Individual: 1-1.5 hours per week
direct patient contact. Telephone
coaching/notes require an additional 0.5
hours (average) per week. Duration 12
months
DBT lite: 2.5 hour group. Total time
required 3.5 – 4 hours. Prep/debrief/notes
as for DBT full, but more crisis
assessment as patients in group have
community therapists. Duration 6 months
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
DBT Modified: 2 hours DBT skills training
occurs weekly Total time per group 3.5
hours – includes prep/debriefing/crisis
assessments/notes. Duration 24 weeks
x2=48weeks
DBT M- Individual: 1 hour therapy :One
on One DBT therapy after group sessions .1
hour per week plus 1 hour prep and notes
Total 2 hours per week . 24 weeks running
concurrently with DBT- M (2x24weeks)
Total 48weeks
Total unique patients: 16- 18
Emotion Regulation : weekly skills training
group for women .
Total 3.5 hours week – includes 2 hour
group/ prep/debriefing/crisis
assessments/notes.
Emotional regulation skills training for
women who have completed meadow
creek substance use treatment program
3 hours a week includes 2 hour group/
prep/debriefing/crisis
DBT- S: 1.5 hours skills training group
occurs weekly Total time per group 3.5
hours – includes prep/debriefing/crisis
assessments/notes. Duration 24 weeks
x2=48weeks
DBT Aftercare: 1.5 hours skills based
mindfulness & healthy living group with
peer facilitation component plus 1 hour
notes and prep. Total 2.5hours Occurs
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weekly for Total 48 weeks
Consultation team :1.5 hour skills based
group for workers (case managers and
outreach workers) occurs weekly for all case
managers that have clients in DBT-M skills
group Total 3.5 hours prep and notes /runs
concurrently with DBT-M (2 x24weeks
)Total 48 weeks
Referral Sources
DBT- full: Inpatient, day hospital, OPD,
eating disorders. Only TOH. Must be
“high utilizers” – at least 1 TOH visit in
past 6 months and SH or suicide attempt
in past year. No active alcohol/substance
dependence.
DBT-Lite: community therapists. Must
have community therapist who is willing
to see patient weekly and provide crisis
support during working hours. Patient
must be in paid work/volunteer work/
school work/ parenting a minimum of 4
hours per week, preferably 20 hours per
week. No active alcohol/substance
dependence. Must NOT have had serious
self injury or suicide attempt in past 6
months

Referrals are generated internally from
CMHA case management and outreach
caseloads .

Referrals are generated from Mental
Health Community Support Services
(MHCSS ) partners from their case
management caseloads.( eg Salus,
Project Upstream, YSB as well as from
CHEO (transitional aged youth
workgroup)
Emotion Regulation: women are referred
through Shared Care, Mood and Anxiety
Disorders program. No active
alcohol/substance dependence. Patients
experience emotional dysregulation.
Patients must have an open chart at The
Royal.
Emotion Regulation : women are referred
through Substance Use and Concurrent
Disorders Program.
DBT grad group: open to any graduates
of DBT who have found DBT useful.
Open group. Must have treating clinician
that they can see once per month.
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Additional Information
Working with Emotions group. Part of
UCC. DBT based skills training group.
Open to all UCC referrals. On average 13 patients in group with BPD. Group is
12 weeks.
Champlain LHIN Health System Improvement Proposal Form, rev. May 2012
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
Supervision :clinical consultation team
for practitioners 1x per week for 1.5
hours (48 weeks)
Research :partnership with the Ottawa
University being forged

Sessional fees :partnership with the
Ottawa Hospital

Partnerships: with MHCSS partners and
Royal Ottawa hospitals for the training
of facilitators and admission to the
CMHA/ DBT team(.Salus and Royal
Ottawa Hospital) have trained 1
clinician each and have joined CMHA
DBT team in order to facilitate groups
to allow for clients from their service to
be admitted to DBT groups at CMHA
ROMHC Youth Mental Health program
also has Behavior Tech trained DBT team.
provides DBT group skills training and
concurrent DBT individual psychotherapy
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Appendix C: Summary of the Evidence-Base for Dialectical Behaviour Therapy
Theoretical Basis for BPD:
 Core feature of BPD is emotion dysregulation
 Bio (emotionally vulnerable temperament) transacts with Social (invalidating environment )
 Bio: Emotionally vulnerable individual
 Sensitive, intense, slow return to baseline
 Transacts with
 Social: Invalidating Environment
 Indiscriminately rejects communication of private experiences (thoughts, feelings, urges)
 Intermittently reinforce escalation of emotional responses and display
 Oversimplify the ease of solving life’s problems and meeting goals
 Individual who is emotionally vulnerable and self-invalidates
 Impulsivity and interpersonal turbulence secondary to affect dysregulation
 5 functions of comprehensive treatment: teach skills, improve motivation, ensure generalization to the
natural environment, improve therapist skill and motivation, structure the environment
Evaluation of DBT
 Overall, there have been better findings for psychotherapy studies (including DBT) for people with
BPD or BPD traits as compared to medication studies: all studies include patients with substance
abuse, meds, suicide and self-harm behaviours
 Results below summarize findings from 8 studies (Linehan 1991, 2006, Turner 200, Koons 2001,
Verhuel 2003, McMain 2009, Linehan 1999, 2002), recognizing that there were differences in some of
the studies with respect to the frequency of individual therapy, and other aspects of service delivery
 Comparing “Treatment as Usual”, some or most of the studies found that:
 DBT decreases suicide attempts and self-harming behaviours (frequency and severity)
 DBT increases retention in treatment programs
 DBT decreases number of hospital days
 In a randomized control trial of providing DBT versus General Psychiatric Management (GPM) for
people with BPD:
 There were significant improvement across time; no between group differences on the
following outcomes:
 Frequency of suicidal behavior
 ER visits
 # Days in Psychiatric Hospital
 BPD symptoms
 Anger
 Depression
 Symptom Distress
 Interpersonal functioning
 DBT saves slightly more in health care costs over pre-treatment costs ($9,653 versus $9,418 for
GPM) and confers a higher improvement in quality of life
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
Currently all guidelines recommend that empirically based treatment is best for BPD. TAU shows
benefit, but not as much as structured treatment. Structured treatment needs to be delivered in a
program. All structured treatments appear to be equal. Why DBT over other structured treatments?
 largest evidence base is for DBT versus other structured treatments
 clear treatment manual, easily accessed ( although somewhat expensive) training
available
 1 study has shown that front line workers are able to learn this material ( as compared to
specialists with years of training in BPD/therapy that are required for other treatments)
 training can be delivered to multidisciplinary teams, although some therapy training and
experience with people with BPD is required
 has been shown to reduce treatment costs over pre-treatment year
 has been shown to reduce ER visits and days in hospital
 local expertise has been developed over past 8 years

Should we consider having more than one BPD treatment available?
 Increasing choice of treatment likely improves adherence with treatment and overall
outcome, but depends on size of centre, most Canadian centres only offering DBT
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Appendix D: Summary Findings – Community Consultation
This community consultation exercise was hosted jointly by The Ottawa Hospital and Canadian Mental Health
Association-Ottawa and was held at the ROHCG on March 2 2011. The purpose of this meeting was to gather
information from stakeholders in Ottawa who are involved in the care of people with BPD in order to find out
what services are available, which are working well, what services are not available, what services are needed
and which of the needed services are highest priority.
The engagement exercise included two phases – phase 1 involved a survey which was forwarded to all
attendees (in some cases there were multiple attendees from one institution, in that case only one attendee was
asked to submit the survey). In addition to the survey from family members and mental health organizations a
separate survey was done of patients/clients currently in the DBT program at the Ottawa Hospital. The results of
this survey formed the basis for the engagement exercises. The results of this summary are included in this
report.
Phase 2 was a meeting with all stakeholders held at the ROHCG. Part 1 of the meeting included 4
presentations. The first presentation, by Dr Paul Links a Canadian researcher and an internationally recognized
expert on treatment of people with Borderline Personality Disorder, addressed issues to be considered when
developing an integrated system of care for people with BPD. The second presentation was given by Mr.
Winston Revie head of Family Connections Ottawa – a not-for-profit Ottawa based organization run by family
members of people suffering with BPD, The presentation included the personal experience of a family member
of a person with BPD and then provided information about the groups run by Family Connections Ottawa. The
third presentation by Dr Sarah Birnie C. Psych covered a survey of patients with BPD who were receiving
treatment in the TOH –DBT program. Lastly, Dr Deanna Mercer presented a summary of the results of the premeeting survey.
This information set the framework for the working group discussion and priority setting exercise. The
members of the working group identified improved access to services, education and coordination of services as
3 highest priorities for improving care for people with BPD in the Ottawa region.
With respect to services, access to specialized services and general mental health services were given a priority
level of 5/5. With respect to specialized services improved access to Dialectical Behaviour Therapy (DBT) and
DBT-lite were the highest priority. Access to other evidenced based treatments for BPD such as Mentalization
Based Treatment rated slightly lower at 4/5. With respect to general mental health services, improved access to
services such as youth outreach, psychiatric consultation and on-going care were given priority levels of 5, 4.5
and 4 making improved access to these services as important as access to more specialized services. These
priorities were consistent with information presented by Dr Links – who emphasized: 1) specialized treatment
for BPD exists, 2) there is good evidence that it works and 3) it may save money when compared to treatment as
usual. Dr Links also identified the need for access to consultation for family physicians as an important
component of an effective system of care.
Education was also identified as a level 5 priority. The working group identified 3 key areas for training as
important:
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i) training in DBT for service providers (therapists and community health centre staff) ii) training for mental
health clinicians who are supporting clients in DBT and iii) training for primary care teams. Dr Links echoed
importance of education, both to improve the effectiveness of treatment provided and in order to change the
prevailing negative attitudes about BPD.
The third high priority area identified was the need for global system coordination and the ability to match
services to an individual’s needs and severity of illness. This priority is in line with Dr Links’ reminder of the
importance of defining levels of care for treatment of BPD. There is a wide spectrum of treatment needs in
BPD – some people do well with outpatient services and follow up with their family physician, whereas others
require more intensive services including intensive outpatient, case management and hospital based (ER, day
hospital, inpatient) services.
Additional points raised by Dr Links included the importance of identifying the needs of acute care services,
such as emergency room and inpatient services, and the need to ensure that treatment programs address the
functional capacity of individuals with BPD as well as treating symptoms and distress.
The next steps identified were to complete the report of the meeting and to forward this to the working group
participants as well as stakeholders, and finally to submit the findings of this committee to the LHIN.
Respectfully submitted,
Deanna Mercer MD FRCPC psychiatry
Medical Director DBT pilot program, Associate Staff
Department of Psychiatry, The Ottawa Hospital
Assistant Professor, Department of Psychiatry
University of Ottawa
Helen Gottfried-Unruh
Senior Manager, CMHA
DBT Team Coordinator
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