TA5 - Working Together Towards Recovery

Concurrent Disorders
• A proposal, Strengthening Community
Supports for Concurrent Disorders
– Reduce ED visits
• SIGMHA – Data Analysis Findings
• Quality Task Team identified 10 strategies
– Including:
• Intensive Case Management (Concurrent Disorders)
• Bridging Program from ED to Community Services
• Home based Withdrawal Management Program
One Program – 3 Services
Crisis Management Support
(St. Elizabeth’s Healthcare, COAST (CMHA-HRB)
Concurrent Disorders Case Management
(Trillium Healthcare, CMHA-HRB)
Community Withdrawal Management Services
Our Mission
CCDP is dedicated to strengthening community
supports for individuals with substance use
concerns or a combination of mental health
and substance use concerns (i.e. Concurrent
Disorders) through the provision of an
integrated continuum of services.
Reducing ED visits by 10% and return
visits by 80%
Crisis Management Support
• Immediate 24/7 Telephone Response to
provide support and arrange follow-up
• Crisis support in the client’s home or in the
• Provides support while being linked to
addiction, mental health or community
Case Management
• Assessment of client’s current situation
• Provides support to identify and develop goals
around substance use and mental health
• Facilitates referrals and linkages to community
supports and services
Community Withdrawal Management Services
• Offers an alternative to residential withdrawal
management for individuals who can safely
withdraw from substances in a supportive
community environment
• Works with the client to develop a safe plan
for withdrawal
• Provides monitoring and support during all
stages of withdrawal
17 Staff Positions
Crisis Management Support
(CMHA- HRB COAST – 1 FTE Concurrent Crisis Worker)
(Mobile Crisis or Peel – 2FTE Concurrent Crisis Worker)
Concurrent Case Management
(CMHA-HRB 5 FTE Intensive Concurrent Case Managers)
(Trillium Health Care – 2FTE Intensive Concurrent Case Managers)
Community Withdrawal Management Services
&Transitional Case Management
(ADAPT – 3 FTE Withdrawal Management Counsellors / Transitional Case Managers,
1 FTE RN, 1 FTE RPN, 1 FTE Program Manager/Counsellor)
(PAARC – 2 FTE Transitional Case Managers)
Transitional Case Management
• Offers support during transition from CWMS
to additional Mental Health or Addiction or
Concurrent Disorders Services
• May include pre and post withdrawal support
Steering Committee
Purpose: to oversee the development and
implementation for the initiative and to uphold
obligations to the LHIN.
In addition, Promote inter-organizational collaboration
A framework for decision making
Key representatives from other organizations
Chaired by the CEO CMHA-HRB
Key Roles and Working Groups
• Implementation Co-ordinator – Nora McAuliffe
• Program Evaluator – Peter Mueller
• HR & IT Working Group
• Communication & Education Working Group
• Process Working Group
HR & IT Working Group
Purpose: To look at the potential for joint recruitment
and hiring processes. (need to add in IT purpose)
• Common Data Base (CRMS)
• Laptops from Lead Agency
• Common Training
Communication & Education Work Group
The group’s primary task was the design and
implementation of a joint orientation package for
new team members.
Common language
Knowledge transfer
Promote common practices
Team building
Process Working Group
Purpose: To develop protocols and processes for each
component of the program and make recommendations
to the Steering Committee on policies and structures.
• Comprised of Team Leads, Clinical Managers/
Directors from participating agencies
• Development and implementation of integrated
• Development of collaborative processes
Process Working Group - 2
• Referral Processes for Hospital Crisis Services
• Community Referrals
– Common Intake Service
– No wrong door
• Eligibility Criteria
• Consent to service
• Common Referral, Admission Criteria,
Screening & Assessment Processes
• Client & Community Brochure
Guiding Principles
Through the provision of integrated, continuum of
services to reduce the usage of Emergency
Departments, CCDP is dedicated to the following
•Client centered, empathic, respectful, hopeful, individualized,
holistic, flexible, supportive, non-judgemental and
comprehensive services
•Philosophy of care (individualized and harm reduction)
•Concurrent Disorders is the expectations not the exception
•Welcoming and Accessible
•Continuity of Care
•Integrated services and processes
Info & Referral
No Wrong Door Approach
Through any participating organization.
Lessons Learned
Moving Forward
Program Evaluation
Peter Mueller – Program Evaluator
Evaluation Framework (Matrix)
Focus Group
Client Surveys
Thank You!
Presented by:
Carrie Woodcock
Program Manager ADAPT CWMS
Jason Barr
Manager CMHA-HRB Coast Program
Funding for CCDP has been provided by the
Mississauga Halton Local Health Integration
Network (MHLHIN)

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