Supporting the Journey to Mental Health Wellness through Coordinated Care

Submitted by CMHA Durham

In  2009, a client came to CMHA Durham’s Community Access Services where his needs were assessed and he was deemed eligible for Group Living Services.  He received assistance in many areas of development including medication management, psychiartist support, coping strategies, appointment reminders and a host of  life skills support such as budgeting, cleaning, grocery shopping, public transpotration and more.

When this client successfully graduated from Group Living, he was offered  a Subsidized Unit with CMHA Durham and began receiving supports from the Intensive Case Management program.  Case managers assisted this individual along the continuum of care by helping him maintain his independence that he acquired from his group living, and encouraging active participation in vocational and social pursuits through CMHA Durham’s Community Wellness Services. During this time, the client participated in numerous   group activities focusing on vocational, life skills and social aspects of rehabilitation, while meeting new people and gaining new perspectives on mental health and recovery.  This individual also  registered with CMHA’s Nurse Practitioner-Led clinic and received his medication from the Bond Street Pharmacy, conveniently located  on CMHA’s premises. 

The integration of CMHA’s services allowed this client to receive timely and comprehensive supports enabling him to flourish in the community.  After three-in-a-half  years, his recovery allowed him to better manage his mental health  and take control of his addictions, allowing him to seek and maintain  full-time employment, establish a supportive social network, and earn enough income, no longer requiring a subsidy.  Arrangements were made to keep his apartment while paying market rent.  After several months of case management services, the client was ready to move on and an agreed upon discharge took place.

One year later, the client was hospitalized at Lakeridge Health Oshawa after a number of emergency room visits due to mental health and addiction struggles. The instability the client experienced from his loss of job created a cascade of events which ultimately affected his housing and mental health, while exacerbating  his struggles with addictions.  While in hospital, the client received support from a  Hospital To Home case manager who would then facilitate a Coordinated Care Plan.  The Care Plan included a number of key supports representing Pinewood Centre for Addictions, Durham Mental Health Services, and CMHA Duham, along with social work and psychiatric support from Lakeridge Health.  In order  to ensure a timely and permanent return to his apartment, resources and tasks needed to be identified and completed.  The client’s apartment was again secured and plans were set in place to cover his arrears.  The client accepted his  previous supports with addictions services and CMHA Durham’s Intensive Case Management  and was provided crisis resources, all of which would ultimately avoid a re-hospitalization.  While successfully transitioning back into the community, this client’s rent subsidy was reinstated, allowing him to recover using his network of community supports. 

Today, this client has successfully maintained his housing subsidy for close to a year.  He has secured temporary employment and has recovered by better managing his mental health. He has aspirations of going back to school, and has welcomed supports from a debt counselor to better managed his finances.  The client has experienced no relapses since his hospitalization last year, and continues to seek support through Pinewood to remain abstinent.

H2H flow chart