Programming Connection

Positive Service Coordination  

LOFT Community Services, McEwan Housing and Support Services
Ontario
2015

What is the Program?

The Positive Service Coordination Program (PSC) based at LOFT Community Services in Toronto provides short- and medium-term intensive case management for people living with HIV who cycle through the health and judicial systems as a result of being homeless, living with a mental illness, using substances or experiencing a physical or mental health crisis.

Clients who qualify for PSC’s services are known as members and are paired with a case manager who, with the member’s consent, works to support them to establish priorities for their health and well-being and achieve their goals.

Case managers work with members to find permanent, stable housing; ensure they have appropriate identification documents and are receiving their maximum social assistance benefit; engage them in HIV-specific care, primary care and mental health care; and make active linkages to appropriate community organizations. PSC operates from a harm reduction model, meaning members can continue to use substances as they engage with the program.

The objective of PSC is for members to set personal goals, be housed, be engaged in care and be engaged in the community by the time they graduate from the program. During the time members spend with a case manager—anywhere from six to 18 months—case managers make active links to and help members navigate available community and clinical services. If individuals are engaged in services through intensive case management, it is less likely that they will disengage from care in the future. 

PSC employs three full-time case managers to work directly with PSC’s members. The program is led by a full-time coordinator who maintains relationships with community and clinical partners, supports the case managers and works with members as needed.

Although LOFT Community Services employs the coordinator and the case managers, PSC has a strong working collaboration among 17 Toronto-based community and clinical partners1, including healthcare institutions and facilities, community-based organizations and housing providers. Two housing intake workers from partner agencies are on-site at LOFT to coordinate housing for members.

In 2011, the Addictions Supportive Housing Program was established for PSC members with the most entrenched substance use who needed more long-term case management. A separate team of case managers provides similar services to members of this program. Although this case study will focus on PSC, more information on the Addictions Supportive Housing Program can be found at the end of this case study.

  • 1. 2-Spirited People of the 1St Nations; Casey House; Fife House; Fred Victor Centre; McEwan Housing and Support Services; Prisoners’ HIV/AIDS Support Action Network (PASAN); Seaton House Shelter, Infirmary Program; Sherbourne Health Centre, Infirmary Program; St. Michael’s Hospital, HIV/AIDS Psychiatry; St. Michael’s Hospital, Positive Care Clinic; The 519 Church Street Community Centre, Trans Program; Toronto HIV/AIDS Network; Toronto People with AIDS Foundation; Action Positive; Latinos Positivos; Africans in Partnership Against AIDS; The Maple Leaf Medical Clinic.