Programming Connection

Positive Service Coordination  

LOFT Community Services, McEwan Housing and Support Services
Ontario
2015

Challenges

LOFT has identified a number of ongoing challenges for PSC:

  1. Partner differences. With 17 partner agencies, LOFT is working across multiple organizational systems, cultures and guidelines. Although they are all working to increase client well-being, it can be challenging to coordinate communication and workflow across community and clinical services. Currently, LOFT and other partners are piloting a coordinated care planning project that may reduce communication challenges among partners.
  2. Discharge planning. Some PSC members start their time in the program by entering treatment for mental illness or substance use. Typically, these services are not offered through a PSC partner, which means that discharge planning with the case manager does not always take place. PSC case managers must ensure that they proactively follow up with external service providers to know when discharge will take place. This makes it easier to move members from  the facility where they received treatment to transitional housing or respite care.
  3. Limited employment opportunities for members. When PSC members are stable, some want to work. Although some of PSC’s partners offer employment and volunteer opportunities, there are not as many opportunities as needed. PSC would like to build stronger ties with educational institutions and employment services to provide members with additional opportunities so that members who want to work can do so.   
  4. Stigma. Stigma remains a barrier to appropriate care for PSC members. Service providers outside the network of PSC’s partners may stigmatize substance use, mental illness and HIV. Most PSC members live with all three, making strong engagement in care a challenge for them. Case managers advocate on behalf of members, modelling behaviour that members can use to advocate for themselves, which may reduce the impact of stigma on their health outcomes.