Programming Connection

Positive Service Coordination  

LOFT Community Services, McEwan Housing and Support Services
Ontario
2015

How Does the Program Work?

Referrals

Most referrals come from Positive Service Coordination (PSC)’s community and clinical partners. Because PSC members tend to be disengaged from care when they are referred, many referrals come from services that people access when they are in crisis, such as mobile outreach teams or hospital emergency departments. Referrals are processed and intakes are performed within two days of being received to reduce the likelihood that people are lost to care.

All referrals are screened and assessed based on need. The assessment takes into account the person’s number of emergency department visits in the last two months and in the last year; number of hospitalizations; number of admissions to withdrawal management programs or day programs within the last year; and number of legal charges in the last year. Any potential member who scores higher than a 10 on the assessment qualifies for PSC. Individuals who qualify for PSC and have significant addictions are referred to the Addictions Supportive Housing Program’s case management service.  As of February 2015, there are 60 clients in PSC.

Partnerships

Although LOFT leads PSC, the program is a cross-sectoral partnership among 17 partners. This partnership is governed by a memorandum of understanding that all partners have signed. LOFT hosts three in-person meetings a year of the PSC partners to maintain relationships and address any issues that have arisen since the last meeting.

The community and clinical partnerships that LOFT fosters are one of the keys to the success of PSC. Each partner brings a specific and necessary expertise to the care of PSC members. By collaborating and combining their expertise, the partners enable the PSC case managers to address member needs holistically.

PSC staff work closely with partners; the collaboration varies according to the needs of clients. For instance, appropriate housing—transitional and respite—is coordinated with Fife House, Fred Victor Centre, Casey House, Sherbourne Infirmary and McEwan House, depending on member needs. Psychiatric care is offered on-site at LOFT Community Services by St. Michael’s Hospital.

PSC partners are both sources of referrals for the program and key stakeholders in the care of many of PSC’s members. Although each partner is critical to the success of member care, the level of engagement of PSC partners in the program varies according to the types of services they offer. For example, partners who provide services such as housing and healthcare are called upon more often than partners who provide cultural or linguistic services that are only requested by members who identify with a specific cultural or linguistic group.  

Intensive case management

The core service of PSC is intensive case management. The goal is for members, by the time they graduate from PSC, to have set personal goals, be housed, be engaged in care and be engaged in the community. Community engagement varies for members: it may include actively participating in events hosted by PSC’s partners, volunteering, or preparing to return to work or school.

After referrals have been assessed and individuals have been deemed to qualify for support, PSC’s case managers triage the new members. Two case managers take on members whose needs can be resolved in six to nine months. Although these members may be homeless and may be disengaged from healthcare, their needs are expected to require less time to address than those of other members. The third case manager works with members who may need more long-term support, typically lasting between 12 and 18 months.   

Members are paired with one of the case managers and they meet to discuss their goals and develop a personalized care plan. Members and the case manager fill out an Ontario Common Assessment of Need (OCAN) form to understand the member’s baseline needs. Completing this form also helps members determine their priorities for services. Members can provide consent for the case manager to discuss their care with PSC’s partners, making it easier for the case manager to make appointments and coordinate care on the member’s behalf.

Critical to the success of PSC is the presence of housing intake workers on-site at LOFT. Both housing intake workers are employed by HIV housing providers. Having this expertise on-site allows the case manager to focus on the other needs identified by the member. Typically, new members meet with the housing intake worker the same week they first meet with their case manager. Members tend to enter transitional housing or respite care, if appropriate, as a stop-gap measure until their case manager and the housing intake worker can find permanent housing. When they enter transitional housing or respite care, members receive a higher level of support that gives them the opportunity to stabilize their health and their lives so they are ready to enter permanent housing when it becomes available.  

The case manager coordinates a member’s care. Some members enter the program without a primary care provider. PSC members have priority access to primary care providers who have experience working with people living with HIV who may also be living with mental illness and substance use challenges. Priority care means members do not have to wait to receive appropriate and non-judgemental primary care.

During the first few months, the case manager makes and accompanies members to appointments with primary care providers and HIV care providers and, if necessary, schedules a first meeting with HIV psychiatry, which is available once a week at LOFT’s offices. Depending on the member’s goals, the case manager may also make linkages to AIDS service organizations and other community-based organizations.

Through the first few months of engagement, a case manager and a member may see each other up to four times a week. This intensive engagement builds familiarity and trust. Case managers strengthen this relationship by helping members to achieve the goals they have identified for themselves. Through these efforts, and by modelling behaviour that members can use to advocate for themselves, case managers bolster member self-confidence, which improves member self-management.  

Gradually, as a member’s circle of care widens and they take on more responsibility for their care, members become more independent. When a member resolves problems or overcomes barriers without the help of their case manager, the case manager reinforces the member’s success.

Building relationships with other service providers

Case managers must also build strong relationships with other service providers to make sure members receive optimal care. Typically, case managers build these relationships by being present at meetings to discuss the member’s care and raising the member’s concerns with service providers in a respectful way.

Graduating from the Positive Service Coordination Program

PSC is meant to be an intensive, short- to medium-term program for people who are disengaged from services and have complex health and social needs. By the end of their engagement with the program, members typically have permanent housing, have a primary care physician and are being monitoring by an HIV healthcare provider and an HIV psychiatrist (if needed). Members are also pursuing the personal goals they set for themselves when they enrolled in PSC, such as returning to school, reuniting with family or getting a job.

Although members graduate from the program, they remain general members of LOFT Community Services through McEwan’s General Member Association. This program provides members with social support and reduces isolation after graduation. Members who experience crises or challenges in their recovery after graduation are re-enrolled in PSC with their case manager, who supports them to re-engage in services.

Occasionally, members disengage from the program. Case managers continue to follow up with these members, understanding that they may need time. Case managers leave messages in places members are known to frequent and leave member files open for months. When members return, case managers reassess their needs and continue to support them to engage in services.

Addictions Supportive Housing Program

Although PSC offers intensive comprehensive support to members, the short-term nature of the program is insufficient for some of them. In 2011,  LOFT received funding from the Toronto Central Local Health Integration Network for the Addictions Supportive Housing Program (ASH) for people living with HIV who have significant addictions and who have had a significant number of hospitalizations, admissions to withdrawal management programs and incarcerations in the previous year. LOFT, in partnership with Fife House, has 32 rent-geared-to-income suites for ASH members. Referrals for ASH are processed through PSC. There is no time limit on engagement in ASH.

ASH provides services for members with the most complex substance use problems and allows them to engage in their care through a supported housing model. Three case managers work full-time with ASH members, the same way that PSC’s case managers work with their clients. They use OCAN to identify client goals, coordinate appointments and services for their members and engage members in care.

Next steps

In 2015, LOFT Community Services, as a result of the Positive Service Coordination Program (PSC), was identified by the Toronto Central Local Health Integration Network and the Mid-East Toronto Health Link (one of nine Health Link services in various regions of Toronto that focus on improving client care in specific areas) as a pilot site for a new care coordination planning program for people with complex mental health and substance use challenges. The pilot builds on the work of PSC and the Addictions Supportive Housing Program by trying to improve care planning for clients through an interagency multidisciplinary care team. In the pilot, a case manager will assemble a unique team of service providers for each client who will meet to develop a coordinated care plan.