Programming Connection

Positive Service Coordination  

LOFT Community Services, McEwan Housing and Support Services
Ontario
2015

Lessons Learned

Five clear lessons have been identified by PSC staff:

  1. Strong partnerships.  PSC is a collaboration among 17 community and clinical partners. Each partner contributes their expertise to member care, and together the partners enable PSC to offer a range of services to meet each individual member’s stated needs. This strong collaboration means that each partner can work to its strength and call on the strengths of other partners when needed to address the holistic needs of members.
  2. Priority access to primary care providers. Members of PSC or ASH who do not have a primary care provider when they enter the program are guaranteed access to one who has experience working with similar clients. This means that members do not have to wait to receive primary care from an experienced and non-judgemental provider.
  3. On-site housing intake workers. Housing intake workers from two partner agencies are on-site at LOFT. This has meant that connections to housing can be made more quickly and more seamlessly. Members can meet with the housing intake worker the same week they enroll in PSC. Additionally, having an on-site housing expert means that the case manager can focus on the other aspects of a member’s care plan.
  4. Staff persistence. PSC members have complex care needs. Many of them live with trauma and multiple co-morbidities and may be mistrustful of service providers, and they may not fully engage with services the first time they are offered. It is key that staff take a flexible approach with members and continue to follow up with them when they may be having difficulty remaining engaged in their care.
  5. Anything is possible. Members may be coming to PSC when they are at their most vulnerable, both physically and emotionally. However, the coordinator and the case managers never assume that members cannot achieve the goals they set out for themselves. This trust in members’ abilities encourages self-management.