Community Support was a natural outgrowth of the expansion of Residential Services. A need became apparent to offer transitional support to clients moving from Residential Services to community life as they established themselves in their new settings.

At its inception, DMHS’ Community Support program was known as Helping Partners. This simple phrase is a perfect summary of the type of relationships the program was designed to foster: stigma-free, true partnerships … just one person helping another with important life goals. The name captured the spirit of recovery years before the term “recovery practice” was widely used.

Years later, the more traditional and familiar term Case Management was adopted and the program was known as Case Management for many years, which brought it more in line with what similar roles are referred to at other organizations.

Not long before Peer Support Specialist Sue Cathcart passed away, she had a conversation with DMHS CEO Rob Adams and said that people are not “cases” that need to be “managed.” This really resonated with Rob and therefore discussions began on how to rename this core DMHS program.

The name Community Support – like Helping Partners – describes exactly what is offered. The program is about supporting people with mental health challenges to live independently in the community. The services offered are person-centered and individualized according to need as determined by the OCAN Assessment Tool that incorporates client self-determination and client input into their goals and needs.

PROGRAM COMPONENTS

Like the Residential Program described in the previous newsletter, DMHS Community Support has many branches serving clients with various specific needs. Many of the Community Mental Health Workers are attached to and partner with important referral sources both in-house and external to DMHS. These branches include:

• Aboriginal Mental Health and Addiction Outreach – helping members of the Central East Region’s First Nations, Métis and Inuit population
• Community Treatment Order (CTO) – in partnership with the Canadian Mental Health Association Toronto’s CTO team, DMHS helps to serve clients with community support and nursing services by the addition of two CTO nurses to their team 
• Court Support and Pre-Charge Diversion – helping individuals in the community who are directly referred by the DMHS Court Support Program, as well as those who, in partnership with the Crown Attorney’s Office and Durham Regional Police, are working towards a Pre-Charge Diversion. 
• Crisis Services – helping individuals who have stayed in one of the DMHS Crisis Beds’ locations or who have received support via the C.A.L.L. Centre or mobile visits, who are in need of some community- based interim transitional support
• Dual Diagnosis – providing hands-on support to individuals who have a Dual Diagnosis – that is, both a developmental disability and a mental health problem – and also providing Urgent Response and Consultations to developmental services and to families
• Hospital to Home (H2H) – helping individuals who have presented at one of the local area hospitals in distress to transition back to their home/community and connect with needed community supports (including DMHS Crisis Services)
• Release From Custody – in partnership with CMHA, Haliburton, Kawartha, Pine Ridge helping individuals who are being released from the Central East Correctional Centre and who will be residing in Durham Region.
• Senior Support – helping clients of DMHS’ Senior Support program, in buildings operated by Durham Non-Profit Housing Corporation and Ajax Municipal Housing Corporation
• Transitional Aged Youth – helping young people via a partnership with Durham Alternative Secondary School
• Transitional Case Managers (TCMs) – in partnership with Ontario Shores Centre for Mental Health Sciences, helping clients transition into DMHS Residential Services (both core program and Complex Care homes)
• Forensic Transitional Case Managers (FTCMs) – in partnership with Ontario Shores, helping forensics clients transition from the hospital into community life (see below)

Forensic Transitional Case Manager Derik Blanchard Talks About His Role

I work for Durham Mental Health Services as a Forensic Transitional Case Manager. In 2007, the Ministry of Health and Long-Term Care funded this new position to help clients with the sometimes difficult transition of moving from the hospital to the community. The difficulty was not only due to the stigma of having both a mental illness and a Not Criminally Responsible status, but also because many clients had become institutionalized from being in hospital for prolonged periods of time.

Before this position was funded, the client would be moving out to the community, which is stressful, and trying to engage with their new outpatient treatment team (normally a new clinician and Psychiatrist). The position was intended to help with that by having someone whom the client knows from his or her time in hospital be there to guide them through their move to the community.

This position was also developed to improve client success rates with community living and therefore improve throughput in the hospital forensic system.

In general, my role is to establish a trusting relationship with the client while they and the treatment team are planning their discharge. We work on goals that are jointly identified by the client and treatment team while the client is still in hospital. These are sometimes referred to as “barriers to discharge.” Many times the client is moving to a completely different community from the one they came from, so, before the move, we go to where the client is going to live to tour and familiarize them with the area. Then, when the time comes for the move to the community, we help the client to move and to establish connections with their new supports.

Once in the community, we play an advocacy role, helping clients link to any supports, activities or resources that they show interest in. Once the client has gotten used to his or her new supports, is comfortable in their routine and is agreeable to discharge, the client graduates from the Transitional Forensic Case Management program. They have now made a successful transition and are well established in their new home.

I really enjoy my job. I get to assist clients with a very important step in their recovery and, if all goes well, get to see them doing well before their file is closed.