Continuing Care Project

What is the system challenge?

Continuing care services and supports are extremely important for helping people to reach their long-term substance use recovery goals. By “continuing care” we mean any kind of support that comes after a period of substance use treatment (whether inpatient, residential, or intensive outpatient treatment) where the goal is to help the person to continue and maintain their recovery over the long-term.

Continuing care can be offered in a number of ways, including:

  • group counselling;
  • individual therapy;
  • telephone counselling;
  • brief check-ups;
  • self-help meetings; and
  • recreational programming.

In Toronto, adequate continuing care services and supports do not currently exist in a coordinated, structured, or intentional way. Service providers and people with lived experience tell us that the lack of continuing care is a major gap in Toronto’s mental health and addictions system.

What are we doing about it?

The Continuing Care Project Steering Committee developed the Community Connect initiative to respond to some of the opportunities for action outlined in the Charting the Path report.

Community Connect encourages better continuity of care for people who have used a residential withdrawal management service (WMS) by (a) improving the effectiveness of referrals to a range of resources that will aid in their ongoing individual recovery and (b) conducting community-based outreach to improve access experiences.

Community Connect focuses on times of critical transition – moving between WMSs and community supports. Smoother transitions are encouraged during periods of significant anxiety and opportunity by drawing on a referral network of trusted partners whose supports and resources closely align with the needs of WMS clients.

Community Connect addresses the distinct challenges faced at each WMS by identifying and responding to the needs of location-specific priority groups, identified through consultations with staff and clients, and by review of available demographic information relevant to each WMS partner.

Who is involved?

The Continuing Care Project is being led by a steering committee of community representatives from a range of service sectors, organizational roles, and lived experiences of accessing treatments and supports for substance use issues. The steering committee members are:

  • Gerry Banks
  • Julia Bloomfield, Clinical Director, The Jean Tweed Centre
  • John Bushell, Addictions Counsellor, Renascent
  • Deborah Gardner, Executive Director, Street Haven at the Crossroads
  • Robin Griller, Executive Director, St. Michael’s Homes
  • Kelly Lawless
  • John O’Mara, Executive Director, Salvation Army: Toronto Harbor Light Ministries; Homestead Addictions Services
  • Linda Picken, Patient Care Manager, Addiction Services, St Joseph’s Health Centre
  • Janet Stevenson, Manager of Case Management and Clinical Programs, St. Stephens Community House
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Installation

The Continuing Care Project steering committee used the methods of human-centered design to develop a workable continuing care solution that address the opportunities outlined in the Charting the path: Findings and opportunities from the Continuing Care Project report.

Next Steps

The Steering Committee and project partners are in the process of finalizing the Community Connect model and developing service agreements needed to support the project’s implementation. The pilot project is expected to run from April 2020 to March 2021.

Resources

Charting the path: Findings and opportunities from the Continuing Care Project outlines feasible and realistic opportunities for improving continuing care in Toronto based on consultations with nearly 100 service users, over 70 service providers, as well as a review of current continuing care literature.