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 was 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. We warmly acknowledge the members of the steering committee, who generously provided their time, support, and guidance throughout the project:

  • Gerry Banks
  • Julia Bloomenfeld
  • Jon Bushell
  • Deborah Gardner
  • Robin Griller
  • Amber Kellen
  • Kelly Lawless
  • Dana Lythgoe
  • John O’Mara
  • Linda Picken
  • Francesca Serwaa
  • Lorie Steer
  • Janet Stevenson
  • Martha Williams
?What's this?

Full Implementation

A one-year pilot project of Community Connect operated from December 2020 to December 2021. Partner organizations included the Glendale House WMS at Unity Health - St. Joseph’s Health Centre, the Women’s Own WMS at the University Health Network, the Neighbourhood Group - St. Stephen’s Community House, and the Provincial System Support Program at the Centre for Addiction and Mental Health (PSSP), which provided project coordination and evaluation support. Full evaluation findings from the pilot project can be found in the resources section below.

Next Steps

Community Connect is currently being offered to clients of the women’s program at the Michael Garron Hospital Withdrawal Management Service by a Community Connect Case Manager from The Neighbourhood Group.


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.

The Community Connect Pilot Project Final Evaluation Report and Executive Summary present findings from the evaluation of the Community Connect pilot project, including key themes and recommendations for future offerings of the model.

The Community Connect Implementation Guide is intended to support community-based substance use and WMS service providers plan for and implement the Community Connect program model. It outlines the essential components of the model and explains what happens during each step of the service, describes observable behaviours for each component that can be used as benchmarks for practice and oversight, and provides resources to guide the development of an evaluation strategy for implementation of the model.