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Mental Health Case Management

Mental Health Case Management

Mental Health Case Management services are offered at each of the five office sites throughout Hastings and Prince Edward Counties.  Services are based on the Recovery Model which supports independence, wellness, personal growth and community living.

Services include, but are not limited to:

  • Community-based service offered in the client’s environment of choice
  • Individualized assessment and treatment planning
  • Supportive counselling
  • Service navigation and coordination
  • System advocacy
  • Personal advocacy
  • Family support and education
  • Skills groups
  • Public education and consultation
  • Linkage to AMHS-HPE’s consulting psychiatrist
  • Relapse prevention and crisis planning

Hospital Liaison Case Management

The Hospital Liaison Mental Health Case Manager provides seamless transition for adult patients with a mental illness who will be discharged from the psychiatric unit at the hospital to their community in Hastings or Prince Edward Counties.  Case Management services begin while the person is still an in-patient and continue to be provided after discharge.

Services include, but are not limited to:

  • Community-based service offered in the client’s environment of choice
  • Individualized assessment and discharge planning
  • Service coordination with hospital staff
  • Ongoing supportive counselling and support after discharge
  • Linkage to other agencies, programs, and services
  • Liaise with general practitioner and/or psychiatrist
  • System and personal advocacy
  • Family support and education
  • Relapse prevention and crisis planning

Activities of Daily Living Peer Mentor

The Peer Mentor program provides support and assistance with activities of daily living as delivered by an individual with lived-experience.  The ADL Peer Mentor develops and maintains supportive relationships with clients while acting as a role model.  Supports and services are provided in clients’ own homes as well as in the community.  The Peer Mentor assists, instructs and monitors clients’ personal recovery abilities as they relate to household management including grocery shopping, budgeting, banking, errands, household chores and home safety.  Support is also available around accessing community resources and transportation and accompaniment to social/recreational and leisure activities.

* Internal Referrals Only

Emergency Room Diversion Case Management

The Emergency Room Diversion Case Management (ERDCM) program is a short-term case management program for addictions and/or mental health clients being diverted from the emergency department.  This program offers services in coordination with other providers, including primary health care. Referrals are received from the Crisis Intervention Centre only.

Services include, but are not limited to:

  • Community-based service offered in the client’s environment of choice
  • Individualized assessment and planning
  • Development of coordinated care plan
  • Service coordination and navigation
  • Linkage to AMHS-HPE’s consulting psychiatrist
  • Monitoring of referrals made
  • Monitoring of Emergency Department presentations
  • Relapse prevention and crisis-planning
  • Transition and discharge planning

Transitional Case Management

The Transitional Mental Health Case Management program is a short-term (6 week maximum) case management program for mental health clients whose needs have been identified as high priority and require a rapid response.  This program delivers services in coordination and collaboration with community agencies and primary health care providers.

Services include, but are not limited to:

  • Community-based service offered in the client’s environment of choice
  • Individualized assessment
  • Coordinated care planning
  • Supportive counselling
  • Service coordination and navigation
  • Linkage to AMHS-HPE’s consulting psychiatrist
  • Referral monitoring
  • Relapse prevention and crisis planning
  • Transition  planning

*Internal Referrals only

Skills Groups and Public Education

Skills groups are offered in the various satellite offices.  Staff facilitate groups according to identified client and collaborative agency needs.

Skills groups are offered to:

  • Assist clients in gaining information about their illness
  • Provide clients with coping tools in order to improve quality of life
  • Teach skills required to monitor and manage symptoms, both physical and emotional
  • Create positive changes and increase wellness
  • Promote the use of self-help skills for balanced daily living

Concurrent Disorders Case Management

The Concurrent Disorders program provides a holistic treatment approach for individuals that are experiencing both addiction and mental health issues in the Bellleville and Trenton area .  A Concurrent Disorders Counsellor provides specialized integrated service while supporting improved, long-term outcomes for individuals.

Integrated service recognizes that co-occurring disorders require a modified approach that is both coordinated and comprehensive.  This program provides a wide range of services relevant to well-being.

Services include, but are not limited to:

  • Community-based service offered in the client’s environment of choice
  • Individualized assessment and treatment planning
  • Supportive counselling
  • Service navigation and coordination
  • System advocacy
  • Personal advocacy
  • Family support and education
  • Public education and consultation
  • Linkage to AMHS-HPE’s consulting psychiatrist
  • Relapse prevention and crisis planning

Addiction Supportive Housing (ASH) Program

In March 2008 the Ministry of Health and Long-Term Care began investing funds for the development of supportive housing programs across Ontario for people with addictions.

Primary Objectives:

  • To reduce the frequency of re-admissions to addiction programs, and particularly to withdrawal management services
  • To increase housing stability for people with problematic substance abuse who are homeless, at risk of homelessness or inadequately housed
  • To reduce pressures on the emergency care and acute care system

Principles for Program Framework:

  • Program is client-centred and responsive to the unique needs of individuals
  • Program is responsive to relapsing nature of problematic substance use
  • Services are based on a harm reduction approach and recovery model
  • Housing support is integrated into the community
  • Individuals should feel safe and secure in housing environment
  • Addictions support services are provided through integrated housing coordination and addiction support services team.
  • ‘No wrong door’ regional coordination of access, application process.
  • Build on existing data systems in place such as the Drug and Alcohol Treatment Information System (DATIS) to measure client outcomes and ensure program accountability

South Eastern Ontario

The Addiction Supportive Housing (ASH) Program was developed as a regional addictions program with housing supports that is managed by Addictions and Mental Health Services, Hastings Prince Edward.

Program Components Include:

Housing

Securing and maintaining safe and stable housing in an essential part of this treatment program.  To assist with this a rent supplement will be provided for variable time periods based on established need.

The program holds 16 subsidies in Hastings/Prince Edward County, 16 subsides in Kingston/Frontenac/Lennox & Addington and 16 subsides in Lanark/Leeds and Grenville.

Case Management/Supportive Counselling & Services

The Addictions Case Managers provide a full range of case management services in the individual environment of choice which include:

  • Case co-ordination
  • Community linkage
  • Advocacy
  • Safety planning
  • Life skills training
  • Financial management
  • Relapse prevention and counselling

Primary Eligibility Criteria:

Individuals with problematic substance use
Who are involved in or completed an addiction treatment program;
History of multiple entries to the addiction system (community treatment programs, withdrawal management services, residential treatment programs….)
Are homeless, at risk of homelessness or inadequately housed
Individual is unable to obtain or maintain housing without support
Willingness to identify harm reduction or abstinence substance use goal (s)
Capable and willing to constructively participate in the ASH program.

Referral Process

Individuals currently engaged with AMHS in HPE, KFLA or LLG should speak to their worker about a referral.

Referrals from other sources may contact AMHS- HPE to obtain the referral form which is to be completed and returned to AMHS-HPE by Fax 613-968-4312.

Once referral is received ASH staff will review referral and contact the referral agent or individual to arrange a time to meet individually to explore the individuals needs and discuss the program.  Individuals who believes the program would be beneficial to them and they are able to commit to the ASH program will be offered subsequent sessions with the Addictions Case Manager to establish and implement a plan to secure/maintain housing with addictions support.

Contact

Belleville

15 Victoria Ave
Belleville, ON
K8N 1Z5
Phone
613-967-4734
Fax
613-968-4312

Bancroft

33 Flint Ave
Bancroft, ON
K0L 1C0
Phone
613-332-3826
Fax
613-332-0005

Trenton

27 King St
Trenton, ON
K8V 3V7
Phone
613-394-1655
Fax
613-394-2151

Madoc

52 St Lawrence St E
Madoc, ON
K0K 2K0
Phone
613-473-9914
Fax
613-473-1005

Picton

35 Bridge St
Prince Edward, ON
K0K 2T0
Phone
613-476-2990
Fax
613-476-6403

For information about residence, call 613-962-7838 or fax 613-962-8388.

For information about court diversion, call 613-968-1111 or fax 613-968-9555.

If you are in crisis, call 613-969-7400, Ext. 2753