LOCAL TOOLS. The tools are presented in alphabetical order and do not indicate any order of priority.

Transcription

1 LOCAL TOOLS The tools are presented in alphabetical order and do not indicate any order of priority. Tool 1 Central East Network of Specialized Care: Memorandum of Understanding for the Crisis Response Network The Memorandum was developed in August 2012 and approved by members of the Network on November 1, The working group that developed the document was a sub committee of the Central East Community Network of Specialized Care and included representation from the four quadrants in the region and the four lead agencies that host the Community Crisis Response Network positions. This included Durham Mental Health, Catulpa, Community Living Ajax, Pickering, Whitby, York Support Services Network, CMHA Peterborough and Community Living Huronia. The Central East Network wanted to create greater clarity and consistency at a regional level for the crisis response service which is delivered through positions in four different agencies two from the mental health sector and two from the developmental services sector. Participating agencies identified the MOU as a way to clarify roles and responsibilities and to define an agreed upon purpose for the Crisis Response Network. The development of the MOU was the result of a highly collaborative process and all participants feel that significant progress has been made in achieving clarity of expectations. For further information contact: Marnie McDermott, Regional Coordinator, Central East Network of Specialized Care Community Living Huronia, ext 321 mmcdermott@clhmidland.on.ca Tool 2 Central East Network of Specialized Care: Best Practice Model for Specialized Accommodation This manual, printed in February 2012, was the result of five years of work by a subcommittee of members from the Central East Network. The committee included representatives from developmental service and mental health agencies, MCSS and the DSO Central East. The content of the manual is based on ONTABA standards (i.e. Ontario Association for Behaviour Analysis), reflects the expectations of the Services and Page 1

2 LOCAL TOOLS Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, MCSS 2008 and represents the culmination of promising practices in providing specialized accommodations to persons with a dual diagnosis. The material in the manual is used to assist sectors and agencies in developing programs for individuals with a dual diagnosis for specialized accommodations. It provides templates that can be adapted to the policies and procedures within the agency providing specialized accommodations for persons with a dual diagnosis. While the manual was developed for Central East region it can be applied to settings across the province. The members of the CE Network of Specialized Care endorse this manual as a best practice. The manual is the property of Community Living Huronia and Behaviour Management Services of York and Simcoe and is available in hard copy only. For further information contact: Marnie McDermott, Regional Coordinator, Central East Network of Specialized Care Community Living Huronia, ext 321 mmcdermott@clhmidland.on.ca Tool 3 Huron Perth System Pathway to: Services and Supports for People with a Dual Diagnosis The project to create this document began in November 2008 with the final product being launched in June This was the result of a work plan goal identified by the Huron Perth Dual Diagnosis Committee, to become a resource to those in need of assistance in supporting individuals with a Dual Diagnosis in Huron Perth. The members of this sub committee consisted of staff from developmental services and both community and hospital based mental health services. The information included in this system pathway covers all of Huron and Perth counties. There are some key urban areas included such as Stratford, Goderich, Exeter and some smaller towns and rural areas. The material was launched at a one day conference on Dual Diagnosis sponsored by the committee. One of the committee co chairs introduced the System Pathway document explaining how it came to be and how it could be a helpful resource to the cross sector professionals who were in attendance. The Protocol Page 2

3 LOCAL TOOLS for Linkages developed by the Dual Diagnosis and the Huron Perth Mental Health and Addictions committees identifies the process that will happen when someone with a Dual Diagnosis enters a Schedule One hospital. Committee members identify this document as an effective practice as it provides comprehensive information in one place that can help professionals, families and advocates. The process of working together on the creation of this document has helped professionals to be more aware of the needs of people with Dual Diagnosis and has contributed to stronger relationships between mental health and developmental service providers where partners are more likely to contact each other with questions when difficult situations arise. This makes working together on new collaborations/projects easier. For further information contact: Lynda Legge, Facilitator Southern Network of Specialized Care Woodstock General Hospital ext 2405 llegge@wgh.on.ca Tool 4 Lanark County: L.E.A.D. Team Protocol This protocol, developed in 2005, was initiated by Dave MacDonald (OPP) and Diana McDonnell of Lanark Mental Health utilizing an example of a police/mental health protocol from the Chatham Kent region. To secure the collaboration, they met individually with local chiefs of police and OPP, managers of ER departments and ambulance services, Royal Ottawa Hospital (mental health) and community hospitals. The Chatham Kent protocol was based on police and mental health collaboration, but the interest was to expand beyond police to include the entire emergency responder network. It now includes children and youth services, addiction services, distress centre and most recently, Brockville General Hospital as it has taken over acute mental health services from Royal Ottawa Hospital. The protocol agreement is reviewed and revised (if necessary) annually. To ensure awareness and adherence to the protocol, front line staff attend a two day training conference. Training, including awareness of mental health issues (including dual diagnosis) and response protocols is offered to all protocol partners as well as all front Page 3

4 LOCAL TOOLS line responders (i.e. ER nurses, ambulance attendants), probation and parole, developmental services, court, crown attorney. Core participants (i.e. emergency, addictions and mental health) are still the signatories of the protocol. Local partners indicate that the protocol has been extremely effective because: police are spending less time waiting in the emergency department; a mental health referral form for police is available in the ER so they can include their observations as part of the individual's mental health assessment; there are improved relationships between frontline responders as a result of having better awareness of each other and their roles, and if issues arise, the protocol identifies the lead individuals to sort issues out. The initial protocol included all of Lanark County, however, the LEAD protocol has been adopted by Human Services and Justice Coordinating Committees and adapted to meet the needs of communities across the South East, as well as parts of Champlain including Prescott Russell, Stormont, Dundas and Glengarry and Ottawa. For further information contact: Diana McDonnell, RN, BScN, CPMHN Director, Lanark County Mental Health ext 222 dmcdonnell@lanarkmentalhealth.com Tool 5 Niagara Region Southern Network of Specialized Care: Crisis Response: Pathway and Guideline The Flow Chart of Crisis Services in Niagara was developed and revised during the period of late 2011 to the summer of 2012 and applies to all of Niagara Region. This pathway was the work of the Niagara Crisis Steering Committee which was a small working group evolving out of the Niagara Service Delivery Network. The Crisis Steering Committee came as a result of years of promoting the benefit of an integrated cross sectoral approach to problem solving. This group took on broader partners including Mental Health (community and hospital based), Addictions, Developmental Services, Crisis Response Services, Justice, Police and Health to accomplish the goal. This group also drafted a community crisis protocol between partners and a template for crisis planning. Its work has resulted in a multi sectoral collaborative approach to implementation, review and revision. Page 4

5 LOCAL TOOLS The Crisis Flow Chart is used to explain the process for responding to crisis in Niagara and to help all partners and sectors see their role within the larger community plan. It will also be used as an educational tool as the committee provides information to front line staff about the guideline and crisis planning tools. The Flow Chart has been an effective tool in that it has enabled the group to talk through the approach including redirecting the process from hospital and has allowed them to see individual sector roles within the larger plan. It has served as a great visual learning aid. For further information contact: Nancy Hall, Facilitator for Niagara, Haldimand and Norfolk The Southern Network of Specialized Care (905) X312 nhall@bethesdaservices.com. Tool 6 North Bay Regional Health Centre Developmental Disabilities Service Continuum of Care The continuum of care map is a draft service pathway developed in house by the North Bay Regional Health Centre to aid the staff of the program in understanding the various sectors and multiple agencies involved in the provision of services. For further information contact: Patti Turcotte, Manager Developmental Disabilities Service, Birch Lodge, Maple Lodge Psychiatric Rehabilitation Program North Bay Regional Health Centre ext3506 patti.turcotte@nbrhc.on.ca Tool 7 North Community Network for Specialized Care Risk Spectrum Analysis The Risk Spectrum Response group was a subgroup of the Supporting Individuals in High Risk Service Situations Working Group. It met from September 2010 to November Page 5

6 LOCAL TOOLS 2011 and was comprised of members from the DS sector and the MOHTLTC from the Muskoka and Nipissing areas. The Risk Spectrum document is used as a means of identifying where an individual falls on the risk spectrum continuum. The Clinical Supports document outlines the corresponding responses to be made by the appropriate service provider. The Scenarios document provides examples of how someone in each of the six scenarios might present in each of the areas of the Risk Spectrum continuum. While no research has been completed in order to identify this as an effective practice both the members of the subgroup and of the working group believe that the documents provide an effective way of coordinating service delivery in order to support and respond to individuals in crisis situations. It also provides a framework for preventing crisis situations. For further information contact: Angie Nethercott, M.A. Senior Behaviour Consultant North Community Network of Specialized Care Hands TheFamilyHelpNetwork.ca ext 3245 anethercott@handstfhn.ca Tool 8 Toronto Network of Specialized Care: Service Resolution Pathway The Service Resolution Pathway in its current form has evolved from earlier process diagrams. As the Toronto Network of Specialized Care (TNSC) has evolved over the last six years and new services have been added, the Network has modified the details of the pathway. The pathway is a guide for accessing the supports of the Toronto Network of Specialized Care. It is an effective illustration of the process that an individual goes through and the details of what is offered as they move through the system. The Pathway leads to the Clinical Conference where individual situations are discussed with those supporting people with complex needs and have the benefit of a larger community providing ideas and recommendations. For example anyone wishing to access the Specialized Accommodation treatment beds follows the pathway through Clinical Conference where recommendations are made including being put on a waitlist for a treatment bed. There are also recommendations generated that span the specialized continuum and beyond to other developmental and Page 6

7 LOCAL TOOLS mental health services, along with supports to families and caregivers as well as health care supports. It is through the Clinical Conference where gaps/barriers and trends get identified and brought to the TNSC Service Resolution. The TNSC Service Resolution looks at systemic as well as individual issues. MCSS is a member of this group, and thus becomes aware of the broader system issues. Recently, the Toronto LHIN has joined the TNSC, and so partners are in the beginning stages of determining an ongoing relationship. For further information contact: Sandra Bricker Coordinator, Toronto Network of Specialized Care Surrey Place Centre ext3115 sandra.bricker@surreyplace.on.ca Tool 9 Toronto Network of Specialized Care: Memorandum of Understanding MOUs have been in use at the TNSC since the early days of the networks and were the result of a consultation process. In 2007, the Network began implementing the use of MOU specifically to increase the utilization of the offerings through the Clinical Conference table. The MOU reflects the commitment of the partners at the Network to working in collaboration and MOUs are currently held with both developmental and mental health service providers. In 2012, the TNSC revamped the format of its MOU to the more streamlined document shared in this report. The supports contained in the MOUs are primarily from the specialized continuum; however there are additional services that agencies have made available such as education and training. The supports offered in the MOUs are based on an agency s ability to deliver certain services and generally relate to assessments and connections to services. For further information contact: Sandra Bricker Coordinator, Toronto Network of Specialized Care Page 7

8 LOCAL TOOLS Surrey Place Centre ext3115 Page 8

9 LOCAL TOOLS Tool 10 Toronto Network of Specialized Care: Special Project: Alternative Level of Care (ALC) Alternate Level of Care (ALC) is a term used to describe hospital patients who face barriers to discharge although the level of care provided is no longer appropriate. Patients may be designated as ALC for a few days until, for example, home supports are put in place, or they may remain ALC for weeks and months, as the level of care they require is simply not available. Patients waiting in ALC for longer than 30 days ( long stay ) account for 13% of ALC discharges in the Toronto Central LHIN, and yet represent over 50% of ALC days, signaling that a small proportion of people are using a large proportion of ALC days. In early 2011, the Toronto Central (TC) LHIN asked CAMH to assume a leadership role, with support from a cross sectoral Advisory Committee to develop a framework and comprehensive plan for the ongoing care and maintenance of individuals with severe behavioural issues including dual diagnosis in the TC LHIN. CAMH recently completed their report Smoothing the Path: Addressing Alternate Level of Care Issues for People with Severe Behaviour Issues including Dual Diagnosis outlining 11 final recommendations. This ALC initiative builds on the recommendations outlined in that report. In support of its priority of reducing emergency room wait times and alternate level of care days, this project will focus on implementing and pilot testing initiatives focused on effective transitions, enhanced community supports and reducing gaps throughout the continuum of care. The project is aimed at individuals with mental health and addictions and behavioural issues including individuals with dual diagnosis, as recommended in the Smoothing the Path: Addressing Alternate Level of Care Issues for People with Severe Behaviour Issues including Dual Diagnosis. One of the selected initiatives was ALC Transition Service for Dual Diagnosis with the following objectives: To reduce the number of ALC days for those with a dual diagnosis who are ALC in TC LHIN hospitals by supporting them to move to an appropriate community setting with the appropriate clinical supports (community setting may include any combination of family home, supported housing or housing supports and community participation support in the developmental or mental health systems). Page 9

10 LOCAL TOOLS To build the capacity of the broader MH and DS community sectors to effectively serve ALC clients from hospital and community transitional treatment beds (I.e. those with high support needs whose discharges are blocked for similar reasons as those who are ALC in hospitals). To improve system utilization and flow for clients with high support needs. In this strategy, 4 5 new clients will be served annually by one Behaviour Therapist (BT) who will provide mobile, individualized clinical supports to transitioning ALC clients in Toronto Central LHIN hospitals and Toronto Network of Specialized Care communitybased transitional treatment beds. Further, team level training and support to strengthen the receiving team s knowledge, skills and effectiveness to implement the required protocols will be provided. The BT will support implementation of the individualized transition plan by providing individual functional assessment and behavior treatment strategies within the context of the new environment. Flex Fund resources will augment and support the BT role by providing experienced and trained frontline staff 24/7 to work alongside the receiving agency staff to implement the individual s treatment and support plan. This is a model that has been in place for over a decade through the Griffin Centre, which also allocates flex funds on behalf of the Griffin Community Support Network and Collaborative and Individualized Resource (CAIR). Together the BT and Flex Fund resources provide additional clinical supports for up to 1 2 years, thus enhancing long term community tenure and preventing emergency department use and a return to higher, more expensive levels of care. This ALC service will be integrated with the existing Collaborative and Individualized Resource (CAIR) service funded by MCSS. Together, and with the support of the Toronto Network of Specialized Care, Griffin Centre and CAMH provide the CAIR service. Griffin s role includes recruitment, orientation and training of one to one staffing (flex fund model) to implement programming that will enhance stabilization and successful community integration, and program management. CAMH Dual Diagnosis Program provides one Facilitator (MSW prepared, performing functions similar to an intensive case manager). CAIR services are limited to 6 months duration. The goal of CAIR is to prevent the need for more intensive and costly services and to enhance system capacity to address complex clinical issues that require more flexible and intensive responses than are currently available. Integrating the ALC BT and Flex Funds with CAIR will extend the current resources beyond 6 months. The ALC BT and Flex Funds will also expand CAIR by providing more intensive supports specifically to ALC clients in hospitals and Page 10

11 LOCAL TOOLS time limited community treatment beds so that clients can move through the continuum of services into longer term permanent community environments. For further information contact: Sandra Bricker, Coordinator, Toronto Network of Specialized Care ext3115 Page 11

12 LOCAL TOOLS Local Tools Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 12

13 LOCAL TOOLS TABLE OF CONTENTS TOOL 1 MEMORANDUM OF UNDERSTANDING (SEPTEMBER 2012) TOOL 3A SYSTEM PATHWAY TO SERVICES AND TOOL 3B SYSTEM PATHWAY TO SERVICES FOR PEOPLE WITH A DUAL DIAGNOSIS IN HURON PERTH TOOL 4 LANARK COUNTY L.E.A.D. TEAM PROTOCOL TOOL 5 NIAGARA CRISIS PATHWAY TOOL 6 NORTH BAY REGIONAL HEALTH CENTRE CONTINUUM OF CARE REFERENCE SHEET TOOL 7 HIGH RISK SPECTRUM DOCUMENTS TOOL 8 TORONTO SERVICE RESOLUTION PATHWAY TOOL 9 TORONTO MOU TEMPLATE TOOL 10A TORONTO ALC BROCHURE TOOL 10B TORONTO CLINICAL RESOURCE PLAN TOOL 10C TORONTO FINAL REVICES CAIR COMUNIQUE Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 13

14 TOOL 1 MEMORANDUM OF UNDERSTANDING (SEPTEMBER 2012) MEMORANDUM OF UNDERSTANDING Lead Agencies and Central East Network of Specialized Care (Community Living Huronia) Lead Agencies: Canadian Mental Health Association Peterborough; Catulpa Community Support Services; Community Living Ajax, Pickering and Whitby York Support Services Network. Service Provider: Durham Mental Health Services for Community Living Ajax, Pickering and Whitby General The purpose of this Memorandum of Understanding ( MOU ) is to describe the nature and terms of the relationship between the Lead Agencies and Central East Network of Specialized Care (Community Living Huronia) hereinafter called the Partners. This agreement governs the provision of a community crisis response service for adults with a developmental disability, mental health needs and/or challenging behaviours; residing in; York Durham Simcoe Haliburton, Kawartha, Pine Ridge The Partners are committed to the principle that collaborative service delivery promotes accountability and quality improvement for individuals, their families and service providers. JOINT RESPONSIBILITIES OF LEAD AGENCIES AND CENTRAL EAST NETWORK OF SPECIALIZED CARE (COMMUNITY LIVING HURONIA) PARTNERSHIP: The Crisis Response Network Coordinators (CRNC) will work collaboratively with each other, the (LEAD AGENCIES) and the Central East Network of Specialized Care (Community Living Huronia) to do the following: Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 14

15 Coordinate and monitor the crisis service response for individuals with a developmental disability and mental health needs and/or challenging behaviours and/or involved or at risk of involvement with the criminal justice system provided by all participating agencies (including hospitals) in the quadrant. The Central East Network of Specialized Care (Community Living Huronia) will play a key role in developing, formalizing, supporting and maintaining linkages between various services and sectors to support an integrated, client-centred response for persons in crisis served by the Network. Work closely with the existing MOHLTC funded community mental health crisis response service and local service resolution structures and personnel to develop and maintain effective pathways to specialized services (when appropriate). Identify and develop education and training that will consolidate and expand the expertise of the Network agencies, generic providers, and families / caregivers. Ensure a timely and appropriate crisis response is accessible to individuals requiring crisis supports. Respond to enquiries, conduct risk assessment, offer consultation (including community visits and short-term follow-up) as required on an individual basis to facilitate crisis resolution. Conduct intakes for Crisis Response Services. Coordinate/match individual needs to Network service providers to develop assessment, intervention and support strategies. Work with Central East Network of Specialized Care (Community Living Huronia), Regional Coordinator and the other three quadrant Coordinators to manage, allocate and assign regional flex crisis funds according to agreed upon established guidelines. Ensure adequate supports are in place and monitor the crisis service response provided by the Network through regular contact and support to service providers and caregivers/family. Refer to the Developmental Services Ontario as appropriate. Develop and implement processes and procedures to work collaboratively with all lead agencies, coordinators and the Central East Network of Specialized Care (Community Living Huronia) Regional Coordinator. Values 1. Partnership - work closely with the Lead Agency (Canadian Mental Health Association Peterborough, Catulpa Community Support Services, Community Living Ajax, Pickering and Whitby and York Support Services Network), Service Provider, Durham Mental Health Services and Central East Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 15

16 Network of Specialized Care (Community Living Huronia), Regional Coordinator and Network partners. 2. Person directed care offering access to support services that are individualized, holistic, respectful, strength-based, and responsive, while respecting natural support. 3. Respecting diversity delivering competent service regardless of race, culture, faith, language, gender, sexual orientation, class, diagnosis or special needs, honouring individuals and families service preferences with respect to these factors whenever possible and to endeavour such service does not create barriers to accessing appropriate individual support services. 4. All partner agencies are committed to accountability, transparency, and continuous improvement. Purpose The purpose of the Program: (a) Respond to requests for crisis service in a timely manner (within 2-3 business days). (b) Provide services to eligible individuals from Central East region for up to thirty days. (c) Maintain all required documentation (including flex fund expenses). (d) Provide orientation and training on services to Network partners. (e) Participate in Network evaluation processes. Central East Network of Specialized Care (Community Living Huronia) Is responsible for: (a) (b) (c) Regional Planning Advocating for Crisis Response Network. Administer Flex Funding. Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 16

17 (d) Supporting Lead Agencies (Canadian Mental Health Association Peterborough, Catulpa Community Support Services, Community Living Ajax, Pickering and Whitby and York Support Services Network) and Service Provider, Durham Mental Health Services (e) (f) (g) (h) Collect, analyze and provide key statistical data and analysis to the Central East Network of Specialized Care Advisory Committee, Participating Agencies, Ministry and other stakeholders. Coordinate, monitor and support access to the resources of the Central East Network of Specialized Care (Community Living Huronia) including clinical consultation. Represent the Crisis Response Network Coordinators at the appropriate Ministry level committees. Initial and ongoing training for the Crisis Response Network Program Standards. Role and Responsibilities of Lead Agencies - (Canadian Mental Health Association Peterborough; Catulpa Community Support Services; Community Living Ajax, Pickering and Whitby; York Support Services Network): *Community Living Ajax, Pickering and Whitby purchases services from Durham Mental Health Services. (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) Provide leadership to the Crisis Response Network Coordinators in the local quadrants, involving key agencies and local stakeholders. Respond to all enquiries / act as spokesperson for the Crisis Response Network Coordinators. Provide the contact and entry point to the Crisis Response Network Coordinators; provide response, consultation, and support to individuals, families, and agencies. Coordinate crisis response and provide direct support in facilitating consents and the development of individual service plans (up to 30 days) including discharge planning. Maintain an inventory of resource information and local Network capacity (vacancies) daily. Track agreed upon data elements. Manage local flex fund budget and allocations. Ensure Memorandum of Understanding are established and updated as needed with partnering agencies. Liaise with the appropriate inter-ministerial resources. Participate in developing linkages with Central East Network of Specialized Care (Community Living Huronia), Regional Coordinator Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 17

18 (k) (l) (m) (n) and engage in regular dialogue regarding service needs and Network development. Participate with other Region Coordinators to provide support and resource sharing. Participate in Local Case Resolution Committees. Support the established policies, procedures, protocols and program standards to ensure they are available to members, to the community and updated as needed to reflect the evolution of roles and functioning. Provide supervision for the Crisis Response Network Coordinators in the local quadrants as per Lead Agency expectations. Accountability Framework Chart: Ministry of Community Support Services Central East Network of Specialized Care Community Living Huronia CONSULTATION - General - Clinical Canadian Mental Health Association Peterborough Catulpa Community Support Services Community Living Ajax, Pickering and Whitby Durham Mental Health Services York Support Services Network Crisis Response Network Coordinators Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 18

19 General Consultation: approval of flex funds and access to regional resources Clinical Consultation: provide access to behavioural, psychiatric and psychological services via regional resources and videoconferencing Termination of Agreement This Memorandum of Understanding will be maintained unless revoked or altered in writing, by any of the parties to the Central East Network of Specialized Care (Community Living Huronia). Either partner may terminate this agreement by providing 90 days written notice to the other partners. This agreement will be reviewed every two years. Signature Tony Vipond, Chief Executive Officer, Community Living Huronia Date Signature Mark Graham, Executive Director, Canadian Mental Health Association Peterborough Date Signature Margaret Gallow, Executive Director, Catulpa Community Support Services Date Signature Barb Andrews, Executive Director, Community Living Ajax, Pickering and Whitby Date Signature Marie Lauzier, Executive Director, York Support Services Network Date Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 19

20 TOOL 3A SYSTEM PATHWAY TO SERVICES AND SUPPORTS FOR PEOPLE WITH A DUAL DIAGNOSIS Huron Perth System Pathway to Services and Supports for People with a Dual Diagnosis September 22, 2010 June 8, 2011 Revised Huron Perth Dual Diagnosis Committee Community Mapping/Crisis Subcommittee Evaluation of the Implementation of the Joint MOHLTC MCSS Dual Diagnosis Guideline Page 20