Building the Path to Home

Case management

It is important to have someone whose job it is to make things happen. This can be a case manager or someone else (e.g., a service co-ordinator) who takes on this role. Case managers can be limited to planning and co-ordinating services, or their role can be much broader. Case management activities may include:

• developing an individual support plan with other support people
• providing supportive counselling
• teaching skills
• intervening in a crisis
• educating the person and his or her family
• planning and co-ordinating services, making referrals, brokering services (including finding housing).

” Most of all we need CHAMPIONS! . . . Champions are those people who always seem to be able to make things happen. It doesn't even seem to matter what their title is or even what they do or where they work-- they just seem to be able to help you along the path. I'm never sure if they succeed because of the system -- or in spite of the system.”

“Case managers who understand both systems and can work with families in supporting them and finding appropriate resources are urgently needed. Unfortunately, some case managers only understand one of the sectors or sometimes only their own agency and are not effective in helping families find integrated supports from both sectors.”

“I need the connection to last . . . I get to know them, they know me for a few years, not just a little while, then change.”

The Mental health sector

For a brief overview of mental health case management, see Challenges & Choices: Finding Mental Health Services in Ontario.

There are three types of mental health case management services:

• Intensive case management offers up to 1.5 hours per week of one-to-one support. It is offered by more than 20 agencies in Toronto.
• Outreach services provide case management to people who are homeless.
• Home care supports connect people who have a medical referral to mental health services through Community Care Access Centres.

Assertive community treatment (ACT) teams offer case management services as part of specialized community-based mental health treatment and support to people who have serious mental illness.

Click the link for a listing of organizations that provide mental health case management, or go to 211Toronto and enter "mental health case management" in the Find field.

Also, see the Supports & Services Resource Handbook.

The Developmental Services Sector

There are two types of case management offered within the developmental services sector: 

• family support workers (for people living with their family)
• adult protective service workers (for people living independently).

Family support workers

A person who continues to live with his or her family or who is returning home is eligible for a case manager who is skilled in working with families. The case manager provides help with accessing services and co-ordinating supports.

Five agencies offer this service:

• Family Service Association (416 971-6326 ext. 224)
• Community Living Toronto (416 968-0650 ext. 2207)
• Surrey Place Centre (416 925-5141 ext. 290 or 233)
• Youthlink (416 967-1773)
• COTAHealth (416 785-9230).

Consultation visits with individuals and families are available by contacting any developmental services agency.

Adult protective service workers (APSW)

People who are 18 years of age or older and who live independently in the community can apply for a case manager through Community Living Toronto. This type of support is for people who do not need the higher levels of support offered by traditional residential services. The APSW assessment co-ordinators will refer the person to one of the four agencies that provide this service in Toronto.

For referral to a developmental services APSW, contact Community Living Toronto and ask for the APSW assessment co-ordinator: 416 963-8656 ext. 232 (referrals for men) or ext. 231 (referrals for women).

Dual Diagnosis

There are some specialized case management programs that work in both sectors. These programs have limited capacity:

• COTAHealth offers programs for adults and youth.
• Griffin Centre offers programs for youth.

Unless the person you are working with clearly has a dual diagnosis, you will probably start with either a developmental services worker or a mental health case manager. The sector you choose will depend on whether adaptive functioning or mental health is the more prominent issue.

If you are unsure how to proceed, contact the Griffin Community Support Network (GCSN) for help to make the referral. The GCSN does not provide long-term case management, but they will develop and support a transition (interim) care plan.

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