Community Networks Background

The Ontario Ombudsman’s report identified the need to address gaps in the developmental services system.

The Ministry’s response to the Ombudsman’s recommendations highlighted the need for increased “enhanced case management supports for people with developmental disabilities with multiple and complex needs through a new CNSCs mandate”.

The Ministry of Community and Social Services is committed to transforming developmental services into a more consistent, fair, accessible and sustainable system of supports for people with developmental disabilities, which, in turn, will support greater inclusion, independence and choice.

Community Networks of Specialized Care (CNSC)Refreshed Mandate

To serve adults with developmental disabilities with complex and multiple needs by:

Coordinating support and service within and across sectors, by providing complex support coordination for individuals;

Acting as a resource to service agencies, Developmental Services Ontario and local planning tables (including urgent response and service solutions / case resolution);

Building system capacity to better support individuals with complex needs through education, mentorship and support to other case managers and service agencies; and

Providing provincial coordination of videoconferencing and French Language specialized resources.

Complex Support Coordinators (New)

Dual Diagnosis

Justice Coordinators

Health Care Facilitators (New Amended

Function)

Service System Resources

Target Population for Complex Support Coordination: High Support & Complex

Care Needs (HSCCN)

As of April 23, 2018, DSOs will identify people as appropriate for referral to the CNSC for Complex Support Coordination based on whether they meet the following target population criteria*, and are in need of complex case management support:

High Supports and Complex Care Needs Definition Criteria (for people who have completed the DS Application Package):

Those with extraordinary medical and/or behavioural support needs: determined by scores on SIS sections 3A (medical; scores of 7 or greater) and/or 3B (behavioural; scores of greater than 10); and

High overall support needs: individuals with overall SIS percentiles of greater than 70%; and

Safety concerns: the primary caregiver (family members and/or paid support persons) has concerns about the person’s safety due to his/her medical and/or behavioural support needs (ADSS s6.3 and 6.5); and

Only to be applied for people with exceptional medical support needs: the person must require overnight support(individuals with extraordinary behavioural support needs do not necessarily need to require overnight support in order to meet the HSCCN definition).

*This target population criteria does not apply to DDJCM supports as part of the CNSC refreshed mandate.

CNSCs are… CNSCs won’t…

• Responsible for coordinating support and service for adults

with developmental disabilities with high-supports and

complex care needs who would benefit from intensive case

management support.

• Responsible for building capacity through education,

mentorship and support to other case managers and

service agencies.

• Responsible for overseeing coordination and delivery of

the four functions within their mandate.

• Involved in developing, promoting and maintaining service

integration (e.g. linkages between justice and health).

• Improving access to complex support coordination in a

provincially consistent manner.

• Assume responsibility for all case management.

• Be responsible for delivering the services and supports that

people with complex and multiple needs require (e.g.

residential services).

• Result in funding reduction for service agencies currently

providing complex support coordination.

Community Networks of Specialized Care:Scope of Role

Connection Across Sectors

CNSCs

Housing Connections

Coordinating Housing

Solutions

Health Care

Facilitators

Complex Support

Coordinators

Health

Links

Health Connections

Service System

Planning Tables

Urgent

Response

Community Planning Mechanisms

Service

Solutions

Dual Diagnosis Justice

Coordinators

Justice Connections

The Network Team!

Dual Diagnosis Justice Coordinators:Amber Huffman - Waterloo, Wellington and Dufferin: ahuffman@cwsds.caSusie Khorsand - Halton Region: skhorsand@cwsds.ca

Complex Support Coordinators:Jodi Marleau - Waterloo, Wellington and Dufferin: jmarleau@cwsds.caIsabel Pereira - Halton and Peel: ipereira@cwsds.ca

Health Care Facilitator:Tracey Hobson - Halton and Peel: thobson@cwsds.caPreethi Knight Mulaka - Waterloo, Wellington and Dufferin: pkm@cwsds.ca

Manager:Tara Hyatt - thyatt@cwsds.caProgram Assistant:Kelly Stockdale – kstockdale@cwsds.ca

Health Care Facilitator

Tracey Hobson - Halton and Peel: thobson@cwsds.ca

Preethi Knight Mulaka - Waterloo, Wellington and Dufferin: pkm@cwsds.ca

Role of Health Care Facilitator

Capacity Building:

Support and educate primary health care providers and non-developmental services agencies about people with complex and multiple needs;

Provide support to developmental services agencies so that they feel equipped to better address the health care requirements of people with complex and multiple needs;

Identify specialized training needs and gaps, and provide trends to agencies;

Provide information to people with complex and multiple needs, caregivers, service providers and staff regarding community health care systems.

Bridging Within and Between Systems:

Facilitate and/or complete referrals and linkages to medical resources and social services;

Create linkages to health services and identify deficits/gaps in order to meet person-specific health care needs within the existing service system;

Develop linkages between health care professionals within the developmental services community, and share knowledge with the existing developmental services community;

Promote equal and fair access/connection to community health services;

Participate in multi-disciplinary case conferences to assist in service planning and coordinating specific health care needs/supports;

Provide an advocacy role ensuring that the rights of people with complex and multiple needs are upheld;

Collaborate with other health care facilitators from across the province.

Dual Diagnosis Justice Coordination Services

Amber Huffman - Waterloo, Wellington and Dufferin: ahuffman@cwsds.ca

Susie Khorsand - Halton Region: skhorsand@cwsds.ca

The core functions of the DDJCM are:

Purpose and Role of the DDJC:

To provide cross-sector coordination support to divert people with a developmental disability or dual diagnosis in conflict with the law through securing appropriate services or treatment in place of the usual criminal proceedings of trial and/or incarceration.

Referrals can be made by:

Court staff (Duty Counsel, Crown, Lawyers)FamilyThe IndividualDS agenciesDevelopmental Services Ontario (DSO) Correctional facilities

The Core Functions of the DDJC:

Outreach and client identification;

Comprehensive individualized assessment and planning;

Coordination and support;

Monitoring and evaluation; and,

Systematic advocacy and coordination.

Complex Support Coordination

Jodi Marleau - Waterloo, Wellington and Dufferin: jmarleau@cwsds.ca

Isabel Pereira- Halton and Peel: ipereira@cwsds.ca

Key Functions of the CSC’s are:

Leading, developing, facilitating, coordinating, monitoring and updating a person-centered plan with people and caregivers. This would include transition planning to and from hospitals and the justice system.

Cross-sector coordination support for case resolution such as assessment, clinical planning, housing, planning tables, including:

Facilitating the acquisition of required supports and services

Coordinating support to enhance existing resources and services; and,

Liaising with different sector partners, including those with the criminal justice system, health care system and others;

Assisting with system navigation, including at urgent response and other planning tables.

Referral and facilitating access to/from specialized resources, including at the local, regional and provincial levels. This would include clinical supports, psychiatric support, psychological support, and specialized accommodations.

A NEW FUNCTION:

Complex Support Coordination (CSC) may be required when the available resources are not sufficient to address a person’s needs and/or supports have exhausted all existing resources within the local system. The CSC’s provides the right type of service and supports at the right time and place that span the service continuum/system. Services and supports are based on what is appropriate for the person.

Understanding Individuals with Dual Diagnosis

Bio-psychosocial model

• Physical health

• Mental/ emotional health

• Individual history

• Life changes

• Individual and family perspective

• Day-to-day circumstances

• Social factors

• Environmental

http://www.community-networks.ca/wp-content/uploads/2015/07/CNSC-O-Consensus-Guidelines-EN-F-08-19-16.pdf

Some Resources

Community Networks of Specialized Care

http://www.community-networks.ca

http://www.community-networks.ca/wp-content/uploads/2015/07/CNSC-O-Consensus-Guidelines-EN-F-08-19-16.pdf

HCARDD: https://www.porticonetwork.ca/web/hcardd

Human Services & Justice Coordinating Committee: http://hsjcc.on.ca

Mental Health Commission of Canada: https://mentalhealthcommission.ca/English

Developmental Services Ontario: https://www.dsontario.ca/whats-a-developmental-disability

Autism Speaks: https://www.autismspeaks.org

NTG- EDSD Tool: https://aadmd.org/sites/default/files/Draft%20NTG-EDSD-Final.pdf

H.I.P – Health Information Profile: http://www.community-networks.ca/health-care/health-information-profile

Developmental Disabilities Primary Care Program: http://ddprimarycare.surreyplace.ca

Health Watch Tables: http://ddprimarycare.surreyplace.ca/tools-2/health-watch-tables

Canadian Consensus Guidelines: http://ddprimarycare.surreyplace.ca/guidelines