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Improving care for people with complex mental health needs

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By Steven Gallagher

A new and innovative program at Niagara Health is enhancing care and access to services for people with complex mental health needs.

The Wellness Recovery Integrated Comprehensive Care program, which was launched in April, helps people to fully understand their mental health needs and to identify and develop strategies to improve their wellness. A goal of the program is to reduce readmissions to hospital and visits to an Emergency Department for non-urgent mental health issues.

“We’re trying to help people enhance their coping skills, their knowledge and their abilities so that they’re able to problem solve in the community, rather than going to the Emergency Department as an immediate response for help with non-urgent issues,” says Robert Cosby, Clinical Manager of Niagara Health’s Outpatient Mental Health and Addictions Program.

Non-urgent visits to the Emergency Department that could be managed in the community include a person wanting to talk to someone; an individual looking for a healthcare provider or someone who is having difficultly navigating the healthcare system.

People referred to the program include individuals with a mental health diagnosis, such as severe depression, bipolar or schizophrenia, and people who are at high risk of readmission to a mental health inpatient unit or who frequently visit Emergency Departments.

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Here’s how the program works:

Participants, who must be 18 years or older, are connected with a team of healthcare professionals from Niagara Health who work collaboratively with them to identify their mental health needs and to ensure they are receiving the best possible care. The healthcare team includes registered nurses, social workers, occupational therapists, nurse practitioners and a psychiatrist.

Participants meet with members of the team at the hospital or in the community to receive care and create an individualized recovery plan based on their needs.

The program is “very person-centred,” says Robert.

“Participants are identifying what they need in their journey of wellness and recovery,” he says. “You have to work really closely with people to help guide them and to see that they do have the resiliency, the strength and the knowledge. With this program, we’re enhancing that.”

Participants also have access to other therapy programs at Niagara Health, and they are connected with services in the community, such as Niagara’s Crisis Outreach and Support Team and Quest Community Health Centre.

Social Worker Robin Crown, the Clinical Lead of the program, is impressed with the new model of care and the impact it will have on people’s lives.

“I’m excited we can be creative, flexible and help people with what they need to make a difference in their life.”

Niagara Health also has an Integrated Comprehensive Care Program for people with chronic obstructive pulmonary disease and congestive heart failure.

Since its launch two years ago, the program has helped hundreds of people manage their symptoms at home. The program has decreased length of stay in hospital by three days and reduced readmissions and unanticipated Emergency Department and Urgent Care visits for participants by more than 10 per cent.

Steven Gallagher is a Communications Specialist at Niagara Health.

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