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Stories of Recovery Centre for Addiction
and Mental Health

A Room of One’s Own - Pierre’s Story

Pierre proudly shows off the new sketch he has been working on. His room is neat and tidy, with family pictures on display as well as examples of his artwork. Living with schizophrenia for most of his life, Pierre has been in and out of hospital for many years. And for the past few years, Pierre has lived as a hospital inpatient at CAMH.

But everything changed for Pierre in the fall of 2013. In response to the numbers of alternate level of care (ALC) clients living long-term in hospital, CAMH and other service providers embarked on a pilot project to meet their needs. With 15 different partners, funding and resources coming from various sources, including the Toronto Central Local Health Integration Network (LHIN), several long-term clients considered too challenging for the traditional supportive housing sector have successfully transitioned into the community.

Pierre in a room of his own
Pierre in a room of his own.

“We’re talking about really complex clients with multiple mental health and physical challenges.  Having high support housing providers, inpatient and outpatient clinical teams, and Community Care Access Centres working together with the client - and families when appropriate - have allowed for integrated transition planning,” explains Melonie Hopkins, Project Manager, ALC High Support Housing Initiative. The program has successfully placed 20 clients and all of them have transitioned into their new homes with the support of many partners.

Over 7,000 people in Toronto with serious mental illness are on the supportive housing waitlist.  Because of this, many clients languish in hospital and run the risk of their mental health deteriorating. This program hopes to increase the odds of ALC clients finally finding a home in the community.

“It’s a system response to look at how we can provide services to an incredibly complex group of clients,” says Melonie. “When it came to housing for those with serious mental illness, most organizations worked in isolation. This project is unique in that we have several high support housing providers and other partners like CAMH who have come together, recognizing the need to make a huge change in the way providers work together.”

Access to supportive housing is a critical component of recovery. Pierre was identified as an ideal candidate and went through an extensive process which included daytime visits and overnight stays to ensure a seamless transition. In October 2013, Pierre packed his bags and moved into his new home at Pilot Place – one of several sites piloting this unique program.

“He’s the type of person who needs a lot of support in the community but he does well with that support and he has gradually gained more skills; he has really flourished,” says CAMH Occupational Therapist Matthew Tsuda, who has worked tirelessly with his team to transition Pierre from his room at CAMH to his new home.

Pierre and Matt
Pierre in his new home with Matt Tsuda, case manager and occupational therapist

Pierre and his housemates, some of whom have lived at CAMH for more than 20 years, are given more freedom, all the while, having access to supports should they need them. “It’s a graded approach in which we provide support and give them some independence and we decrease the assistance gradually while we increase the level of independence. They gain more confidence and that has an effect on how successful they are in the long term,” explains Matthew.

It makes such a difference that it feels like a home rather than an institution, says Matthew, who sits with Pierre in a sun-filled dining room, chatting about his recent shopping trip to buy new clothes. “We provide support but then we decrease assistance so gradually they can gain more confidence and independence,” he says. The casual banter, the relaxed manner and a wide smile are evidence of a client settled and secure in his new home.

Pierre still struggles with motivation but is working hard with his team from CAMH to identify the barriers to living a fuller life. Whether it’s charting out plans for his weeks or looking at his diet, Pierre is reminded of his goals and knows he has a team working with him to achieve them.

Inter-professional cooperation is key to lasting change. As part of the team responsible for transitioning ALC clients into the community, Matthew works closely with behavioural therapist Wayne Harrison and registered nurse Parm Sran to ensure Pierre stays on track. “There is a real commitment to collaboration between all the parties, from the housing providers to psychiatrists to behavioural therapists to nursing. All the disciplines bring their different perspectives to the table to address different areas of need to support our clients,” he explains.

And part of that support is helping Pierre maximize his level of function in the community. “So the focus is integration -- whether he’s painting, attending coffee group at Archway, listening to music, or re-learning how to read at a literacy program which he identified as one of his goals.” For Pierre, getting back in touch with his family was very important. With planning, support and well-wishes from supportive CAMH and Pilot Place staff, Pierre was able to travel by public transit last Christmas to spend the holidays with his family in Brampton.

“It’s really about empowerment of our clients; being able to provide them with choices, capitalize on their own strengths, what they want to accomplish, help build that capacity and finally help them take more control of their own lives,” says Matthew.

The multi-disciplinary coordinated approach has paid great dividends for Pierre. He is compliant with his medication, is more actively engaged and has an improved quality of life. Clients are also more motivated to receive treatment when they are given some choice around scheduled activities, treatment and down-time.

“I think the reason it’s been so successful for these clients is there are many dimensions of wellness and recovery, and by moving Pierre out of CAMH and into the community, so many have been met through support from front-line housing staff, CAMH staff, good living conditions and meaningful activities. They all contribute to an overall sense of wellness,” says Matthew.

Pierre has found his place among his housemates who also have struggled with the debilitating effects of mental illness for many years. When asked his favorite part of living independently, Pierre smiles warmly and shares without hesitation. “I’m really happy here in my own home, with my own room. I like being able to listen to the radio when I want.” And with a twinkle in his eye, he says, “And I love the food here. It’s really good. It just feels like a real home.”

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