In Ontario, five per cent of patients account for two-thirds of all health care costs. These are most often patients with multiple, complex conditions including but not limited to, individuals living with mental health and cognitive challenges. In order to improve services for these individuals, Ontario has introduced 82 Health Links across the province. Health Links are intended to coordinate and inspire hospitals, family doctors, community organizations and others to work better, as a team, to meet the needs of these individuals.
Cota is actively involved in a number of Health Link activities across Toronto. In fiscal 2015 -2016:
- Cota continued to offer an interdisciplinary support service (FOCUS), in collaboration with St. Michael’s Hospital, for individuals with complex mental health and addictions challenges living in the Mid-East Toronto Health Link area.
- Cota is a network partner in various Health Links, initiating Coordinated Care Planning with Health Links clients who live with complex care needs. Cota has completed 39 Coordinated Care Plans (CCPs) for Mid-East Toronto Health Link clients, and 23 CCPs for East Toronto Health Link clients.
- We continue to participate in North York Central Health Link community rounds meetings and offer services, as needed.
- Our Executive Director acted as the Mental Health and Addictions (MHA) Committee Chair for the North York West Health Link.
- Over the past year the MHA Committee developed and implemented rapid response protocols for individuals with complex MHA presenting at the Black Creek Community Health Centre. These services resulted from collaborative planning and coordination of care.
- Cota initiated its involvement in the Scarborough North and Scarborough South Health Link activity and now participates in the Scarborough Health Link Steering Committee.
What Our Health Link Partners Say About Us
From the East Toronto Health Link (ETHeL) perspective, working with the team at Cota has been nothing short of incredible. From the very early days of the Health Link, starting with a meeting with Paul Bruce (Executive Director of Cota), and followed by Sylvia Starosta (Director of Clinical Operations), it was clear that Cota’s senior management team was committed to partnerships with healthcare and social service organizations, aimed at positive outcomes for patients and their families. Cota and ETHeL formed an early partnership after the leadership of both organizations identified a need to serve patients in East Toronto with complex needs including services for mental health, supportive housing and addiction supports, which led to Cota designating a full time resource to provide transitional case management support. This relationship is almost 2 years old and Cota has continued to stand by its commitment and dedication to the partnership with ETHeL, and more importantly, to the patients who are in desperate need for solutions. Cota continues to provide leadership for ETHeL’s Cross Continuum Team, which uses a case conference approach with interprofessional and intersectoral providers, with both the patient and their caregiver physically present. We applaud Cota for its continued support, collaborative leadership and solution oriented approach to patient care.
Aasif Khakoo, Director, East Toronto Health Link
Cota has been a great partner in the Mid East and Don Valley Greenwood Health Links, participating on both of the Health Link Councils as well as being very involved in the Health Link’s coordinated care planning work. Cota has supplied a full time Transitional Care Coordinator dedicated to the two Health Links who is invaluable in providing care coordination for vulnerable clients with complex health needs who are identified by hospitals and family physicians. It is always a pleasure to work with such a willing partner!
Mary Eastwood, Director, Mid-East Toronto Health Link
The Impact of Our Work with Health Links
Wai-Yin says that “Cota has helped, and Sandra has helped me a lot”. Wai Yin hears voices, and experiences sadness and depression due to a severe trauma in her past. Wai Yin experienced sexual harassment from a colleague in Hong Kong, 1983. The issue went to the court system, and resulted in media coverage which led to Wai Yin and her family experiencing harassment from the general public, labelling Wai Yin as schizophrenic, although a formal diagnosis would not be received until 1990.
In 1994, Wai Yin came to Canada. Her mother who provided emotional and spiritual support to her, passed away in 2013. Wai Yin describes it as a “big blow” to her self-esteem, and called crisis centres because she wanted to commit suicide. In 2014, Wai Yin was laid off, and due to an error she was not able to receive EI.
Wai Yin applied for Mental Health Case Management program through The Access Point, and Sandra Corrado, a Cota Case Manager started to provide service. Once Wai Yin and Sandra met, they mutually agreed that she would be a good fit as a health link client. Wai Yin consented to Mid-East Toronto Health Link care coordination support and care planning.
A coordinated care planning meeting was arranged for Wai Yin, including Wai Yin’s sister, doctors, and Sandra. For years, some of Wai Yin’s service providers had not believed that the experience was not real; many at the table had believed that this was a symptom of mental illness. For the first time, Wai Yin’s family was involved. Her sister said, “This is real, this happened. I was there.” This was the first time that Wai Yin’s experience was validated. People at the table apologized to her. From there Wai Yin could move forward.
“Sandra really helped me, physical and mental.” Wai Yin says Sandra has helped her a lot with connecting helping her to sign up for a program at George Brown called “Transitioning to Post-Secondary Education” and the school provides counselling to students. Sandra has also provided information about trauma support groups and other community resources. Wai Yin wishes that the Short-Term Case Management was just a little bit longer than three months.
Wai Yin wanted share a message about stigma. She said just because people live with mental illness, and just because they were angry, they were bullied, it does not mean that they will become criminals. She says, “I want people to have a good life. I hope people don’t experience the same thing as me. I lived with torture, with bullying. I want to contribute to society”.