Individuals with serious and persistent mental illness may need more support than a regular doctor’s visit can provide. CMHA/Peel’s Access to Recovery Mental Health Case Management recognizes this need and aims to achieve three outcomes for the client:

• Clients have a life skills coach, in their own environment, who works with them and, where desirable, their family and friends, to achieve their goals and satisfy their needs – housing, income and activities of daily living
   
• Clients have someone to help them navigate the social and community services system and link them to services
   
• In terms of their mental illness, clients have someone who helps them understand and manage their illness and achieve recovery

Case managers meet clients in the community or at their home. After an initial assessment to determine suitability for the program, the case manager does a more thorough assessment that includes:

• Developing a therapeutic relationship with the client
   
• Gathering pertinent demographic and personal information
   
• Establishing a crisis plan with each client, with updates as needed
   
• Determining need for change through ongoing evaluation regarding goals, discharge, etc.
   
• Monitoring client’s symptoms and initiating interventions to stabilize illness
   
• In partnership with client, establishing goals for recovery

Case managers:

• advocate for clients by assisting them with accessing and sustaining their entitlements, e.g. social assistance, housing, leisure activities, legal system, education, employment, etc.
   
• coordinate services by completing Community Support Agreements to avoid duplication of services and assist clients to effectively utilize community services, and develop and maintain effective working relationships with other service providers
   
• refer clients to appropriate community services
   
• provide practical application of life skills training

Prior to Discharge, a transition plan is established with the client, which may include referral to other agencies or CMHA programs, and the option to evaluate re-entering the program.