INTEGRATED SERVICES

	facilitates the polyvalency of the workers
	facilitates the decompartmentalization of the services
	assures a continuity of the services
	assures a better accessibility to the services
	contributes to increased efficiency in the dispensation of services
	contributes to a better knowledge of our users’ needs.

	Mental Health Program
	Elderly and Handicapped Adult Program
	Rehabilitation Program (all clients)
	Perinatality Program.

	To assure to the Pontiac population the availability of complete services in mental health on our territory (psychological distress, behavior problems, severe and persistant psychotic behavior).
	To favour an integrated organization of the services : Aimed objectives : Optimal continuity of services Optimal accessibility of services Principle of primary access to our services in order to avoid division Optimal coordination of services.

	Aimed objectives : To offer the necessary service as close as possible to the users’ life environment Mental health problem enlightenment (awareness/prevention activities).
	Community vision Development of community organizations and support to the community. Aimed objectives : To facilitate a better reintegration into the natural environment, especially for clients with severe and persistent mental health behaviors Planning and continuity of « treatment » services (ex. : discharge from hospital) with the rehabilitation To facilitate the support in the same environment Enlightenment of mental health problems (awareness activities).
	Interdisciplinarity : Working with different types of polyvalent professionals on the same team. Aimed objectives : To permit a more adapted and concerted intervention towards the user To facilitate the continuity and exchange of pertinent information at the follow- up To avoid « division » between the different teams.

	Commitment of the executive directors towards the development of the Pontiac model (history)
	Orientations centered around the clients’ needs and not on the structures
	Flexibility and adaptability to the realities of the surroundings
	Polyvalency of the workers
	Recognition and important support from the regional partnership of the « Centre hospitalier Pierre-Janet »
	Application of the oganization according to good judgement
	« Small is beautiful ».

The integrated mental health team offers global services (1st line, 2nd line and sometimes 3rd line) to all types of clientèle. For the 0-18 years and the 60 and more : The youth and elderly teams assume their 1st line (contact/evaluation/follow-up) Mental health team role : Consultant/evaluation Joint intervention Take charge Collaboration with the teenagers/pedo and gerontology-psychiatric services from « Centre hospitalier Pierre-Janet »..

	To assure the clinical management (receives all requests, even the ones from
	the physicians, and dispatches them)
	To assure human resource management
	To assure that the oritentations and services be offered according to the modalities provided in the protocol
	To assure the « monitoring » of the situation and the evaluation of the services
	Territory’s responsible to the « Régie régionale de la Santé et des Services sociaux de l’Outaouais" »

	Reception/evaluation/orientation : Description :  Service centred around the human contact, the screening, the summary evaluation, the first interventions and the initial accompaniment. Assumed by :  All mental health workers. Accessibility :  From 8:30 a.m. to 9:00 p.m., from Monday to Friday. N.B. : Usually, the worker that welcomes the client assures the follow- up (facilitates continuity).
	Help and treatment : Description : Help and treatment services for any person when her/his mental health is threatened, affected or perturbed. The offered services are : Anxiety and stress Depression/burn out Conjugal problems Personality behaviors Suicidal tendencies Violence Non-resolved grief Harassment Etc... Assumed by : All mental health workers (according to the field of competency). Accessiblity : From 8:30 a.m. to 9:00 p.m., from Monday to Friday.
	Intervention services in crisis situation : Description : To assure to all persons whose physical and/or psychological integrity is affected for a short term, the help and support in order to go through this crisis period and also to assure the post-crisis follow-up. Assumed by : All mental health workers. Accessiblity : - From Monday to Friday – from 8:30 a.m. to 9:00 p.m. – on call worker within the establishment. From Monday to Friday – on call worker outside the establishment (pager in connection with Info-health).
	Rehabilitation and reintegration services, accompaniment and support in the community : Description : Activities to facilitate the reintegration and support in her/his environment, even the users with severe and persistent mental health behaviors. Activities :  Promotion and awareness of mental health Individual and/or group follow-up Activities Social activities Support centred around natural families Support group. Assumed by : « Intervalle » in collaboration with the mental health team. Accessibility : From 8:30 a.m. to 4:00 p.m., from Monday to Friday.
	Lodging services : Description : Assure lodging adapted to the needs of the Pontiac community affected with mental health problems. Activities : Four (4) family type resources (foster family): - For the clients needing a daily family type support - The clinical follow up is assumed by the « Centre hospitalier Pierre-Janet » Center worker and the mental health team. "Intervalle" residence: Assures lodging services centred on internal rehabilitation (6 months maximum) for users motivated to changes Four (4) regular places and two (2) half-way places Assumed by the "Intervalle" in collaboration with the mental health team. Group home in Shawville: Assures the lodging services for a clients presenting severe and persistent mental health problems and showing no motivation to change. The follow up is assumed by the Special Education Technician and the members of the mental health team. Accessibility : All requests are oriented towards an admission committee which is composed of : Worker of the « Centre hospitalier Pierre-Janet » Director of the "Intervalle" Mental Health Coordinator.
	Promotion and awareness: Description : Numerous activities achieved in dialogue with our partners. Activities :  Mental Health awareness week Violence awareness week Drug and alcohol awareness week Suicide awareness week Radio broadcast on CHIP-FM (community radio)
	The network’s next step : To update the protocol to the new organisational realities (amalgamation) Adjust the services to the new clinical realities (increase of service requests in transitional situations).

	Two sections: Regular follow-up of the evolution of the development of services via the actualization table of mental health services. Five (5) obligatory evaluations achieved under the supervision of the "Régie régionale de la santé et des services Sociaux de l’Outaouais" by external companies.
	Evaluated parameters : Accessibility Coordination Continuity Self valorization Community involvement Quality of life

We give you a brief description of the other three (3) programs :

The psychosocial services, particularly for the elderly, are offered on an integrated basis. That is, whatever the place of residence: Residence, Family-Type Resource, Lodging Centre and Long Term Care Unit, the same social worker ensures the client's follow-up as well as the evaluation of his needs, even during his stay in hospital.

The client therefore does not have to repeat his case history and to familiarize himself with a different social worker when changing environments.

The integration of this service was done in different phases. Initially since 1997, the same social worker ensured the client's follow-up at home and at the hospital, since this year he continues the follow-up in a Family-Type Resources and in a Long Term Lodging Centre. The results are rather conclusive. The woven links between the client give a state of confidence in addition to accelerating certain procedures, for example, hospital discharges. Moreover, for the implicated social worker, the Long Term Care or Family-Type Resource admission procedures have been facilitated.

The integration of the Family-Type Resources and the Day Centre to the home care team (nursing care, social service, home care, etc.) has also brought conclusive results. It is easier to have an overall view, to foresee a more elaborate and rigorous service plan by having access, under the same direction, to these various services offered in any event to a common clientèle.

It also appeared that the inter-mission links were perceived as being reinforced inside the establishment itself. The workers are more sensitive to the client's condition and to the possibilities that are offered to him, in connection with the resources available in the establishment and those which revolve around, that is to say the community organizations: Golden Peak, Pontiac Respite Services and Volunteer Transportation. An overall picture is thus stimulated and encouraged.

REHABILITATION PROGRAM (ALL CLIENTÈLE)

In regards to rehabilitation, the Centre de santé du Pontiac also offers an integration of services but in another form. That is the team of professionals implied (occupational therapist, physiotherapist and respiratory therapist) ensure the intervention in their respective mission, while keeping a close contact with their peers.

Thus, the client goes from the hospital to his home with an automatic hospital rehabilitation referral to the home care rehabilitation services (also covering the FTR) and this way of functionning also applies from the hospital or the home towards the Long Term Lodging Centres.

Moreover, each worker can, in a specific way, ensure a coverage or a replacement in another mission of the establishment (holidays, staff shortage). This brings to the client reassurance in regards to the necessary services and to the worker a versatility out of the ordinary.

Therefore, one sees services revolving around a client and not the reverse. One maximizes quality, accessibility, and the continuity of the service and the speed of response. Of course the client is the big winner but the worker also gains there as much.

The obstetrics department at the Pontiac Community Hospital, as well as the perinatal department at the CLSC are two services that have been integrated in the Pontiac community, which co-ordinates various services such as pre, peri and post-natal care.

The integration of these services has enabled us to put into practice these areas of specialities through the CLSC and the Pontiac Community Hospital, which required a merger of all procedures, politics, teaching practices, as well as health care approach.

A common perspective is shared by these two services which is the continuance of services; therefore enabling the follow-ups to be adapted to the needs of the clientele. Referals can be done directly between caseworkers, which is more time efficient and personalized. The nurse from the CLSC can also meet their clientele at the hospital.

The obstetric department has been restructured in order for the CLSC nurse to assist the physician. This approach enabled us to strengthen the tie between physicians and patients.

Certain projects were realized in a common manner, such as: car infant safety inspection campaign, lending of infant car seats (infants weighing less than 20 lbs), an evaluation of the post-partum depression screening tool. Promoting nursing, as well as screening for mothers who are at risk.

With the preoccupation of improving our services we have created a perinatal committee, made up of nurses from the CLSC and Hospital, a physician and also a co-ordinator of the program. They will meet on a monthly basis in order to maintain the quality of services and seek for future development, improvement.