Personal Support & Care Planning at Seaton House

In response to the George Street Revitalization the Local Health Integration Network (LHIN) along with consultants approached Fife House to develop and deliver a model of personal support and coordinated care in collaboration with the integrated shelter support teams and clinical teams at Seaton House, on the 3rd Floor Infirmary/Annex Program and the 4th Floor Long Term Program. The primary goals of this initiative are:

1) To address unmet health and personal care needs of men staying at Seaton House who have complex health, mental health and substance use issues.

2) To support client engagement in their personal care to identify goals around activities of daily living and instrumental activities of daily living and the development of individualized service plans which support life skills development.

3) To develop coordinated care planning/service planning processes which engage shelter, housing, and community partners and smooth transitions of care and support for clients through the George Street Revitalization process.

Fife House has a support team working at Seaton House on the 3rd Floor Infirmary/Annex Program and the 4th Floor Long Term Program. This team includes a full-time Mental Health and Addictions (MHA) case manager/Coordinated Care Planning who will supervise, schedule, and support four full-time, two part-time and relief personal support workers. The MHA case manager will lead ongoing assessment of personal care needs and the delivery of personal care, in collaboration with Seaton House staff, Inner City Family Health Team, Inner City Health Associates and Toronto Central LHIN Home and Community Care.

The MHA case manager will work in collaboration with Seaton House staff to develop client identification/intake process, assessment of need, and the development of model of care for Annex/Infirmary, and 4th Floor clients. Consultation will also be needed from Seaton House staff, Inner City Family Health Team, and Inner City Health Associates to prioritize the scope of care of activities of daily living and instrumental activities of daily living for clients.

The delivery of personal care services will focus initially on the unmet basic care needs such as bathing, hygiene, transfers, toileting, grooming care with the highest needs clients, and then build a broader psychosocial client engagement and goal setting process around the fuller scope of activities of daily living and instrumental activities of daily living.

Service delivery started in February 2018 and since that time more than 40 clients have completed intake and over 1000 units of service have been delivered.