Page1of7

OUTREACHPROGRAMGUIDELINE

Philosophy&Approach

WearebuildingacommunityresponsemechanisminWindsor-Essex;anon-emergencymechanismthatnotonlynotices,butpaysattention,topeoplewhoarevulnerableorlivingatrisk.Wearebuildingasystemwhereourcommunity–whetheritisserviceproviders,institutions,orconcernedneighbours–willbeabletonoticeandoffermeaningfulsupportBEFOREacrisishappens.

RegistrationforOutreachSupport

Therewillbetwophonenumbersthatwillbeavailableforpeopleinthecommunity:

1) TheCompassionateCareRegistrationOfficeforinformationonneighbourhoodexchanges,intentionalcommunities,andtoregisterforCompassionateCareCoaching.

2) TheDistressCentreforpeoplewhoareindistressorareconcernedforsomeonetheynoticeinthecommunity

Eachofthesenumberswillprovideaccesstobothinformalandformalcommunityoutreach,andanyone-peopleneedinghelp,family,friends,neighbours,agencies,etc.-iswelcometocall.

OutreachResponse

Thefollowingmodelillustratesthecommunityresponseandoutreachoptions:

Page2of7

TheCommunityResponseandOutreachOptionsdiagram(above)willbeusedasatoolfornavigatingwhichservicetheWECCCRegistrationOfficewillrefertobasedontheperson’ssituation:

• Forindividualslivinginpoverty,theywillbereferredtothepovertynetworkthroughtheleadcontact.1

• Forindividualswhoarechallengedbycultureandlanguagebarriers,theywillbereferredtotheRegistrationOfficetobelinkedtoanappropriateculturalTimeBanksorreferredtothemulticulturalnetworkthroughtheleadcontact(whowillutilizetheHealthEquityforNewcomersandImmigrants[HENI]serviceinventory)2

• Forindividualswhofrequentlyuseemergencyservicessub-optimallyordemonstratechallengingbehaviours,theywillbereferredtoservicesavailableintheircommunitythataredesignedtosupportthemtocontinuefunctioningassafelyandindependentlyaspossible,suchastheEmergencyMedicalServicesVulnerablePersonNavigator(EMSVPN).

1Theleadcontact,process,andresponseeachnetworkwillorganizetooffersupporttoapersonhasbeenoutlinedineachagenciespartnershipagreementwiththeWECCC.2TheHENIserviceinventoryisastandardizedandgovernedcollectionofcomplementaryservicesofferedwithinWindsor-EssexforNewcomersandImmigrants.

Page3of7

Oncetheservicesreceiveareferral,theywillfollowoutreachprotocoltoconnectwiththepersonandoffertoreferthemtothelife-longcompassionatecarecoachingprogram,ortolinkthemtoothercommunityhelp.

OutreachPathway

FormalResponse

Formalservices(e.g.,communityprogrammingandsupportservices)willcomeintocontactwithpeoplewhoneedadditionalhelpinthedeliveryoftheirdaytodaywork.Thesearepeoplethat:

• Haveneedsthatextendbeyondthescopeofregularcasemanagementfunctions• Areisolated• Arelivingatapossibleriskforharmtothemselvesorothers• Frequentlyuseemergencyservices

FormalservicestaffwillcalltheCompassionateCommunityRegistrationOfficetoregistersomeonewhohasagreedtocoachingsupportorconnectthemtooutreachsupport.OncetheRegistrationCoordinatorreceivesareferral,theywillcontactthepersonandregisterthemtothecoachingprogramoroffersocial/practicalhelpfromtheirneighbourhoodiftheyhaverefusedcoaching.ForpeoplewhochoosenottobelinkedtoWECCC,theprovidercancontactFamilyServicesWindsortomakeareferraltotheSituationTable.

ReviewingCaseload

Formalserviceproviderswillreviewtheircaseloadtoidentifypeoplewhoare:a)inoneofthethreetargetpopulations,orb)haveneedsthatarenotbeingadequatelymetbecausetheyfalloutsidethescopeortimeframeofusualservices.Onceidentified,theproviderwilloffersupportasusualandoffertomakeareferraltocoachingsupport.Iftheclientchoosesnottoregisterforcoaching,theproviderwillinformtheRegistrationOfficewhowillsupporttheproviderwithcommunityhelpoptions(e.g.,neighbourhood-exchangesandintentionalcommunitycoordinators).

Referringpeopleincontact

Existingservices(e.g.,COAST,VPN,theDistressCentre,emergencyroomstaff,etc.)thatfrequentlycomeintocontactwithpeoplewhouseprogrammingoremergencyservicessub-optimallywilloffertoreferthevulnerablepersontotheWECCCRegistrationOfficeforcoachingortobelinkedtoothercommunitysupports.

InformalResponse

Neighbours,friends,family,andothercommunitymembersmaynoticesomeonewhoneedsextrahelporsupport.Iftheconcernedpersondoesnotfeelcomfortableorcapableofferinghelp,theycancalltheDistressCentreorvisittheWECCCwebsiteforcommunityresources.

Page4of7

CallingtheDistressCentre

Usingtheinformationavailable,theDistressCentrewilltriagethereferraltothemostappropriatefirstcontact.Appropriatefirstcontactsareoutreachservicesthatcanknockontheperson’sdoorandcheck-inoroffersupport.Someoftheseoutreachservicesarewithinbuildingsalready(e.g.,LifeafterFiftyandAssistedLivingSouthwesternOntariooutreachbuildingsandCommunityUniversityPartnership)andsomeoftheseoutreachservicesarecommunity-based(e.g,COASTandEMSVulnerablePersonsNavigator).

TheoutreachservicewillreceivethereferralfromtheDistressCentreanddecideontheappropriatefirstcontactaction.Foroutreachservicesinbuildings,theoutreachworkerassignedtothebuildingwillvisitwiththepersontooffersupport.Community-basedoutreachserviceswillassignaworkertoconnectwithpeoplewhodonotliveinbuildingswithexistingoutreachstafforpeoplewholiveinhouses.Outreachworkerswillcheck-inontheperson,offertoreferthemtothelife-longcompassionatecarecoachingprogram,ortolinkthemtoothercommunityhelp.

UsingtheWECCCWebsite

TheProjectManagementOffice(PMO)willdevelopalistofneighbourhoodexchanges(TimeBanks)andIntentionalCommunityCoordinatorsservingeachpilotgeographythatwillbeavailableontheWECCCwebsitewithinstructionsonhowtoaccess.IfyouarereferringapersontotheneighbourhoodexchangesonTimeBanksoranintentionalcommunity,youcaneitheraccesstheinformationonthewebsiteorcontacttheRegistrationOffice.

ThePMOwillalsodevelopabrochurewhichwillincludeinstructionsonhowtoaccesstheavailableneighbourhoodexchanges(TimeBanks)andintentionalcommunitycoordinatorsineachpilotgeography.Thesebrochureswillbedisplayedinlocallibrariesandcommunityagenciessuchas:

• TheHospiceofWindsor-Essex• AssistedLivingSouthwesternOntario• Alzheimer’sSociety• CanadianMentalHealthAssociation• CommunityLiving,FamilyServicesWindsor-Essex• LifeAfterFifty• SouthEssexCommunityCouncil• Localmunicipalbuildings

SituationTable

HostedbyFamilyServicesWindsor,theSituationTableisacollaborativeresponsebetweenlocalservicesthatwillconsiderthecaseandcreateaplanforanappropriateengagementstrategy.Thisresponseexistsforwhenallotherattemptsatofferinghelpontheinformalandformaloutreachlevelsisnothappeningornothelping,orincaseswhereexistingcoordinationmaynotbeappropriateforlong-termsolutions.ThefocusoftheSituationTableistocreateacollaborativeresponsethatenhances

Page5of7

theeverydaysupportthevulnerablepersonisreceiving(bothformallyandinformally),andisnotresponsibleforofferinganyintervention.

IntentionalcommunitycoordinatorsandotherinformalsupportswillcontacttheRegistrationOfficetorefersomeonetotheSituationTable.Formalsupports,likeusualservicesandothernetworkpartnerscancontacttheSituationTablecoordinatoratFamilyServiceWindsordirectlytorefersomeone.Onceareferralisreceived,theSituationTablecoordinatorwillopenarecordforthecase(identifiedbyinitials),determinetheappropriateattendees,andcallameetingwhereeveryonerelevanttothecasecontributestoaroundtablediscussioninordertoaddressthesituationanddevelopacoordinatedresponse.Participantswillincludetheinitialreferralsourceandmayincluderepresentativesfromfire,police,communityservices,publichealth,andothernetworkstaffthatareappropriatebasedonthesituation.Thesituationwillbebroughtforwardasacase,andnoidentifyinginformationwillbesharedatthetable.

OncetheSituationTablereviewsallpreviousoutreachattemptsanddiscussesanappropriateresponse,theywillupdatetheircaserecordandsupporttheworker(representingtheprogramorservicethepersonisattachedtoalready)toworkwithintheirprogramtorespondtotheneedsofthevulnerablepersonusingnewideasfromthecollaborativediscussion.Thisnewresponsemayincludesupportfromotherservicesthepersonhasnotbeenattachedtoyet.TheSituationTablecoordinatorwillestablishtheReportBackProtocol-taskingthepersonresponsibletoreportbacktotheSituationTablewiththeresultsoftheirdecideduponoutreach.

*Green=follow-upsupport(i.e.,originalreferringagency,VPN,COAST,etc.)

AttheSituationTable,discussionswillincludethingssuchas:

• Riskfactors• NeedforIntervention

o Purposeofintervention

Page6of7

o Approacho Whowillleado Whichagencieswillbeinvolvedo Timeframetoreportback

• ReportBackProtocol

Movingforward,criteriawillbedevelopedthatwillhelpdeterminewhenasituationiseligibleforaSituationTableresponse.FigureCbelowillustratestheSituationTableProcess.

TheSituationTableProcess

• PROGRAMSANDSERVICESRECEIVEREFERRALSTHROUGHREGULARCHANNELSANDADDRESSTHEMTHROUGHREGULARMEANSINCLUDINGCOORDINATIONWITHOTHERS

IniaalResponse

• ANYUSUALSERVICECANSUBMITSITUATIONSTHATMEETELIGIBILITYCRITERIATOTHESITUATIONTABLE.PARTICIPANTSMUSTCOMEPREPAREDTOEACHMEETINGWITHUPDATESONALLTHEINTERVENTIONSPREVIOUSLYATTEMPTED.

• WECCCREGISTRATIONOFFICECANREFERTOSITUATIONTABLEIFPERSONREFUSESCOACHINGOROTHERCOMMUNITYSUPPORT.

ReferraltoSituaaonTable

• SITUATIONSAREPRE-SCREENEDBYSTAFFANDPRESENTEDTOSITUATIONTABLE.

SituaaonTableMeeang

• THESITUATIONTABLEREVIEWSPREVIOUSATTEMPTS

• THESITUATIONTABLEDECIDESONACOLLABORATIVERESPONSE

• THESITUATIONTABLERECORDSTHEIRDECISION

CoordinatedResponse

Page7of7

OutreachPathway