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Adult Intensive Addiction and Mental Health Services: An Update from CMHA WW


For the past year, the Waterloo Wellington LHIN has been leading a review of Intensive Services for adults in our region with complex mental health and addiction needs. This became a priority area because of the long wait times for those needing intensive services. The redesign reviewed the current Support Coordination and ACT services and worked to create a model that would increase flow, reduce hospital visits, and minimize wait times.

So What Did We Do?

We needed to design a flexible, recovery-oriented treatment and care model for people with complex addiction and mental health needs. As an integrated multidisciplinary team service delivery model, this model enables people with concurrent health challenges to access flexible team-based care that can adapt to their changing needs.

You might have heard of the “FACT” (Flexible Adult Community Treatment) team. This model of care has revolutionized the way people receive intensive care in many areas around the world. We took the best of this model and made it suit the needs of the residents of Waterloo Wellington.

This model was designed to include primary Substance Use Disorder clients in the scope of service provision, which previously had been excluded from complex care teams that have historically focused on mental health. This is a very important addition to our model, as many people are living with severe substance use issues, and they do not have the supports they need.

This local approach has three main characteristics:

• Working with people on their addiction and mental health in a concurrent way;

• Acknowledging the resilience of people facing mental health and/or addiction issues;

• Approaching recovery as a fluctuating, cyclical, or up-and-down process; and, adjusting the intensity of support and care based on individual requirements.

Although we want to be as welcoming as possible, the following criteria is in place to ensure that the service is best meeting the needs of those who are most suited for it:

• are between 18 and 65 years of age; are facing severe and persistent addiction and/or mental health issues, with or without other co-existing complex challenges that limit their ability to function on a daily basis

• are residents within the Region of Waterloo and the County of Wellington

What can our clients expect?

People supported by the Team can expect customized individual and group-based treatment grounded in recovery-oriented functions including relationship building, personal goal and recovery planning, support with medication issues, service and system coordination, assistance with crisis management, connecting to formal and informal supports, practical supports in multiple life areas, and advocacy.

Is this a “new” service?

CMHA has been successfully operating a FACT Team in Kitchener Waterloo for several years. This team, as well as the prospect of using existing resources to build new interdisciplinary team-based care was part of the adult intensive services review. Last year, the Waterloo Wellington LHIN made further investments in community-based addiction support. This funding was added to existing resources to create the new Teams – providing fully concurrent care. Although many of our existing clients will be supported by the Teams, we will have some capacity for new referrals. We are working with our addiction partners and our primary care partners to ensure that our highest risk people (who are already on our waiting lists) in the community are connected to our Teams.

We have exciting recruitment news to share

CMHA WW is very excited to announce the arrival of two new psychiatrists to our team! Husband and wife team, Dr. Emily Gavett and Dr. Anson Liu will be moving to Guelph from Maryland, USA at the end of August, and will begin working with us in late September. They will be spending some time with our Children’s Services Team in Guelph Wellington, with our Guelph Wellington Adult Services Team, and also be providing Forensic Assessments across the agency. We are working to prepare for their arrival, and we will provide more specific information about their work with us in the weeks to come.

Next Steps in the Process:

CMHA WW will continue to recruit psychiatrists for our remaining Teams (ie Cambridge North Dumfries). We are also working closely with our Intensive Services Partners to ensure that people who need a Team are referred. We also continue the re-design work in our adult mental health and addictions system to fully maximize our resources across ACTT, FACTT and Support Coordination.


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