The Comprehensive Care and Integration Specialists (CCIS) team’s specialists (registered social workers, addictions therapists, and psychotherapists) strive to fill gaps in care for clients living with complex health and psychosocial issues. The CCIS specialists connect clients to essential services and supports; coordinate follow-up care; and provide case management, counselling and advocacy on housing, legal, financial and immigration issues. We work with clients to develop individual Coordinated Care Plans and support their care providers to work as a team. Our goal is to bridge the gap between acute and medical care providers and the community sector. CCIS is a short-term intensive program, providing up to 3 months of service for clients.

The focus of the program is on individuals with significant gaps in care, those who may struggle to follow up on care recommendations , those who have a history of multiple Emergency Department (ED) visits, are Alternate Level of Care (ALC) or are at risk for ongoing visits and in-patient stays, those who experience challenges related to the social determinants of health (such as housing or income), those who would benefit from integrating the work of multiple health providers, and those with complex health needs from the following groups:
i. individuals experiencing mental health and/or addiction issues,
ii. psychogeriatric populations (55+ with mental health and/or addiction issues),
iii. frail elderly.

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