Transforming Mental Healthcare at St. Joe’s: A Stepped Care Approach

Transforming Mental Healthcare at St. Joe’s: A Stepped Care Approach

Toronto is in the midst of a mental health crisis, and St. Joe’s is on the front lines, ensuring that those who need care can access it when they need it most. Our west-end community has one of the highest concentrations of people living with mental illness in the city, and young people are particularly affected—70% of mental health problems begin in childhood or adolescence. Yet, too many individuals face long wait times and a fragmented system that can make accessing support overwhelming.

Thanks to donor generosity, St. Joe’s is transforming how we deliver mental health services. The introduction of a Digital Front Door for referrals and a Stepped Care Model for mental healthcare is creating a seamless path to the right level of care for every patient. This model ensures that care is available at multiple levels—ranging from self-guided support and early intervention to intensive inpatient treatment—so that every individual receives the support they need at the right time and in the right place.

A Digital Front Door for Mental Health Care

Navigating the mental health system can be challenging. That’s why St. Joe’s is leading the way with a Digital Front Door, a centralized access point that streamlines referrals, assessments, and care coordination. Assessing a client’s needs and identifying the most appropriate service for them, at a “Digital Front Door”, is a critical step in offering a stepped care model for mental health care.

With donor support, we’ve developed a new appointment management system, allowing for faster and more efficient scheduling, and implemented the Level of Care Utilization System (LOCUS)—a standardized assessment tool that helps clinicians determine the best treatment path for each individual based on their level of need.

Creating this new system at the first point of contact improves the experience of people seeking treatment at St. Joe’s, and enables greater care for our west-end community.

Strengthening Community Partnerships for Comprehensive Care

Mental health care doesn’t begin and end at the hospital doors. That’s why St. Joe’s has built strong partnerships with trusted community organizations, ensuring that patients receive support beyond our walls. With over 20 professionals from different health disciplines providing care in our community, hundreds of individuals are benefiting from these partnerships every day. Some of our key collaborations include:

• LOFT Community Services – Providing community-based Intensive Case Management for individuals with serious and persistent mental illness.
• SCOPE (Seamless Care Optimizing Care in the Community) – Connecting primary care providers with mental health specialists for early intervention and coordinated care.
• Pine River Institute – Supporting youth with addiction and mental health challenges through outpatient therapy.
• LAMP Community Health Centre – Delivering early intervention services for youth and families in need of mental health support.

These partnerships allow us to extend our network of care beyond the hospital, providing continuous support across all five levels of mental health care—from prevention and early intervention to crisis support and highly specialized treatment.

Putting it together: A Stepped Care Model

With the Stepped Care Model in place, St. Joe’s is ensuring that mental health care is accessible, coordinated, and responsive to individual needs—based on the most appropriate level of care. With the community partnerships we’ve established, we are now able to provide care to patients across all five levels of need—offering a true Stepped Model of Mental Health Care for our community.

• Tier 1: Early prevention and mental health promotion programs in partnership with community based family support organizations
• Tier 2: Early intervention and self-management functions targeted to people at risk, with referral to appropriate community care provider
• Tier 3: Treatment planning, risk/crisis management and support functions for patient with identified needs. Referral to community partner or outpatient care at St. Joe’s.
• Tier 4: Specialized care functions targeted to people assessed/diagnosed with more intensive care needs.
• Tier 5: Highly specialized inpatient care for individuals in crisis or with complex needs, including the Mental Health Emergency Services Unity (MHESU) at St. Joe’s

Your Support is Transforming Mental Health Care

You can ensure more people receive the care they need, when they need it most.

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