Community Mental Health

What is it?

Community mental health refers to the delivery of mental health services in community settings. This may mean working with clients in their own home or bringing mental health services directly to individuals in supported residences shelters or those who are marginally housed.

Community Mental Health Services allow people to receive specialized services outside of a hospital setting and to also support community providers and partners with education and consultation.

The Community Mental Health Program’s eight specialized community-based mental health teams operate out of a main office in Carlingwood Shopping Centre.

Mental health care when and where it’s needed most

The assessment, consultation and treatment services provided by The Royal’s Community Mental Health Program assist people with serious and persistent mental illness to live in the community and work towards their recovery.

Eight teams provide a range of levels of specialized support, depending on the needs of the individual. We also offer education to care providers to help increase their understanding and ability to cope with mental illness. The work of community mental health teams can:

• Prevent unnecessary admissions to hospital (or reduce the length of time in hospital if required)
• Assist clients in their recovery from mental illness and re-integration into their community
• Help clients reach their optimum level of independent functioning
• Provide support and education to staff of community partner agencies
• Conduct research and evaluation on models of community mental health care

Our community mental health teams

Psychiatric Outreach Team

This is an Ottawa based team of mental health professionals that work in the community with adults who are homeless or vulnerably housed) and who are experiencing serious and persistent mental illness.

The team provides assessment, short term intervention and links to other services. They also provide service to clients of Renfrew Mental Health located in Arnprior, Renfrew and Pembroke.

The Psychiatric Outreach Team works collaboratively with community partners including shelters, drop-ins and supportive housing to provide care to our mutual clients. The team’s role is also to provide support and education on mental illness and intervention to staff of these agencies.

Clients are referred through community partner agencies.

Regional Dual Diagnosis Consultation Team

This specialized consultation team provides clinical assessments, education and treatment recommendations for the care of dually diagnosed (intellectual disability + mental illness) individuals who are over age 18. The team is based in Ottawa and serves
individuals in the Champlain LHIN.

Referrals are made by family physicians or other caregivers at +1 (613) 722-6521 ext. 7141 

• Central Intake Referral Form

Note to referring physicians and nurse practitioners: Referrals to The Royal’s Dual Diagnosis Program can be submitted electronically directly from your EMR if you have been set up with Ocean eReferral. Ocean eReferral is a regional program that offers an integrated solution at no cost for all primary care providers in Champlain with compatible EMRs (Telus PSS, QHR Accuro, and certain versions of OSCAR). Once set up, referrals can be initiated directly from the patient's chart in your EMR, launching the appropriate electronic referral form and automatically populating it with much of the appropriate information for the patient and referring clinician. For more information about eReferral, please email: contact@ereferralontarioeast.ca

Flexible Assertive Community Treatment Team for Persons Dually Diagnosed (FACTT-DD)

This specialized team provides a continuum of treatment from very intensive service during periods of crisis and acute illness to less intense service during periods of stability.

One can refer people with an Intellectual Disability (DSOER eligible) over the age of 18 who are experiencing symptoms of mental illness and who may experience the following:

1. significant behavioural challenges;
2. extended hospital stays and frequent use of emergency services; and
3. involvement in the criminal justice system.

For further information, please contact +1 (613) 722-6521 ext. 7141.

• Referral Form FACTT-DD

Assertive Community Treatment Teams (ACTT)

The 2 Ottawa based ACT teams are comprised of interdisciplinary mental health professionals working in partnership with clients living with serious and persistent mental illness. The team works with clients to develop recovery goals - they help clients with housing, school or jobs, life skills, relationships and integration into their communities. The team also provides treatment and medication monitoring and ongoing assessment of mental health concerns.

ACT teams work closely with other care providers including family physicians, drop-ins, staff from supportive housing, and inpatient teams to provide the best possible care to their clients. ACT teams are available days, evenings and weekends and have an emergency after hours on-call system for their active clients. The ACT teams do not accept emergency admissions.

• ACTT Central Intake Referral Form

ACT Team for Persons Dually Diagnosed (Brockville Mental Health Centre)

This specialized team provides service to individuals with both a severe and persistent mental illness and intellectual disability. The team provides multi-disciplinary services to clients and works with their care providers to establish effective treatment and behavioural plans. The team is based at the Brockville Mental Health Centre and serves the South East LHIN and North Lanark, Leeds and Grenville.

For further referral information please call +1 (613) 498-1492 ext. 1500.

• Regional Client Access Form

Step Down from ACT

The Ottawa Step Down Program has a team made up of 6 interdisciplinary staff. Step Down receives referrals from the five Ottawa based ACT teams.

Step Down provides case management services to clients who no longer require the intensive level of service that ACTT provides. This service works collaboratively with clients on Recovery goals. Ottawa area ACT teams are able to refer to this service

Community Treatment Order Coordination

A Community Treatment Order (CTO) is a doctor’s order for a person to receive treatment or care and supervision in the community. People who have difficulty engaging in treatment and meet the appropriate criteria may be considered for a CTO.

The CTO Coordinator works with physicians, patients, families and care providers to set-up community treatment plans. The Royal’s CTO Coordinator works in partnership with The Ottawa Hospital and The Montfort Hospital to provide regional CTO services to the Champlain LHIN. Referrals are usually made through a person’s physician. 

For CTO referrals in the Champlain area, contact Montfort Hospital’s CTO Coordinator at +1 (613) 746-4621 ext. 3959.

Homes for Special Care

The Homes for Special Care program provides residential care to individuals with a mental illness who no longer require hospitalization. Administered by the Brockville Mental Health Centre, the program is funded and residences are licensed by the Ontario Ministry of Health and Long Term Care. There are currently 181 HSC beds in Champlain and South East.

Most of the homes are privately owned however the HSC program has begun work with transfer payment agencies to develop new models of supportive housing. Referrals can be made through the HSC office at +1 (613) 345-1461 ext. 1600.

ACTT Central Intake

ACTT Central Intake for the 5 Ottawa area ACT teams is currently managed by the Community Mental Health Program. Referrals to the ACT program are accepted from mental health-care facilities, family, community providers and family physicians. Applications for all Ottawa area ACT teams are reviewed by a central intake team. A client assessment will then be done to determine eligibility for ACT services.

For more information about referrals to Ottawa ACT teams, please contact the ACT Central Intake at +1 (613) 722-6521, ext. 7325.

• ACTT Central Intake Referral Form