When Anisa Carrascal was a psychiatric nurse working in hospitals, she saw the massive gap that existed between the highly-structured setting of a hospital and the community. “You're discharging a patient from the hospital to nothing, truly nothing,” she said. Anisa envisioned a safer, gentler way to support people with complex mental health issues, preparing them and “holding them” as they transitioned from acute care to community living.  

Now, three years after joining CMHA Toronto’s Nurse Practitioner (NP) Stepped Care program, that bridge has been built and Anisa and a team of five others (nurse practitioners and nurse case managers), led by manager Jennifer Pettigrew, are walking hand-in-hand with their clients to cross it. 

Jennifer, who helped establish NP Stepped Care program in 2018 and now oversees it and CMHA Toronto’s primary health care program, explains that NP Stepped Care’s job “is to increase the client's capacity to manage their own mental health independently in the community.”

NP Stepped Care liaises with four community-based ACT (Assertive Community Treatment) teams to identify and transition clients who are at a point in their recovery where they no longer require intensive support but still require medication, counselling, and case management services. The program also accepts clients from other CMHA Toronto programs. 

By being able to accept clients who are medically stable and ready to move to a less structured model, NP Stepped Care not only fills in the crucial missing step in preparing clients to successfully return to the community, they also free up capacity within the system “so psychiatrists can take on new clients, and [ACT teams] still have capacity within their program to follow clients in the community,” Jennifer said.   

NP Stepped Care is an important and effective way to reduce the long waitlists for psychiatric resources, by transitioning clients out of more intensive programs and into NP Stepped Care. And, once a client is ready to graduate from NP Stepped Care into the care of a general practitioner, it also addresses the Ontario’s chronic shortage of family doctors. CMHA’s nurse practitioners, with their dual role within NP Stepped Care and CMHA Toronto’s primary health clinics, can fulfill the role of the family doctor where the client doesn’t have one or where the family doctor is not comfortable taking over mental health medical management. 

Without NP Stepped Care to fill these gaps, the risk is an endless cycle of recovery and relapse, with much suffering as clients unable to successfully make the transition to independent community living end up back in hospital – or worse. As Anisa puts it, “this is how the system should work.” 

Centering the client in a web of support

The nurse case managers of the NP Stepped Care program wear many hats: social worker, therapist, nurse, case manager. The role is as unique as the program, sitting at the centre of a web made up of the strands of mental, physical, social, educational and employment resources and supports that clients with complex mental health issues need. 

CMHA Toronto’s NP Stepped Care program is a significant factor in positive outcomes for clients. The team can prescribe, treat and counsel clients, and tap into wrap-around services that are essential for successful community reintegration. With in-house services like employment, housing, and addictions counselling under the CMHA Toronto umbrella, these referrals are faster and easier than those made to external agencies, making the program exceptionally effective. 

“The important thing to understand is the continuation of care. When a person is really acute, they usually are in hospital [and then may be] referred to an acute care team working in a community setting,” said Anisa. As a client progresses towards needing less support “we [work on] other areas such as their educational goals, their work and personal goals,” she added. 

This model of care means a better, more flexible, flow of support between the different parts of the system – and better care for clients to make progress in their recovery by being appropriately supported along their journey. “The beauty of programs like CMHA Toronto’s is that we can do that progression back and forth. [If a client in NP Stepped Care] doesn’t do well, if they have a little crisis, we can refer them back to ACT for a while,” Anisa said. 

It is a testament to the program’s effectiveness that very few clients are referred back to ACT – less than ten percent according to Jennifer. In Anisa’s time with the NP Stepped Care program operating in west Toronto, which opened in 2021, she has only referred one client back to ACT. There is no limit on how long a client can stay with NP Stepped Care although most will move on when they reach the level of independence to manage their own mental health. Anisa has discharged three clients to the community and all are doing well. 

The pathway to healing is built on relationships, trust and confidence

There are several steps on the NP Stepped Care pathway, but the most important one – and the one that both Jennifer and Anisa stress is fundamental to the program’s success – is the relationship that the nurse case manager builds with their client. 

Anisa emphasizes that this bond is both different than the experience clients typically have in the hospital system or with the ACT team, as well as a vital, but often missing, component of the recovery process for people with complex mental health issues.  

“We all have a set of clients and we develop a long-term relationship. I know their parents, their pets, their houses, what they like to eat,” Anisa said, laughing. The relationship and trust they build with each of their clients is what takes “progress to a different level and really sets them up for success,” she added. Jennifer explains that “clients coming from ACT are a little bit reserved, but because they are seeing the same primary nurse case manager from week to week to week, it doesn't take long before they open up.” 

Unlike the hospital or ACT team experience, which is highly structured with more frequent visits of shorter duration by varying members of a nursing team, Anisa and her colleagues in the NP Stepped Care program offer a one-on-one, personalized experience based on the client’s specific needs. They engage in longer visits, usually every week, during which they build trust and the client’s confidence, uncover and address their client’s wide spectrum of needs – physical and mental health, social, employment, housing and others – and work collaboratively with the client toward the goal of living independently in the community.  

“The thing we’re really, really good at is that engagement piece, making the clients feel welcome,” Jennifer said. “Finding out and being interested in their lives, finding out what their goals are. When you have that connection, you have much more rich information and can really home in on what their needs are.” 

Trauma-informed care: NP Stepped Care offers a place for healing

Another important issue is how NP Stepped Care works to address the trauma that clients with mental illnesses have invariably experienced having “gone through the wringer of the mental health system,” said Anisa. “They [may have had] encounters with police at some point; they may have had hospitalizations that may have been involuntary. They have a lot of trauma with the system itself. We’re the answer to some of that; we’re part of the healing cycle. This is where we can address that trauma. We have the time to sit down with clients and speak about these issues, letting them slowly work through the trauma of what they have gone through as they are recovering.”  

Trauma-informed care is embedded throughout CMHA Toronto’s programs, as is a recognition of the vital importance of the social determinants of health: housing, employment, inclusion, and other factors that directly impact a client’s recovery and longer-term health outcomes. “Reconnecting with society in general is what is going to make the transition successful. So if we don't treat [these factors], we're going to have them back. It's going to restart the cycle and what we want is to prepare them to be successful,” said Anisa. 

“Everybody has their bad times, right? Everybody feels depressed sometimes and everybody has a stumble,” Anisa adds. “But there's a difference when you have the coping mechanisms, when you have the right tools to manage that stumble rather than just dissolve. And I think that's why our work is important.”  

Bella: An NP Stepped Care success story

The warmth and depth of the relationship between NP Stepped Care’s nurses and their clients was on full display as Bella* shared her story. Severely ill for many years, with frequent hospitalizations, Bella was on her way to recovery when she experienced a relapse. “It was around 2013 when I got sick again,” she said. “I'd been working for many years, and I changed medications – actually stopped medication; I was transitioning – and I got sick again. And when I got sick, it was a really long process of recovery,” Bella said. 

* name changed to protect client privacy 

Bella moved from the hospital to ACT before the NP Stepped Care program existed. As she started to improve, she was facing the prospect of being discharged directly to the community, and she was not sure she was ready for that step. It was a relief when there was another option for her. Anisa explains that Bella, one of her first clients, “was very happy when she knew that she was going to stay within CMHA Toronto. That gave her quite a lot of breathing room,” Anisa said. 

“At first it was scary for me to come to the office to receive my medication,” Bella said. Homebound even prior to the pandemic, Bella’s early time in the program consisted of home visits by Anisa, a pandemic precaution but also a comfort zone for Bella.   

Anisa’s job is to ease clients into a new mindset, encouraging them to explore new opportunities and exercise their independence. “I started pushing [Bella] out of her comfort zone. She used to never go out of her house, she was really scared. And now [as COVID restrictions have eased], she's coming to the office, she's going places, she's going to the mall, she's taking the TTC again,” Anisa said. 

Bella explains that with NP Stepped Care, she’s had support on the medical side, has had counselling, and she’s been able to work with employment counsellors. “Now I'm coming to the office every month to receive my medication. I still have symptoms, but it's so amazing how supportive Leticia [nurse practitioner in NP Stepped Care West] and Anisa are.”  

Although she is quick to credit the NP Stepped Care team for her success, it is clear how far Bella has come and how much confidence she’s built: “I've been employed for two years now, and I’ve been well. I’m independent now. It’s been so helpful, so amazing. I couldn’t picture my life without them.”  

Both Jennifer and Anisa emphasize that the program works in a client-centric way that involves the client in every step of decision-making. “We set up the standard for them to be successful, that's what we really want to do. And we never discharge them unless it’s a mutual decision,” said Anisa. The goal is to build the client’s confidence, reflect on and celebrate their successes and progress at each step of the journey until they feel ready to be discharged and able to manage on their own.