Nurse Practitioner Stepped Care Program

About The Program

The Nurse Practitioner (NP) Stepped Care Program is a pathway from clinical supports to community-based services. The program provides medical treatment and support services to individuals diagnosed with a serious mental illness who no longer require intensive services offered by the Assertive Community Treatment (ACT) program.

Individuals are transitioned from ACT into NP Stepped Care, where care and treatment are provided by a nurse practitioner alongside nurse case managers, who collaborate as a team to assist and support in furthering the client’s health care and wellness goals. 

Services are provided in the home, community and office and can include: prescribing medication, medication monitoring, mental health status exam, crisis management, connection to internal/external/community supports, education about mental illness and symptom management, intermuscular injections (home or office), metabolic monitoring and family support. 

The NP Stepped Care Team promotes and supports independence, accountability and responsibility, and empowers individuals to carry out the day-to-day responsibilities for maintaining good health and wellbeing. We work to connect individuals to community supports and services as they advance in their recovery and fully transition into the community.

Who's It For

Clients currently registered in a CMHA Toronto program who would benefit from ongoing support and treatment as they advance in their recovery journey.

How IT Works

  1. Existing clients work with their case manager as part of a CMHA Toronto ACT program 
  2. As clients advance in their recovery, case managers may send a referral to NP Stepped Care
  3. Clients meet with a Stepped Care nurse case manager, nurse practitioner, and their existing case manager to discuss client care needs
  4. Clients receive care at home or in the community from a Stepped Care nurse

FREQUENTLY ASKED QUESTIONS

Who are NP Stepped Care services for?

The NP Stepped Care Program is for clients currently registered in a CMHA Toronto program. The NP Stepped Care Team works in partnership with various CMHA Toronto programs to identify individuals who no longer require intensive services but could benefit from ongoing support and treatment as they advance in their recovery journey. 

What services does the program provide?

Services can include: prescribing medication, medication monitoring, mental health status exam, crisis management, connection to internal/external/community supports, education about mental illness and symptom management, IM injections (home or office), metabolic monitoring and family support. 

Where are NP Stepped Care services offered?

For NP Stepped Care, we have two locations–you will be enrolled at either our West or East office site based on your geographic location. Our mental health support services are available in our office, at your home or in the community. Our clients are provided with the flexibility to meet with our nurse practitioners or nurse case managers over the phone, in person or through virtual platforms like the Ontario Telemedicine Network (OTN). 

If an NP Stepped Care client’s mental health deteriorates and they require more intensive support services, what happens?

If a client’s current needs are beyond what NP Stepped Care can provide, we transition them back to the ACT Team from which they originally transitioned. 

Does NP Stepped Care work with any other CMHA programs other than ACT?

Yes. Some of our programs (eg. Case Management) do not have nurses on their teams.  Therefore, NP Stepped Care will provide “shared-care,” meaning they will provide nursing support (eg. IM injections). 

If a client is discharged from NP Stepped Care into the community, can they come back to the program?

Yes, if it is within a three-month period from time of discharge 

If an NP Stepped Care client goes into the hospital as a result of mental health deterioration, do they automatically go back to ACT?

In most cases, no. NP Stepped Care will continue to provide support services after the client has been stabilized and discharged from hospital. 

Can a nurse practitioner prescribe anti-psychotic and other mental health medications?

Yes

Contact Us

West Office
700 Lawrence Ave W,
Suite #480 Toronto,
ON M6A 3B4

East Office
1200 Markham Rd,
Suite #500 Scarborough,
ON M1H 3C3

Subscribe to Living. Working. Belonging.

A monthly newsletter from CMHA Toronto about thriving together and improving mental health care