Experience Exchange: Using the Ontario Common Assessment of Need to support client care in York Region

This edition of Experience Exchange features a conversation with Christine Mariano, a Case Manager at York Support Services Network (YSSN). YSSN works with people who live with serious mental illness and/or a developmental disability, helping them develop relationships and connections to their community, to benefit their overall well-being. Through 310-COPE and their  24/7 Crisis support, case management, peer mentorship, and access services, YSSN connects people with the services and supports they need to achieve their goals and live a full and meaningful life.

Q: Tell us about yourself. What is your role at YSSN?

Christine: I work as one of YSSN’s mental health case managers, where we serve adults in York Region who require support around their mental health recovery. This includes community resource navigation, referrals to various programming, coordination with client support systems, and help to strengthen their connections in their own community.

At YSSN, we work in a six-month model, so we provide each client with Intensive Case Management services for a minimum of six months. But there is no cap on the services they can access or the duration of services. If they have not achieved their goals after the initial six-month period, the case manager applies for an extension (one to three months) or a continuation (three to six months) and our streamline access committee decides how much time the client would need to achieve their goals.

Q: What is the main purpose of the OCAN, from your perspective?

Christine: The main purpose is to inform our clients’ treatment plans. Collaboratively, the case manager and client identify physical, social, or mental health issues in a number of domains that affect the client’s daily living and their relationships.

Q: What is your process for completing OCANs. When do you do the initial OCAN and when do you complete reassessments?

Christine: The case manager starts to do a new client’s OCAN assessment immediately. One of the first items that we ask a new client to fill out is the OCAN consumer self-assessment portion, which is very helpful in supporting a client-centred approach. And, although new clients don’t always complete the self-assessment due to such barriers as low comprehension skills or literacy, the case manager starts to build rapport with them and starts to gather the information needed to complete the OCAN.

At YSSN, we like to take a casual approach to the OCAN, one that feels less formal. Just in conversations with the client, you’re going to get to what is going on in each domain. And in the event that we want to apply for an extension or a continuation at the end of the six months, we would do a reassessment. And then, once the client has achieved their goals, we do another OCAN prior to discharge.

Q: You mentioned the OCAN self-assessment, which the client may or may not complete. Do you have any strategies to support a client to complete the self-assessment or to complete it at a later time?

Christine: Upon receiving a new client, the case manager makes the initial contact by either phone or email to explain that they’re going to receive some brochures and different forms to fill out, including the OCAN Consumer Self-assessment. The case manager asks the client to review these on their own. Then, during the second contact with the client, the case manager reviews the OCAN self-assessment with them. We explain how to complete the self-assessment and, if the client needs a bit more explanation on some of the domains, we sort this out together.

Q: What do you like most about using OCAN? What do you see as the benefits of using it?

Christine: I started using the OCAN in 2012. Prior to using the OCAN, we completed individualized support plans with all clients to help identify their goals. We only had what they identified as their unmet needs to work with. What I like about the OCAN is that the 24 domains cover every aspect of an individual’s life, ensuring that we capture all of their needs—maybe even needs they didn’t know were priorities in their present situation. From there, goals can be developed to address identified needs.The OCAN reassessments and the pre-discharge OCAN are also very useful because they show the client’s movement or improvement within service. These OCAN assessments are a great way to capture that using a common language.

Q: What do you find challenging about using OCAN with clients?

Christine: We have some clients who have a community treatment order[1] and engaging these clients—using OCAN and building rapport with them—can be quite challenging. With these clients, we need to complete the staff portion of the OCAN, regardless. The self-assessment portion is voluntary and some of these clients don’t complete it for a variety of reasons. But we always complete the staff portion, and put “unknown” in the sections for which we don’t have information. 

With other clients, it can be difficult to even establish goals because they might never have thought about any of the OCAN domains and they are only able to think about their basic needs. In other cases, the client’s goals might be unrealistic given their current situation. For some clients, trying to consider all 24 domains in one meeting can feel really overwhelming and can interfere with their engagement with treatment.

Q: Have you found any strategies that have helped to address some of these challenges?

Christine: Breaking the OCAN down has been helpful for these types of clients. If all 24 domains are too much for a client, we’ll slow the process down. Maybe we’ll have a casual conversation with them—we’ll break it down and only do the first five domains, then move on to the next at their next meeting. If the goals are unrealistic in their current situation, we’ll break them down into smaller, more achievable SMART goals.

Q: Can you explain what are SMART goals?

Christine: The SMART goal framework helps us make any goal possible for the client to achieve. The model includes the following elements:

Q: How do you use OCAN content to inform goal and service planning with clients?

Christine: Once a client identifies an unmet need, I help them establish a goal related to this need using the SMART goal model. We help the client focus on what they can achieve in the next six months given their current situation. For example, if a client would like to get a specific job but they don’t have the required experience, or if they want to go to university but they don’t have a high school diploma, the case manager helps them break the goal down into pieces that they can achieve over six-month periods. Then, the case manager meets with the client at a frequency that makes sense for both of them—weekly, biweekly, monthly—by phone, virtually, or in the community—to ensure the client stays on track to achieve the identified goal.

Q: Can you give us an example of a client who had an overwhelming goal and how you used the OCAN tool and a SMART goal to help them?

Christine: I have a very young client—she’s 19 years old and she applied for service with us at the beginning of the COVID-19 pandemic, when she was 17. Anxiety and social isolation has been at an all-time high during the COVID pandemic, so she hasn’t had any interactions with peers her age—only her immediate family—in years. The OCAN identified that she had unmet needs in the domains of “Company” and “Psychological distress”. One of her goals was to feel comfortable being with extended family—aunts, uncles, cousins—in her home.

The way we approached this goal was to create a SMART goal. It was specific—the goal was to see extended family at home. It was measurable—she would make one phone call per week to an aunt, a cousin, or an uncle. It was achievable—she could make one call to a family member per week with my support. We helped manage her anxiety with making the phone calls in the beginning by using different coping strategies that worked for her. It was reaslistic—because it was a new habit, we built upon an existing habit, which was the weekly calls with me. She would call her family member right before our weekly case management call. That way, during her call with me, I could check in with her and keep her accountable.The goal of making one phone call each week was relevant to her ultimate goal because it was helping her get comfortable spending time with extended family members. And it was timely—we were focused on achieving this goal within a six-month period. I’m happy to say that she now sees cousins her age, which is the first time she’s done it in two years.

Q: How do you use OCAN information and the OCAN language in your day-to-day work with clients?

Christine: In terms of the domains, I use language that’s easy for my client to understand. I would say “housing” instead of “accommodation”. I wouldn’t say “psychological distress” with most clients—I would say “stress”. So I don’t necessarily use the exact language that is in the OCAN when I speak with clients. But the way that it’s explained in the assessment is great. By using the OCAN prompts, I’m able to have a discussion with the client to help them understand exactly what their needs and strengths are in each domain. Within our agency and with other colleagues, we have no problem with the OCAN language, but with clients, we just make it a little bit more approachable and relatable.

Q: The OCAN can be used in practice in a way that helps a recovery approach. Does YSSN use a recovery-based approach and, if so, how do you connect that to the OCAN?

Christine: Yes, we definitely use a recovery model. We use SMART goals and we use weekly meetings with clients, although the frequency of client meetings can be biweekly or monthly. We make sure that whatever OCAN domain is identified,  we break it down to ensure that each actionable step feels empowering to the client and they have their case manager’s support throughout each step. As much as the responsibility is the client’s to do the work behind the scenes, an important part is the case manager keeping the client accountable, to make sure they are following through on each step. And if they don’t achieve a goal, we explore what happened—maybe there’s an adjustment that needs to be made. But, of course, always making the client feel that there’s so many different ways to achieve any goal. It’s not linear. I think, as a case manager, to support the recovery model, you make adjustments along the way.

Q: What would you say to anyone who doesn’t feel the OCAN is a useful tool in client care or feels it’s a burden?

Christine: I would be naturally curious. I don’t understand how it would get in the way of client care. Maybe the person just needs to shift their perspective. I think we all naturally use the OCAN domains in our work, it may just not be laid out in a formal way as it is in the OCAN, with the 24 domains. So, first I would explore why they feel it’s a burden and then maybe I would share how I like to use the tool. I would suggest using it as a mental checklist, to cover each aspect of an individual’s life, to provide the support they need, and to capture all their needs. Like I said, in our work, we already subconsciously do this, but just seeing it on paper with the 24 domains ensures that we’re covering all our bases.

[1] A community treatment order is a provision under the Ontario Mental Health Act that allows a physician to mandate supervised treatment for a patient when they are discharged from hospital. Community treatment orders are used for individuals who have had repeated psychiatric admissions and who do not voluntarily engage in outpatient follow-up.

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