Embracing Compassionate Care: The County of Renfrew Mesa Initiative

By: Andrea Patrick

April 2025

OMSSA is featuring several 2024 Local Municipal Champion award recipients and their work in the Knowledge Exchange Blog. Please read this entry from the County of Renfrew below. 

Introduction

In early 2024, the County of Renfrew launched a groundbreaking initiative centered around a collaborative approach to providing compassionate care in the community. This phased approach, named Mesa (pronounced “mey-suh”), embodies bold and compassionate work to address the root causes of homelessness, substance use, addictions, and mental health issues while fostering a resilient and healthier community for all residents of the County of Renfrew. This blog post explores the essence of Mesa, highlighting its innovative strategies and the profound impact it has on the community.

The County of Renfrew is the largest geographic municipality in Ontario, defined by an area of 7,336.24 square kilometres. It is in the heart of the Ottawa Valley in Eastern Ontario and includes 17 municipalities. The City of Pembroke, Garrison Petawawa and Algonquins of Pikwakanagan First Nation are also located in this region. The vast distances, diversity of social determinants of health, rurality and health equity issues pose unique service delivery challenges.

Understanding Mesa

Mesa is more than just a program; it's an approach rooted in empathy and collaboration. At its core, Mesa seeks to break down barriers and create a seamless support system for individuals in need. This approach ensures that help is available when and where it's needed, fostering a sense of dignity and respect for all community members. One of the goals is to provide low-barrier access to services – supporting individuals navigate the numerous systems.

Innovative Approaches to Support

The Mesa Warming Centre, which is operational 24 hours a day, seven days a week, offers clients a safe space to get out of the cold where they can access comprehensive wrap-around supports.

One of the standout features of Mesa is its reimagined warming centre. Unlike traditional models, this year's warming centre is designed to provide comprehensive wrap-around supports. This means that individuals seeking shelter are not only given a warm place to stay but also access to a range of services that address their broader needs if they wish to access them and engage with the Mesa team.

The Centre is staffed with front-line staff from MacKay Manor trained in helping people access addictions and mental health support. The Mesa team supports this work during the day with the goal of providing low-barrier wrap-around supports to these individuals. The Warming Centre is funded through a municipal partnership involving the County of Renfrew, City of Pembroke, Town of Petawawa, and Township of Laurentian Valley.

Wrap-Around Supports

Wrap-around supports are a cornerstone of the Mesa initiative.  

Mesa Crisis Workers, Paramedics, Addictions Outreach Workers, and Community Supports Workers collaboratively offer person-centered care. They provide medical assessments, wound care, and patient education; mental health support including service navigation, counselling, and housing assistance; addiction outreach with harm reduction and individualized support; and community supports staff provide case management to ensure that individuals have financial support, are supported in their goals, and are assisted with navigating supports within the community, including but not limited to housing.

Addictions Treatment Service Counsellors offer free in-person or virtual confidential assistance to individuals 12 years of age or older residing in Renfrew County who are personally experiencing problems with alcohol, drugs, or gambling. Family and friends are also encouraged to contact ATS for support if they are concerned about somebody who is struggling with substance use/addictions.

By offering these resources in one place, the initiative ensures that individuals can receive holistic care tailored to their unique circumstances. This integrated approach helps to address the root causes of homelessness and instability, paving the way for long-term solutions.

Meeting People Where They Are

A key principle of the Mesa initiative is meeting people where they are. This means recognizing that each individual's journey is different and requires a personalized approach. The initiative's outreach teams are trained to engage with individuals in a compassionate and non-judgmental manner, building trust and rapport. This approach not only makes it easier for people to seek help but also ensures that they receive the support they need in a way that respects their dignity.

Breaking Down Barriers

Access to support services can often be hindered by various barriers, such as transportation, stigma, and bureaucratic hurdles. The Mesa initiative is dedicated to breaking down these barriers to make support more accessible. For example, the initiative has introduced mobile support units that bring services directly to people in need. These units travel to different parts of the county, ensuring that even those in remote areas can access the help they need.

Mesa's Collaborative Approach

Mesa was designed as a coordinated and integrated approach to address the intersections of mental health and addiction, housing, and homelessness crises. It is an innovative and evidence-informed collaborative model that focuses on compassionate, trauma-informed care and local needs. This collaborative approach aligns Emergency Services, Community Services, and Development and Property resources with community partners’ expertise and programs. The Mesa team works collaboratively to coordinate services and navigate a pathway for vulnerable community members to receive the right support and resources at the right time and in the right place. The County of Renfrew has direct partnerships with:

• Pembroke Regional Hospital, as represented by the Mental Health Services of Renfrew County (MHSRC)
• MacKay Manor as represented by Community Withdrawal Management Services of Renfrew County (CWMS)
• Renfrew Victoria Hospital as represented by Addictions Treatment Service (ATS)

Mesa Outreach Team

Pictured above are representatives from Emergency Services – Community Paramedics, OPP –  MCRT, Community Services, Community Withdrawal Management, Community Mental Health, and the Youth Wellness Hub Ontario (YWHO).

The Mesa Outreach Team includes Community Paramedics, Crisis Mental Health Services (Pembroke Regional Hospital), Addictions Support Services (Mackay Manor), and Community Supports Caseworkers. The Mesa Team connects with individuals in the community through various means:

• Encampments
• MCRT joint outreach
• Drop-in centers
• OATC (Ontario Addictions Treatment Centre) – Pembroke clinic
• Warming Centre
• 911/Emergency Department diversion

The goals of the outreach team include meeting community members where they are, encouraging harm reduction and prevention models, providing education, coaching, and treatment options for medical concerns, and connecting clients with community supports when they are ready. Daily communication among the Mesa team ensures coordinated care and support.

The daily morning check-in allows staff from Addictions Treatment Service (who is a direct Mesa partner) to connect with the Mesa Outreach team and for there to be a discussion around low-barrier supports for individuals and goals of care. During these meetings if it is determined there is a need for a care conference to discuss an individual case with members of the entire care team, then it is scheduled for a different time.

Some Mesa Initiatives to Note

Mesa East Supportive Housing Model

• Goal-oriented short-term transition housing model with daily check-ins supported by Mesa Mental Health Workers
• Candidates are presented in a Care Conference model and collaboratively discussed
• Mental Health Assessments and Addictions Assessments are completed and discussed at the care conference
• Care plans are developed to provide candidates with wrap-around supports to ensure the highest rate of success
• If a client is not a candidate for Rocky due to high needs, alternative care plans are put in place to help the individual meet their goals of care

The Mesa Wellness Clinics held at Renfrew County Housing units are a collaborative effort between the Community Services Department staff and the County of Renfrew Paramedic Service.

Wellness Clinics and Tenant Supports

• A collaborative and responsive approach involving community housing caseworkers, maintenance staff, and community paramedics to address tenant needs related to health, wellness, safety, and housing stability
• Community paramedics conduct health and wellness checks with tenants and connect individuals to a family physician through RCVTAC when required
• Bi-weekly wellness clinics are held in community housing common rooms, with follow-ups conducted between sessions
• Personalized wellness checks are conducted in tenants' homes by caseworkers and community paramedics
• High content and hoarding supports are provided in collaboration with Pembroke Regional Hospital

Wellness Clinics/Wellness Assessments in Renfrew County Housing Units

• More than 300 in-person interactions
• 90% success rate for in-person interactions
• Goal to have 600 in-person interactions by the end of the year
• 40% of these individuals have called 911 in the last six months
• 99% of these individuals are now enrolled in the program

Highlighting Key Components

The Mesa initiative includes several key components aimed at increasing housing supply and supporting individuals currently housed. These include the outreach team, morning check-ins, temporary supportive motel stays, the Mesa warming center, and supportive bridge housing set to open in the new year. Additionally, wellness clinics inside housing buildings, conducted in collaboration with housing caseworkers and community paramedics, and wellness assessments by community paramedics are crucial elements of the initiative.

Community Involvement

The success of the Mesa initiative is also a testament to the power of community involvement. Local businesses, volunteers, and organizations have come together to support the initiative, providing resources and expertise. This collaborative effort has created a strong network of support that amplifies the impact of the Mesa initiative.

Key 2024 Outcomes

• March 2024 - Mesa team launches with a dashboard measuring tool to track program performance measures.
• April 2024 - Affordable Housing Summit - the County hosted an affordable housing summit to learn, share knowledge and build partnerships.
• May 22, 2024 - Mesa Gathering - a community engagement workshop with 180 participants and 49 collaborating agencies.
• May 2024 - County of Renfrew partners with the Town of Deep River to purchase an unused school building and repurpose an existing asset for the creation of affordable housing and community space.
• June 2024 - Expressions of Interest submitted for collaborative development projects to support affordable housing builds in 2025.
• July 2024 - County of Renfrew and Carefor partner for the creation of supportive bridge housing in the City of Pembroke.
• July 2024 - Renfrew County Housing Corporation prioritizes a shared vision with Mesa moving forward.
• December 2024 – Opening of Mesa Warming Centre for 2024-25 season

Looking Ahead

As the County of Renfrew continues to embrace the Mesa initiative, the future looks promising. The initiative's innovative approaches and compassionate care model serve as a blueprint for other communities looking to address similar challenges. By continuing to adapt and evolve, the Mesa initiative will undoubtedly continue to make a positive difference in the lives of many.

Conclusion

The County of Renfrew Mesa initiative is a shining example of how a collaborative approach to compassionate care can be transformative. By meeting people where they are, breaking down barriers, and providing comprehensive support, the initiative is creating a more inclusive and supportive community. Individuals are leaning into their wellness journey as doors are opened and they are creating their own path forward. As we look to the future, the Mesa initiative stands as a beacon of hope and a model for compassionate care.

About the Author

Andrea Patrick, Director of Community Services for the County of Renfrew, has a wealth of experience and a passion for integrated service delivery and compassionate care. She has dedicated more than 25 years to advancing social services and improving the quality of life for vulnerable populations through innovative and collaborative approaches. Andrea’s leadership is marked by a commitment to breaking down silos and fostering partnerships that ensure holistic support for individuals and families. Known for her empathetic approach and unwavering dedication, Andrea continually strives to create inclusive and supportive environments where everyone can thrive. Andrea’s vision for and dedication to a person-centered approach, while also addressing the diverse needs of the community, have significantly contributed to the development of comprehensive service models.