People with mental health and addiction challenges can ‘fall through the cracks’ when transitioning from inpatient hospital care to home or community-based care. The District of Thunder Bay Service Collaborative identified and selected this transition as a system gap that requires attention. System fragmentation, poor communication, and consent to share client information are significant barriers to efficient and effective patient discharge planning. Several issues were identified, specifically the need for: 

• improvements to formal discharge plans, including communication and care pathways;
• recognition of the potential challenges for people transitioning from a remote community to an urban centre;
• consideration of transportation time and costs;
• improvements to engagement in aftercare when a client leaves treatment;
• improvements to central intake;
• acknowledgement that the system can be difficult to navigate and supports are needed; and consideration of privacy legislation.

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