Evidence:

Evidence shows that people with mental health and addiction challenges can fall through the cracks when transitioning from inpatient hospital care to home or community based care. In their multi-year work in Ontario (and elsewhere) developing and implementing a Transitional Discharge Model (TDM, now called a Transitional Relationship Model), Forchuk et al. referred to the transition out of hospital for many patients with mental health or addiction concerns as a “vulnerable point” that can exacerbate or worsen clinical symptoms if proper care is not given to social support and connection with known caregivers and peers. Evidence also shows an increase in hospital re-admission rates, and associated costs to the health system.

It has been noted with TDM implementation that, “the transition from hospital to community is complex and can be challenging for people who have been diagnosed with a mental illness. Research shows the first days and weeks following psychiatric discharge are particularly high-risk periods for relapse. As many clients are between care providers, they are vulnerable to emergency room visits and readmission to hospital. Forty-three per cent of suicides occur within the first month post-discharge.”

Learn more about the Transitional Discharge Model.

Find more evidence

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.

What are we doing about it?

Currently in the Exploration phase, the District of Thunder Bay Service Collaborative stakeholders met three times during the fall of 2016 in Nipigon, Ontario. While the transition to home/community for mental health and addiction clients was targeted by the Service Collaborative, a specific intervention has not yet been determined, nor have pilot sites in the Service Collaborative’s geographic range (City of Thunder Bay and the District of Thunder Bay that includes Nipigon, Greenstone, Marathon, Manitouwadge and Terrace Bay).

Exploration
Installation
Initial Implementation
Full Implementation

?What's this?

Exploration

Currently in the exploration stage, the service collaborative will be meeting with the Northwest PSSP team over the next few months to further discuss possible interventions to improve the transition from hospital to home/community, as well as to establish pilot sites and clarify participation.

Who is involved?

The District of Thunder Bay Service Collaborative includes representatives from primary care, community health services and education in mainstream, Aboriginal and Francophone agencies.

The wider stakeholder group includes representatives from the regional health care centres (hospitals, clinics, etc.), community-based organizations, poverty and housing advocacy groups, academics, law enforcement and justice. The group will become more targeted once the intervention and pilot sites are selected.

Next Steps

The Northwest PSSP team will continue monthly meetings with the Service Collaborative and engaging local stakeholders (hospitals/agencies), researching the service gap that has been selected, identifying possible interventions and pilot sites, and supporting the Service Collaborative to move forward in making improvements to client experiences when transitioning from hospital to home and community-based services.

For more information, please contact:

Renée Monsma, Regional Implementation Coordinator

Thunder Bay
(807) 626-9145 ext. 77207
Renee.Monsma@camh.ca

CAMH PSSP

Improving the Transition from Hospital to Home or Community-based Care

What is the system challenge?

What are we doing about it?

Exploration

Installation

Initial Implementation

Full Implementation

Who is involved?

Next Steps

For more information, please contact:

Renée Monsma, Regional Implementation Coordinator

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