"Safety net" between hospital and community benefits mental health patients

group photo

Pictured above: Dr. David Hill, Scientific Director, Lawson; Dr. Cheryl Forchuk, Lawson scientist and TDM lead; Deborrah Sherman, Executive Director, Ontario Peer Development Initiative; Dr. Gillian Kernaghan, President & CEO, St. Joseph’s Health Care London; Karen Michell, Executive Director, Council of Academic Hospitals of Ontario, Murray Glendining, President & CEO, London Health Sciences Centre, pose at the results announcement of the Transitional Discharge Model.

Lawson Health Research Institute (Lawson) recently announced the province-wide impact of an innovative model for discharging mental health clients from hospitals: the Transitional Discharge Model (TDM). Led by Lawson’s Dr. Cheryl Forchuk, and funded by the Council of Academic Hospitals of Ontario’s (CAHO) Adopting Research to Improve Care (ARTIC) Program, the TDM bridges hospital and community for benefits to both individuals and the health system. St. Joseph’s Health Care London (St. Joseph’s) was part of the province-wide research project.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.

The TDM is designed to provide seamless support as clients make this transition. Essentially the TDM creates a safety net, ensuring hospital inpatient staff continue to provide care until the client is connected with a community care provider. It also partners discharged clients with a peer who has successfully integrated into the community after a psychiatric diagnosis.

After successful prior studies established the TDM as a best practice, the model was deployed in nine hospitals across Ontario in April 2013. Over 580 clients participated in two year implementation project.

Results of the project show benefits to all parties – clients, inpatient staff, community peer supporters – as well as the health system itself:

  • Clients’ length of stay in hospital was reduced by an average of 9.8 days.
  • Staff reported fewer client readmissions.
  • Clients reported feeling less overwhelmed and lonely, and more reassured, during the transition. Many referred to the TDM as a “safety net.”
  • Clients built more personalized care relationships with inpatient staff and peer supporters, tailored to the type, degree, and frequency of care each individual needed.
  • Inpatient staff and community peer support groups reported an improved understanding and appreciation of each other’s services, resulting in stronger working relationships and more opportunities to leverage resources to respond to the needs of local client populations.
  • Inpatient staff and peer supporters experienced more fulsome outcomes of their work, boosting their sense of pride and purpose.
  • Many peer supporters reported their experience in the TDM actually further enhanced their own personal recoveries.


“We have consistently found improved outcomes with the Transitional Discharge Model, and have learned more about strategies for implementation in this project,” says Dr. Forchuk, a Scientist and Assistant Director at Lawson. “I would like to see this approach become the standard of care across the province.”

“Projects like the Transitional Discharge Model are crucial to ensuring Ontarians have access to mental health services when and where they need them most,” says Dr. Eric Hoskins, Minister of Health and Long-Term Care for the Province of Ontario. “Increasing quality of service and supporting the role of peer support groups are key components of Ontario’s Comprehensive Mental Health and Addictions Strategy. I commend Dr. Forchuk and her team for their innovative approach to supporting Ontarians through this vulnerable transition from hospital to community.  Through the Adopting Research to Improve Care (ARTIC) Program, I am pleased that my Ministry is able to help implement research evidence to improve care for patients.”

The Honourable Deb Matthews, Deputy Premier for the Province of Ontario and MPP London North Centre said, “During times of transition, it is crucial to provide ample support to those who are most vulnerable and ensure they don’t fall through the cracks. When you leave no one behind, you arrive at a new destination stronger than ever.”  She added, “I am proud of London’s Lawson Health Research Institute’s TDM Project leadership and collaboration with nine hospitals across Ontario.  Implementing research evidence at scale across the system is critical to our government’s plan for health care and raising value.” 

St. Joseph’s participated along with either other hospitals in Ontario: Baycrest (Toronto), Centre for Addiction and Mental Health (Toronto), Hôpital Montfort (Ottawa), London Health Sciences Centre (London), Ontario Shores Centre for Mental Health Sciences  (Whitby), Providence Care (Kingston), St. Joseph’s Healthcare Hamilton (Hamilton), and Thunder Bay Regional Health Sciences Centre (Thunder Bay).

The following Consumer/Survivor Initiatives/Peer Support Programs participated in the province-wide project: Centre for Addiction and Mental Health Internal Peer Support (Toronto), Psychiatric Survivors of Ottawa, CONNECT for Mental Health Inc. (London), Mental Health Support Network South East Ontario (Kingston), Krasman Centre (Richmond Hill), Patient and Family Collaborative Support Services, St. Joseph’s Healthcare Hamilton (Hamilton), Can-Voice (London), People Advocating for Change through Empowerment (Thunder Bay), CMHA Durham (Whitby).

The project was funded by a $1.4 million grant through the Council of Academic Hospitals of Ontario (CAHO) ARTIC Program, funded in part by the Ontario Ministry of Health and Long-Term Care. The goal of the program is to support the successful and rapid adoption of evidence into the practice of health care. It supports projects like the TDM.  The TDM improves coordination and continuity of health care for patients/clients in transition, to reduce hospital stays and readmission rates, while improving quality of care.

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