“Safety Net” between hospital and community

A model that benefits mental health clients, care providers, and the health system across Ontario

Ottawa, January 20, 2015 The transition from hospital to community is complex for most patients, and can be especially challenging for people who have been diagnosed with a mental illness.

In order to facilitate this transition, province-wide model for discharging mental health clients from hospitals is underway in nine hospitals across Ontario: the Transitional Discharge Model (TDM).

In the Ottawa area, Hôpital Montfort tested the results for this innovative approach, for which the results have been released last week.

tdm.jpgLed by Dr. Cheryl Forchuk, a scientist at Lawson Health Research Institute in London, ON, and funded by the Council of Academic Hospitals of Ontario’s (CAHO) Adopting Research to Improve Care (ARTIC) Program, the Transitional Discharge Model bridges hospital and community for benefits to both individuals and the health system.

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 percent of suicides occur within the first month post-discharge.

The Transitional Discharge Model 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 at Hôpital Montfort and eight other sites across Ontario in April 2013. Over 580 clients participated in the two year implementation project.

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

  • Staff reported fewer client readmissions. In fact, after the implementation of TDM, there were two fewer readmissions per month at Hôpital Montfort.
  • Clients’ length of stay in hospital was reduced by an average of 9.8 days across all sites.
  • 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.”

“So far, Hôpital Montfort has recruited 107 people for the project,” explained Ann Salvador, Director of the Mental Health Program and Family Birthing Unit at Hôpital Montfort. “Some participants and families informed us that, thanks to the Transitional Discharge Model, they do not feel alone during their transition from the hospital to the community. This initiative has allowed us to greatly improve the patient’s continuity of care from hospital to community services and has contributed to the quality of care and patient safety.”

“Psychiatric Survivors of Ottawa is pleased to have been in this partnership with Hôpital Montfort,” said Sonja Cronkhite, Executive Director of Psychiatric Survivors of Ottawa. “We believe that relationships are key to helping us get back to our lives and we have seen how the TDM model has shown people that there is a thriving community of peers where support can be ongoing.”

“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.”

Nine hospitals participated in the province-wide project: Hôpital Montfort (Ottawa), Baycrest (Toronto), Centre for Addiction and Mental Health (Toronto), London Health Sciences Centre (London), Ontario Shores Centre for Mental Health Sciences (Whitby), Providence Care (Kingston), St. Joseph’s Healthcare Hamilton (Hamilton), St. Joseph’s Health Care London (London) and Thunder Bay Regional Health Sciences Centre (Thunder Bay).

The following Consumer/Survivor Initiatives/Peer Support Programs participated in the province-wide project: Psychiatric Survivors of Ottawa, 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.

Hôpital Montfort is a Francophone university health institution that offers quality care in both official languages and works with its partners to improve the health of communities. In 2014, Hôpital Montfort obtained its accreditation with exemplary standing from Accreditation Canada. It also earned recognition from the Registered Nurses' Association of Ontario (RNAO) as a Best Practice Spotlight Organization. In June 2013 the hospital was designated as a Group A teaching hospital.

For more information, please contact:  

Communications Department
Hôpital Montfort
613-746-4621, ext. 2049