Transitioning from the hospital to the community can be stressful and
challenging for people who have been diagnosed with a mental illness. During
the first few days after discharge, when clients are between care providers,
the risk of relapse is high.
CAMH has launched an implementation project on the Transitional Discharge
Model (TDM). This model provides seamless support for clients making the
transition from the hospital to the community. What is unique about this model
is that through phone calls and community visits, on-going support is provided
by clinicians and peer support workers from the client’s in-patient unit. This
support role is called ‘bridging’.
Two units in the Complex Mental Illness Program - the Early Psychosis Unit
(EPU) and the Mood and Anxiety Unit (MAUI) are enrolled in the study.
Diane Kirsopp, EPU Manager, says “the benefits of bridging are explained to
clients by staff on her team as part of the discharge planning process. Those
who wish to take part in bridging are provided with on-going support in the
community from a clinician and a peer support worker.”
(L to R) RN Randi Ford, Social Worker Jamea Corney and EPU Manager Diane
Support continues until the client is connected with a community care
provider. The therapeutic relationship that has been established between
clients and staff during the hospital stay is maintained during transition into
the community. The peer support worker provides recovery focused coaching
and mentoring and helps the client connect to consumer survivor initiatives in
Research conducted in Ontario and Scotland has
shown that the TDM results in shorter lengths of stay and reduced readmission
“Implementing the TDM in psychiatric hospitals involves providing clients
with enhanced staff support and peer support as they are discharged. The
Complex Mental Illness Program is pleased to be a taking part in this important
project,” says Tania Saccoccio, Deputy Administrative Director CMIP.
The TDM project is part of the Adopting Research to Improve Care (ARTIC)
Program, launched through the Council of Academic Hospitals of Ontario. Seven other
hospitals in Ontario
are also participating in the study. Data from these hospitals will be tracked
to assess the impact of bridging on re-admissions rates and length of stays for
those clients who took part in the project.