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CAMH Stories Centre for Addiction
and Mental Health

Bridging Clients Back Into the Community

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.”

Transitional Discharge model team(L to R) RN Randi Ford, Social Worker Jamea Corney and EPU Manager Diane Kirsopp

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 the community.

Research conducted in Ontario and Scotland has shown that the TDM results in shorter lengths of stay and reduced readmission rates.

“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.

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