What is the system challenge?

When transitioning from inpatient hospital care to home or community-based care, people with mental health and addiction challenges can ‘fall through the cracks’. The first days and weeks following psychiatric discharge are particularly fraught periods. People can relapse. They’re also more vulnerable to suicide (Chung et al., 2017). Proper follow-up care (Kalseth et al, 2016) and social support (Donisi et al., 2016) within their community, however, can reduce this risk as people transition from hospital to community care.

Evidence from Ontario shows that timely transitions from hospital to community care are associated with lower hospital readmission rates and lower costs to the health system (Rahman et al., 2018).

What are we doing about it?

Service Collaboratives were established throughout Ontario to support local systems to improve coordination and access to mental health and addictions services. The District of Thunder Bay Service Collaborative, supported by CAMH’s Provincial System Support Program (PSSP), came together and identified the transition from inpatient mental health services to community care as a system gap requiring attention. The District of Thunder Bay Service Collaborative is made up of local service providers covering the City of Thunder Bay and the District of Thunder Bay (including Nipigon, Greenstone, Marathon, Manitouwadge and Terrace Bay).

To learn more about this gap, a team from PSSP’s Thunder Bay office led engagement sessions with stakeholders from 19 communities across the district and with persons with lived experience. The three major barriers to effective transition planning were system fragmentation, ineffective communication, and the absence of a standard consent process to share client information within the circle of care. The Service Collaborative identified several opportunities for system improvement, including:

  • The development of a specific hospital to community discharge protocol;
  • Formal communication and care pathways;
  • A process to obtain consent for sharing client information within the circle of care; and
  • Maintaining connection with client throughout follow up care.

To promote patient-centred care, the Service Collaborative recommended that solutions consider:

  • Potential challenges for people transitioning from an urban hospital back to a district community;
  • Support needed for clients to navigate the system; and
  • Privacy legislation.

The Service Collaborative elected to develop an evidence-informed Hospital Discharge Planning Protocol to ensure more consistent communication between the Thunder Bay Regional Health Sciences Centre (TBRHSC) and the clients’ home communities.

The TBRHSC and three family health teams are in the initial phase of implementing the Discharge Planning Protocol in district communities. This new process is intended to support people when they are often most vulnerable, such as during the transition from in-patient adult mental health hospital treatment back into their homes and communities.

Who is involved?

PSSP’s Thunder Bay team will apply a health equity lens at all stages of the implementation process. This includes the voices of Indigenous and Francophone communities, as well as people with lived experience of mental health challenges. Participating organizations include:

  • Greenstone Family Health Team (Geraldton, Longlac)
  • Marathon Family Health Team
  • North Shore Family Health Team (Terrace Bay, Schreiber)
  • North of Superior Programs (Geraldton, Longlac)
  • Thunder Bay Regional Health Science Centre
?What's this?

Initial Implementation

The TBRHSC and three family health teams have started using the Hospital to Community Discharge Planning Process. Using fidelity checklists and regular coaching calls, the Thunder Bay PSSP team will monitor the implementation process and perceived effectiveness of the protocol, making changes as needed.

Next Steps

The Service Collaborative Intervention Team will continue to pilot the discharge protocol with the hospital inpatient mental health unit and with the three district family health teams. Monthly coaching calls will allow the team to speak to the successes and challenges that they experience. The team will complete fidelity checklists for evaluation purposes and for the purpose of keeping track of how the protocol performs in action. With the support of a Health Equity Coach, the team will conduct a Health Equity Impact Assessment of the discharge process. Evaluation findings will be reviewed regularly and discussed, and protocol changes will be made as necessary.

For more information, please contact:

Megan Tiernan, Implementation Specialist (Interim)

Thunder Bay

(807) 626-9145 ext. 77211



Chung, D.T., Ryan C.J., Hadzi-Pavlovic, D., Singh, S.P., Stanton, C., Large, M.M. (2017). Suicide rates after discharge from psychiatric facilities: A systematic review and meta-analysis. Journal of the American Medical Association Psychiatry, 74(7):694-702

Donisi, V., Tedeschi, F., Wahlbeck, K., Haaramo, P., Amaddeo, F. (2016). Pre-discharge factors predicting readmissions of psychiatric patients: A systematic review of the literature. BMC Psychiatry, 16:449

Kalseth, J., Lassemo, E., Wahlbeck, K., Haaramo, P., Magnussen, J. (2016). Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature. BMC Psychiatry, 16:376

Rahman, F., Guan, J., Glazier, R.H., Brown, A., Bierman, A.S., Croxford, R., Stukel, T.A. (2018). Association between quality domains and health care spending across physician networks. PLoS ONE, 13(4): e0195222.

Storm, M., Lunde Husebø, A.M., Thomas, E.C., Elwyn, G., Zisman-Ilani, Y. (2019). Coordinating mental health services for people with serious mental illness: A scoping review of transitions from psychiatric hospital to community. Administration and Policy in Mental Health and Mental Health Services Research, 46:352-367