What is the system challenge?

People with mental health and addiction challenges can ‘fall through the cracks’ when transitioning from inpatient hospital care to home or community-based care. Clinical symptoms can worsen if proper care is not given to social support and connection with known caregivers and peers. 

Evidence shows an increase in hospital re-admission rates, and associated costs to the health system. The first days and weeks following psychiatric discharge are particularly high-risk periods for relapse as many clients are between care providers, and are vulnerable to emergency room visits and readmission to hospital. As many as 43 per cent of suicides occur within the first month post-discharge.(Forchuk et al.)

The District of Thunder Bay Service Collaborative, covering the City of Thunder Bay, the District of Thunder Bay (including Nipigon, Greenstone, Marathon, Manitouwadge and Terrace Bay) identified and selected this transition as a system gap that requires attention. System fragmentation, poor communication, and consent to share client information are significant barriers to efficient and effective patient discharge planning. The Service Collaborative identified several issues, specifically the need for: 

  • improvements to formal discharge plans, including communication and care pathways;
  • recognition of the potential challenges for people transitioning from a remote community to an urban centre;
  • consideration of transportation time and costs;
  • improvements to engagement in aftercare when a client leaves treatment;
  • improvements to central intake;
  • acknowledgement that the system can be difficult to navigate and supports are needed; and consideration of privacy legislation.

What are we doing about it?

Currently in the Installation phase, the Service Collaborative has selected Critical Time Intervention (CTI) as the most appropriate model to apply in a number of initial implementing sites throughout the District. CTI is an evidence-based intervention that supports people during critical transitions, when they are often most vulnerable, such as when transitioning from hospital (or other institutions) back into their homes and communities. 

This limited, nine-month intervention has shown to significantly improve health outcomes for people by easing community integration and improving the client's continuity of care. It ensures that a person remains connected to their community and support systems during this critical transition period.

Learn more about CTI here.

?What's this?


Currently in the installation phase, the Service Collaborative is working closely with the initial implementing sites to ensure that CTI is implemented in a way that meets the needs of the community and clients, while also working to support sustainability and fidelity to the model.

Who is involved?

A health equity lens is being applied at all stages of the CTI 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:

  • Dilico Anishinabek Family Care (providing mental health services to 13 First Nation communities)
  • Marathon Family Health Team
  • North Shore Family Health Team (Terrace Bay, Schreiber)
  • North of Superior Programs (Geraldton, Longlac)
  • Greenstone Family Health Team (Geraldton, Longlac)
  • Thunder Bay Regional Health Science Centre 

Next Steps

Up to 60 mental health service providers will receive CTI training in May, 2018. To support sustainability of the intervention, initial training will be followed by a smaller train-the-trainer session in September, 2018.

A Service Collaborative Implementation Team (SCIT) has been formed, and will be working to develop an outreach and evaluation plan that includes key informant interviews, compiling baseline data on hospital discharges to the communities, and practice profiles for each initial implementing site. The SCIT will also be preparing a communication plan and creating working groups to focus on health equity and engagement, and also evaluation.

For more information, please contact:

Renée Monsma, Regional Implementation Coordinator