Easing the transition from hospital to home

May 24, 2024

In health care, transitions are pivotal moments that can help or hamper a client’s recovery. One of the most crucial, especially for people who’ve been hospitalized for mental health concerns, is the transition from hospital to home. For those who also often face other social challenges – lack of housing, newcomer status, unstable income or employment – an abrupt hospital discharge may leave them unsure of what type of community supports are available or how to access them. 

Enter CMHA Toronto’s Hospitals to Homes (H2H), a program designed to ease the transition between the hospital and a well-supported return to home and community. The program's name says it all: H2H case managers provide rapid access to resources and service navigation for people being discharged from either of two Scarborough Health Network hospitals to community-based living.  

Amping up efficiency and effectiveness with rapid case management

At its core, H2H is a rapid case management program that works with clients before they exit the hospital and prepares them with service linkages and fast supports. It helps people get as well-equipped as possible before they go back home,” explains Courtney Detwiler-Moreira, Program Manager of CMHA Toronto’s Community Treatment Order and Hospitals to Homes programs 
When people are still in hospital, before they're discharged, that's the most effective time to meet them. A good chunk of what we're doing is crisis intervention and service navigation – making the necessary referrals so that longer-term support and solutions can step in. 
The program was recently restructured to make that rapid access even faster. Staff roles were redefined, new technology for case communication was introduced, and the program shifted its focus towards service navigation. Prior to the restructure, the wait time for case management services for people exiting a hospital stay for a mental health issue was three to six months. “That doesn't sound like a lot compared to other case management programs, some with waits up to two years, but when it's for a hospital-to-home pathway, it really doesn't make sense to have a waitlist,” says Courtney. “Discharges can be fast, so we’ve got to move equally as fast.” 

Stopping the cycle of frequent hospital readmission

Courtney explains that once someone leaves the hospital, they can fall through the cracks. “The reality is that follow-up is very unlikely if it's an unfamiliar face trying to reach out to you after you've been discharged,” she says. Often, she adds, clients are trying to put that part of their life behind them, making it even less likely that they will learn about or be able to take advantage of services that might help them.  

The result is that people are more likely to revisit the emergency department or be readmitted to the hospital.  

Erin Anstey, Program Manager, Adult & Youth Inpatient Mental Health & Crisis at SHN, explains that the rapid access model offers several benefits, both to the hospital and to patients: “The speed with which it all occurs now has certainly become a major benefit. H2H can see more people and they can take on a larger caseload based on that efficiency, which means that we're able to help more people where they belong – in their community.” 

On-site services mean help is an elevator ride away 

H2H can respond so quickly because it has a case manager available at each of SHN’s Birchmount and Centenary hospitals. “Usually within 48 hours a case manager is going to meet the client, create a service plan, and guide them to get supports in place. If clients need longer-term or more traditional support, we can point them in the right direction and know that those supports are going to step in for the long term,” Courtney says.

The H2H case manager attends rounds and is available to any department with a single call or notification on the hospital’s Epic electronic health record system. The H2H team also includes a case manager who is available for longer-term as well as language-specific (Tamil) support in certain cases.

“It's all done with a click of a button – [the referral] goes to the H2H case manager, and they can see the person basically within minutes or same day,” Erin says. 

Alleviating the burden on hospital social workers

One of the benefits of the CMHA Toronto and SHN partnership is that it alleviates the burden on the hospital’s in-house social workers, who simply haven’t the time to provide the crucial service navigation and community resource links.  

Erin explains that at SHN, “each emergency department shares a social worker – one social worker! – who covers multiple programs, with a day here and a day there in emergency. On our mental health unit, we do have social workers, but with 32 or 40 patients they don't have time to do any kind of true system navigation: connecting people, for example, with ODSP [the Ontario Disability Support Program], Ontario Works, help them get a health card, make sure that they find their way with some housing or group homes, and so on.”  

This is where H2H steps in. “A good piece of what we're doing is crisis intervention and then service navigation – linking people with supports, other agencies, and internal CMHA Toronto programs,” Courtney says.  

Community support networks offer a safety net

H2H staff have extensive knowledge of what’s available in the community and who to reach out to when needed. For certain clients, for example those who may be suicidal, CMHA Toronto’s partnership with The Access Point can help fast track those who need immediate or more intensive resources.  

Where longer-term supports are necessary, Courtney says that other case management teams sometimes step in. “The Community Treatment Order team, when we're at lower capacity, can provide up to three months of short-term case management and then navigate from there. And there’s RAP (the Rehabilitation Access Program) – they start with 12 weeks of support and can extend to a year if needed,” Courtney says. 

The H2H team typically calls on crisis response resources to safely manage wellness checks, however there are instances when in-person follow-up can be essential and appreciated. “Our services don't stop once the person is discharged from hospital. If the client is willing to engage, we can do that outreach by phone, virtual, and in person,” Courtney says. She shares an example of someone who had left the hospital but struggled with their mobility. “They couldn't go for groceries, so we were able to bridge that gap on a one-to-one basis by checking in on what it looks like at the home and help them get some groceries.” 

Optimizing outcomes

From psychoeducation, to connections to specialized services, to linking people with the proper resources to resolve practical matters, the H2H program fills a gap that might otherwise lead to poorer outcomes for people.  

Without H2H, Erin explains that one of two things would happen: “We’d see a higher readmission rate, not necessarily for the primary mental health diagnosis, but for things like social issues such as housing, finances, refugee status, just being able to find support in the community. Or, we’d see a longer stay in the unit – also not something you want for patients. We want that turnover [so people can reintegrate successfully] to their community.” 

Without H2H case management support, we wouldn't be able to discharge people the way we can right now knowing that they're going to have that wraparound support in the community.

“One of the biggest reasons that the program was implemented in the first place is to reduce rehospitalization,” Erin says. “The best place for people is not in the hospitals, it’s in the community. As a hospital, we want to ensure that any person that comes in is then supported back in the community.” 

Erin notes that when H2H and a Rapid Access Addiction Medicine (RAAM) clinic were put in place, “re-visit rates for substance use – that’s one type of type of mental health challenge – at the General Hospital were reduced by almost 80 percent, a staggering number.”   

Although not the only factor, Erin points out that H2H contributed to this result both directly and indirectly. H2H offered those with addictions issues a variety of community resources which helped directly, and it also helped indirectly by making referrals to the RAAM clinic, increasing the number of people the clinic saw and boosting its impact. 

Addressing the needs of those in greatest need

H2H is particularly important for people who have been hospitalized for long periods. “Once you're in the hospital for a long time, it's hard to go back home. For some folks home might be a supportive environment, but for a lot of folks it’s not. You might be going back to live alone, or you might have a difficult family situation,” Courtney says.  

She adds that the H2H team often sees people caught in a cycle of hospitalization and rehospitalization. “The system is essentially failing them. Something's not being addressed,” she says. “H2H works to close that gap and break that cycle,” Courtney says, adding that “the barrier to entry is very low. It's basically just a conversation. We’re really just trying to help catch those people that are falling under and set them back in place with more linkages and more hope.” 

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