Integrating Care for People with Schizophrenia: Hospitals and Community working together

May 5, 2023

An integrated care pathway for people diagnosed with schizophrenia has been developed through a partnership between Ontario Shores Centre for Mental Health Sciences (Ontario Shores), Scarborough Health Network (SHN), Canadian Mental Health Association (CMHA) Toronto, and Canadian Mental Health Association (CMHA) Durham. This integrated care pathway follows best practices and standards to ensure that individuals participating receive the highest level of care regardless of where they are in their recovery journey. 

The initiative started in the fall of 2022 to formally establish an integrated care pathway between these organizations, ensuring that participants receive a continuum of care that advances their long-term recovery based on evidence and measurement-based care. Since the initiative launched, more than 50 individuals have been assisted by the pathway. 

Individuals eligible for the pathway are identified by SHN staff in the mental health inpatient unit, after which they and their families can consult with a care coordinator who bridges the care between Ontario Shores and SHN. Patients whose psychosis symptoms have not adequately improved after two weeks will be transferred to Ontario Shores' Assessment and Reintegration Program (ARP). Wherever the individual receives treatment in this transition, they will still be cared for by "one team,” following the same best-practice treatment plan. 

Once an individual is ready to return to the community, they can be supported on the pathway by providers at any of the four organizations who are part of this partnership.    

This will ultimately result in a more seamless transition from the hospital to the community programs and ensure individuals are provided with the right care at the right time in the right setting without delays. 

This integrated pathway and collaboration will positively impact access, outcomes, and the ability to navigate one's way through the mental health care system. 

About CMHA Toronto 

CMHA Toronto, a branch of the Canadian Mental Health Association, is the city’s leading community mental health agency. We provide accessible, quality care for people in Toronto through programs, research and advocacy. From supporting individuals experiencing a mental health crisis to providing tools that support day-to-day mental health, when people need support in Toronto, we’re here to help create belonging and hope. Learn more at 

About CMHA Durham 

Canadian Mental Health Association Durham is an integrated community mental health and primary care hub that has been providing mental health services to Durham Region for over 60 years. Our Mental Health and Primary Care Hub promotes and enhances the mental, emotional, and physical well-being of our community. We do this through education, collaboration, advocacy, and the provision of a broad range of direct services that meet our community’s needs. Learn more at 

About Ontario Shores Centre for Mental Health Sciences 

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is a public teaching hospital providing a range of specialized assessment and treatment services to those living with complex and serious mental illness. Exemplary patient care is delivered through safe and evidence-based approaches where successful outcomes are achieved using best clinical practices and the latest advances in research.  Patients benefit from a recovery-oriented environment of care built on compassion, inspiration and hope. For more information, visit: 

About Scarborough Health Network  

Across our three hospitals and several community-based satellite sites, Scarborough Health Network (SHN) is shaping the future of care. Our innovative programs and services are designed for the specific needs of the Scarborough community, and our medical expertise and compassionate care are accessed from well beyond our borders. We operate Ontario’s largest regional nephrology program and regional community-based cardiovascular rehabilitation service; the designated cardiac centre for the Central East region of Ontario; and an internationally designated cardio-oncology clinic centre of excellence. As a community-affiliated teaching site for the University of Toronto; member of the Toronto Academic Health Science Network; and partner with other universities and colleges, we are committed to helping to train the next generation of healthcare professionals. Learn more at 

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