A “safety net of relationships” to bridge the gap between hospital and community at discharge


LONDON, ON – A beneficial and cost-effective approach to mental health care that supports people as they go from hospital and back into the community is outlined in a new resource and has been recognized internationally by the World Health Organization (WHO). 

“The immediate period after discharge from hospital, usually the first month, can be one of the most vulnerable times in the life of someone experiencing a mental illness. It can be when they are most at risk of committing suicide,” explains Dr. Cheryl Forchuk, Assistant Scientific Director at Lawson Health Research Institute. “However, what we’ve seen is that there’s often a gap between when someone says ‘goodbye’ to the hospital inpatient unit and ‘hello’ to the community care provider.” 

Today during a virtual book launch, a research team from Lawson and several community organizations discussed details of a new publication from Routledge, From Therapeutic Relationships to Transitional Care: A Theoretical and Practical Roadmap, edited by Dr. Forchuk. The book combines theory, research and best practices into a “roadmap” for organizations and others worldwide coordinating services or studying mental health care systems. It includes a practical toolkit for implementing the Transitional Discharge Model (TDM), developed and tested in communities across Ontario.  

TDM was born from a participatory action project with consumers of mental health services. They identified two factors that were most important to them when they were going from hospital to the community: consistency in therapeutic relationships and a supportive peer friendship. They described it as a “safety net of relationships” that would bridge the gap between hospital and community services.  

“As a person-centred, evidence-based model, transitional discharge supports a smooth adjustment from hospital to community,” says Dr. Forchuk. “The inpatient staff continue to care for discharged clients until therapeutic relationships are established with community care providers. At the same time, we have a friendship model of peer support. These are trained people with lived experience of mental illness who have made the same journey.” 

Lance Dingman was a TDM client during the early phases of the project. “It makes a big difference when you’re able to get back to living in the community and in your own dwelling. You get to make more of your own decisions and learn about what you want to do. You grow with your experience and the guidance of others who are there to support you.”  

Later becoming a peer support coach, Dingman feels implementing TDM for mental health care is important because people can learn from each other and get healthier in the process. “As a peer support worker, I sit with people and they tell me their story. It takes me back and I know what they are going through – I was where they are. I can share my own story and tell them what I did to get better.”  

Dr. Forchuk’s team analyzed the cost of TDM after being tested in nine hospitals across Ontario, including London Health Sciences Centre and St. Joseph’s Health Care London. On average, the length of stay in hospital was reduced by almost 10 (9.8) days per admission and each site saved approximately $3.3 million per year. “People can return home sooner because a higher level of care and support is in place when they leave hospital. If all hospitals in Ontario with mental health services were able to implement our transitional discharge model, we would save $60 million per year in hospital stay costs alone while providing enhanced mental health care.”  

The TDM approach is now considered a “good practice” by WHO and was recently the only Canadian example included in its Guidance on community mental health services: Promoting person-centered and rights-based approaches. This set of publications provides information and support to all stakeholders who wish to develop or transform their mental health system and services to align with international human rights standards including the UN Convention on the Rights of Persons with Disabilities.  


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About Lawson Health Research Institute

Lawson Health Research Institute is one of Canada’s top hospital-based research institutes, tackling the most pressing challenges in health care. As the research institute of London Health Sciences Centre and St. Joseph’s Health Care London, our innovation happens where care is delivered. Lawson research teams are at the leading-edge of science with the goal of improving health and the delivery of care for patients. Working in partnership with Western University, our researchers are encouraged to pursue their curiosity, collaborate often and share their discoveries widely. Research conducted through Lawson makes a difference in the lives of patients, families and communities around the world. To learn more, visit www.lawsonresearch.ca.

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Celine Zadorsky

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Lawson Health Research Institute
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