Helping people thrive in the community following discharge from psychiatric hospitals

After a week of in-patient treatment for depression, Joan was stable and doing well. However, she was back in hospital again less than a month later.

When a patient is readmitted to hospital within a few weeks of being discharged, it’s an indicator that his or her care may not have gone according to plan. In 2009/10, more than one in 10 patients discharged from psychiatric units in Ontario hospitals were re-hospitalized within 30 days. Women’s College Hospital has proposed a program that will address the transitional needs of patients after discharge from a psychiatric in-patient hospital unit: the Psychiatric Structured Treatment Extension Plan (Psych STEP).

The program is modelled in part on the success of Women’s College’s Virtual Ward, a partnership designed to keep medically high-risk patients out of hospital by providing them with the best features of hospital care – such as fast access to an interdisciplinary team through a single point of contact – after they are discharged. “Program elements will mirror the Virtual Ward, but will be tailored to the needs of individuals with mental health problems,” says Dr. Valerie Taylor, chief of psychiatry at Women’s College Hospital.

Like the Virtual Ward, Psych STEP would identify patients at high risk for early rehospitalization. These patients would receive community-based intervention to help ensure successful transition to outpatient treatment that targets important modifiable risk factors for re-hospitalization, such as lack of followup care and difficulties with medication management.

“They’re getting specialized care with multi-disciplinary services to ensure a successful discharge,” says Women’s College Hospital psychiatrist Dr. Simone Vigod. Recent research found that up to half of Ontario patients discharged from hospital with a diagnosis of schizophrenia, bipolar disorder or major depressive disorder received no followup care within 30 days.

“The STEP model is a way to deliver that followup care, ensure patients do not fall through the cracks, and support primary care practitioners in caring for these patients over the long-term,” says Dr. Vigod. “It is a unique intervention to fill a gap in the system.”

As a model of ambulatory care, Psych STEP has immense potential to offer mental health solutions and reduce re-hospitalizations in other parts of the city and the province. “What we want to do is export this program so that other hospitals can create something similar,” Dr. Taylor says. “We want to teach other hospitals how to provide this model of care.”

The project has already won the support of many community partners, including Mount Sinai Hospital, Community Care Access Centres, Toronto Central Local Health Integration Network (LHIN), and the Centre for Addiction and Mental Health (CAMH), which will refer appropriate patients upon discharge.