Implementing the Transitional Discharge Model (TDM) ARTIC Project

The transition from hospital to community is complex and can be challenging for people who have been diagnosed with a mental illness. Recent research shows the first days and weeks following psychiatric discharge are particularly high-risk periods, with 43% of suicides occurring within the first month post-discharge.

In order to successfully move the focus of care to the community, effective care models of collaborative support are required. The TDM is one such model, and is based on the provision of therapeutic relationships to ensure a seamless safety net exists throughout the discharge and community reintegration processes. It consists of: 1) hospital staff continuing with the person being discharged until there is a therapeutic relationship with the community care provider, and 2) peer support from someone who has successfully integrated into the community after a psychiatric diagnosis.

The TDM supports the successful community integration of people with mental health challenges and thus decreases unnecessary in-patient and emergency room hospital visits for this population.

In a study involving four Ontario psychiatric facilities, length of stay was reduced by an average 116 days per client. This was equal to over $12 M worth of freed bedspace from the 200 intervention group participants in the study compared to the control group.  The study found that the TDM intervention group consumed on average $4,400 less hospital and emergency room services per person in the year after discharge.  Similarly, a 2004 study concluding that a usual care control group was more than twice as likely to be readmitted in the five months following discharge compared to the TDM intervention group.

Led by Dr. Cheryl Forchuk from the Lawson Health Research Institute, home of hospital-based research in London, Ontario, as a part of London Health Sciences Centre and St. Joseph’s Health Care London, 9 hospitals are participating in this program: Baycrest, Centre for Addiction and Mental Health, Hôpital Montfort, London Health Sciences Centre, Ontario Shores Centre for Mental Health Sciences, Providence Care, St. Joseph’s Healthcare Hamilton, St. Joseph’s Health Care London and Thunder Bay Regional Health Sciences Centre.

Final Report

Objective: This project supports the successful discharge of and bridge to the community for people diagnosed with a mental illness discharged from hospital. More specifically, it reduces lengths of stay and readmission rates, and improves the quality of patient care for people diagnosed with a mental illness.  The project facilitated partnerships and collaborations across nine hospitals and consumer survival initiatives.

Key Accomplishments

  • Reduced average length of stay by 9.8 days.
  • This amounts to a potential savings in hospital days of $31,360,000 if TDM were to remain on participating wards.
  • Reduced readmission rates.
  • Better integration of care between hospital and community:
    • increased communication and collaboration among hospital staff, community staff and peer supporters;.
    • integration of peer support into hospital and follow-up care; and
    • increased staff and client comfort and sense of security with discharge process due to provision of support.