Update to phone lines at our Birchmount and General Hospitals: If calling through Birchmount main line (416-495-2400), add “7” when dialing an extension. If calling through General main line (416-438-2911), add “8” when dialing an extension.

Integrated Care Pathway for People Diagnosed with Schizophrenia

The Integrated Care Pathway for People Diagnosed with Schizophrenia is a collaborative effort between Scarborough Health Network (SHN), Ontario Shores Centre for Mental Health Sciences (Ontario Shores), Canadian Mental Health Association (CMHA) Toronto, and Canadian Mental Health Association (CMHA) Durham. This pathway follows best practices and standards to ensure individuals receive the highest level of care throughout their recovery journey.

Our aim is to provide integrated and comprehensive care to individuals diagnosed with schizophrenia, promoting their well-being and facilitating their successful reintegration into the community. Our vision is to establish a seamless and supportive care pathway that enhances the quality of life for all participants. For any inquiries about the pathway or the available services, or if you are interested in partnering with us, please contact the integrated care coordinators at 905-430-4055 or integratedcarec@ontarioshores.ca.

Step 1: Comprehensive Assessment

After admission, our dedicated patient care team engages in a conversation with the patient, gathering information about their condition and determining the level of support required. This assessment allows us to identify the most suitable services tailored to the individual’s unique needs.

Step 2: Discuss Initial Treatment Options

Patients on this pathway receive the best possible medications to support their treatment. Our clinicians may recommend the use of long-acting medication or Clozapine, depending on the patient’s response to previous treatments. These medications have demonstrated effectiveness in helping individuals with schizophrenia. Each treatment option will be thoroughly discussed.

Step 3: Complete a Reassessment

Approximately two weeks after admission, the patient consults with our care team to determine if their symptoms are improving and to make any necessary adjustments to the treatment plan.

Step 4: Additional Treatment Options and Transfer

If the patient responds positively to treatment at SHN, we will facilitate their transfer to outpatient community services at SHN, CMHA Toronto or CMHA Durham. Ontario Shores may provide specialized inpatient care when needed. Our care coordinators will guide the patient through this process and discuss available options.

Step 5: Monitor Progress

Ongoing communication with the patient’s care team is crucial. We continually monitor progress, allowing adjustments to medications and other support as needed. Our goal is to find the most effective treatment for each patient.

Step 6: Transition Planning

Once the patient is coming to the end of their stay at Ontario Shores or SHN, they will meet with their care coordinator to discuss the next steps in their recovery goals. This may mean being referred into Ontario Shores or SHN outpatient services, or community services at CMHA Toronto or Durham.

Step 7: Exiting the Pathway

When the patient is connected to the appropriate community services and making progress toward recovery, a meeting with the patient’s care coordinator will be scheduled to discuss exiting the care pathway. This decision will be made collaboratively with the patient and their support person(s).

Ontario Shores:

  • Psychosis Clinic: Flexible services tailored to individual needs, including assessments, consultations, behavioral support, and Cognitive Behavioral Therapy (CBT).
  • Assertive Community Treatment Team (ACTT): Community-based treatment and support, including medication management, intensive case management, and individual therapy.
  • Outpatient Complex General Psychiatry: Flexible and tailored services offering psychotherapy, medication support, and symptom management.
  • Transition Team: Support for successful community reintegration after inpatient care.

Scarborough Health Network:

  • Outpatient Mental Health Services: Access to psychiatrists, medication clinics, intensive case management, and online psychotherapy.
  • Day Treatment Programs: Support and education for managing mental health concerns after inpatient care.
  • Pathways Program: Community-based social and recreational support, including group classes, work activities, leisure activities, and medication clinics.

CMHA Toronto and CMHA Durham:

  • Case Management: provides support for people experiencing serious mental health conditions to live and work in the community.
  • Housing – offers safe and affordable housing options for people experiencing mental health challenges. This includes both short-term and long-term housing options, with different levels of support.
  • Assertive Community Treatment Team (ACTT) – a multi-disciplinary team that helps patients with their recovery by providing treatment, rehabilitation and support services.

Who is eligible?

Adults with schizophrenia or schizoaffective disorder enrolled in the Assessment and Reintegration Program (ARP) or Integrated Community Access Program (ICAP) at Ontario Shores or SHN. Also, individuals admitted to and/or discharged from settings where partnerships have been established and inclusion criteria have been met.

What is Ontario Shores Centre for Mental Health Sciences (Ontario Shores) and what services do they offer in the hospital?

Ontario Shores is a tertiary mental health hospital specializing in providing care in a short amount of time. It offers both inpatient and outpatient services. The Assessment and Reintegration Program at Ontario Shores is provided by an interprofessional team of assessment and treatment specialists. This team collaborates with patients and families to develop a care plan with the goal of reintegrating the patient into the community.

What is Scarborough Health Network (SHN) and what services do they offer in the hospital?

SHN is a network of three hospitals and community clinics that provide a range of services to the Scarborough community. Inpatient mental health services are available for patients living with mental illness who require hospitalization. An interprofessional team offers assessment and treatment while focusing on collaboration and patient/family-centered care.

What is the Canadian Mental Health Association and how are they involved in the pathway?

The Canadian Mental Health Association (CMHA) provides community mental health services through its 135 branches. CMHA Durham and CMHA Toronto, two local branches, are involved in the integrated care pathway with Ontario Shores and SHN. This collaboration ensures close cooperation in identifying the best treatment(s), programming, and support for individuals living with schizophrenia in the community.

Can a patient decide not to participate in this pathway?

Yes. A member of the patient’s care team will discuss the pathway with the patient, and they have the option to decline participation. The pathway aims to provide superior care to people living with schizophrenia compared to standard treatment. By participating, the patient will receive seamless, integrated care regardless of where it is received. To address any concerns about the sharing of personal health information, please contact the patient’s care team.

How long does the integrated care pathway typically last?

The duration of the pathway can vary depending on individual needs and progress. It is designed to provide comprehensive care throughout the recovery journey. The care team will work closely with the patient to determine the appropriate length of time for their involvement in the pathway.

Are family members or support persons involved in the care pathway?

Yes, family members or support persons are encouraged to be involved in the care pathway. Their participation and support play a vital role in the patient’s recovery. The care team values collaboration with family members and supports their inclusion in decision-making and planning.

Will the integrated care pathway address other mental health needs or comorbid conditions?

Yes, the integrated care pathway acknowledges that individuals diagnosed with schizophrenia may have other mental health needs or comorbid conditions. The care team takes a holistic approach and works to address all relevant mental health concerns to provide comprehensive care.

What happens after exiting the integrated care pathway?

After exiting the care pathway, patients will be connected with appropriate community services and resources to support their ongoing recovery. The patient’s care coordinator will assist in making these connections and ensure a smooth transition to continued care and support.

Can individuals who have previously received treatment for schizophrenia join the integrated care pathway?

Yes, individuals who have previously received treatment for schizophrenia can join the integrated care pathway. The pathway is designed to support individuals at any stage of their recovery journey, whether they are newly diagnosed or have received treatment in the past.

Bundled care is a service delivery and funding model designed to promote greater integration in healthcare delivery, drive high-quality and efficient care, and improve patient outcomes and experiences. It is particularly relevant today as Ontario advances its mental health and addictions strategy, known as the “Roadmap to Wellness.” The Roadmap to Wellness includes a shift towards integrated care models for mental health, aligning with the goal of optimal patient outcomes.

We hope this improved version provides a clearer and more comprehensive understanding of the integrated care pathway for individuals diagnosed with schizophrenia and the services offered by the partnering organizations.

Should you have any further questions or need additional information, please feel free to contact the integrated care coordinators at 905.430.4055 or integratedcarec@ontarioshores.ca.