In a fragmented health care system, four groups have come together to reduce inefficiencies, prevent people from falling through the gaps, and align practitioners around a best-practice approach to care for people diagnosed with schizophrenia, their families, and their care teams.
Launched in fall 2022, the Integrated Care Pathway for People Diagnosed with Schizophrenia pilot project is a collaboration between Scarborough Health Network (SHN), Ontario Shores Centre for Mental Health Sciences, and the Durham and Toronto branches of the Canadian Mental Health Association.
“The driving factor was to improve the experience of people who access services across the continuum of care,” says Bethany Holeschek, an occupational therapist on the professional practice team at Ontario Shores. “We know that people don’t just come to Ontario Shores or to one of the CMHAs or to Scarborough Health Network. They often will access all of us at some point along their journey. The challenge right now is we are all siloed, we’re all separate entities,” Bethany adds.
As Tracey Hardinge, Senior Director of Clinical Operations at CMHA Durham, says, “one of the things that we looked at is what we can do better to support people as they navigate through the different levels of hospital care and then into the community. Ultimately, we don’t want people in the hospital. We want them in the community. It’s been really exciting watching the two levels of hospitals and community come together to create this pathway to support people.”
Coordinating Care Along A Continuum
While the teams at Scarborough Health Network, Ontario Shores and the Toronto and Durham CMHA branches regularly referred people to each other, there was no seamless transfer that took advantage of a single intake assessment. As a result, clients were forced to “start over each time. They’re being asked the same 20 questions over and over. So there’s a lot of extra effort, misdirected time, and that affects the person’s spirit,” says Bethany.
“One of the things that was really important was having people not have to retell their story, because it’s so evident the trauma that it brings each time,” adds Tracey.
The onerous and often retraumatizing process hampers access to “the right care at the right time” and can discourage clients from seeking care at all.
Dr. Ilan Fischler, Chief of Psychiatry and Medical Director of the Mental Health & Addiction Program at SHN, explains that “individuals with schizophrenia are often placed on waitlists for the services and treatments that we know will help them recover or keep them well in the community. People may relapse while they are waiting. One the key wins for the pathway is that individuals can be seamlessly connected to the services they need when they need them.”
A Key Role: The Integrated Care Coordinator
To ensure seamless transitions across organizations, the pilot project created a key role: the integrated care coordinator. “They work across all four sites to facilitate timely access through seamless transitions from one organization to another. They’re able to advocate and make sure people don’t fall through the cracks or that a referral doesn’t get missed,” explains Bethany, whose role involves supporting the work of the care coordinators.
There are currently two coordinators based out of Ontario Shores and working with all four partners. “We are working to advocate for some of the most vulnerable folks in our community,” says integrated care coordinator Emily Willchuk. In these instances, people often become more difficult to reach, treat, and support. “Long hospitalizations and disjointed care lead patients to lose their trust in the system and feel less in control of their own recovery,” Emily adds. “By advocating for their recovery and working towards reducing barriers to care, we are preventing these folks from slipping through the cracks and losing their chance at a meaningful life.”
Coordinators also play a role in creating a better experience for members of the care team. They know about the client’s overall situation and can share that information with members of the care team at any site and any point on the client’s recovery journey. “They help demystify what each organization does,” adds Bethany, who says that, with a bird’s-eye view of what’s available, the care coordinator can help the team find resources and develop solutions to best meet the client’s needs.
“We are making a difference to our clients’ lives by connecting them with allied staff across different sites,” adds integrated care coordinator Shane Mammen. “We see this time and time again as they are supported throughout every stage of their recovery journey. It is exciting to be a part of a program that aims for these successes and is growing every day.”
Clinical Best Practices and Standards of Care
“The HQO (Health Quality Ontario) standards are guiding us to do evidence-based care,” says Bethany. “It’s one thing to have seamless transitions, but if everyone is not following the same standards, it erodes the quality of care and the outcomes we can achieve,” she says. This refers both to evidence-based psychotherapy (cognitive behavioural therapy for psychosis) and prescribing practices. “Ultimately, we want people to have access to the established best practices,” says Tracey, which includes making sure that “all the psychiatrists that are prescribing are on the same protocols.” And especially, says Tracey, “we want to reduce readmissions to hospital and visits to ER.”
Successes So Far
The first Integrated Care Pathway implemented – from acute care at Scarborough Health Network to tertiary care at Ontario Shores to community care at CMHA Toronto or CMHA Durham – handled more than 100 referrals in the first year. The second – from Scarborough Health Network directly to one of the CMHAs – was implemented in August 2023, and there have already been 15 referrals along this pathway from acute to community care.
While referrals fluctuate from month to month, the rates have often been higher than predicted. “We realized people hadn’t been referring from one setting to another because the wait is so long, sometimes up to two years. Now people are at least getting referred to an appropriate service in a timely way and we’re working towards reducing the barriers and those wait times even further,” says Bethany.
As the program completes its first year, a comprehensive evaluation is underway to measure its impact. The multi-agency team, led by Frank Sirotich, Chief Research Officer with CMHA Toronto, is looking at metrics such as improvement in symptoms, time to improved symptoms, and adherence to clinical best-practice and quality protocols. Ilan Fischler notes that “all four of our organizations are committed to measuring clinical improvement and functional recovery using validated rating scales. Care is then individualized to provide the highest-quality treatments and optimize people’s recovery.”
Another metric the team is tracking is time spent in hospital versus in the community. “We know people who are able to be well in the community longer most likely have a higher quality of life and we want to improve and provide that,” says Bethany. “We’re also measuring quality of life and the client’s experience from what they tell us and we can already see that we’ve improved the experience,” she adds.
“The piece that hits home for me quite often is the value of those seamless transitions, of sharing communications, and clients not having to start from scratch at each organization,” Bethany adds. “Clients see the value of that single point of contact. As an example, one of the families reached out to their care coordinator and wanted to make sure that the coordinator would come to all their care team meetings because they really felt supported and advocated for by them. It’s such a nice experience to learn that clients feel that way. They wouldn’t have had that before. They would have had to learn a whole new team every time they transitioned from one place to another.”
A Solid Foundation to Build On
The project team is proud of the foundations they’ve laid and the capacity building that has been achieved. The team has learned together and shared those learnings in a way that simply didn’t happen before.
For example, “we looked at what people were getting in a hospital setting that they weren’t getting from the community because we didn’t have the capacity or training [within CMHA Durham]. One of our successes has been training some of our staff in cognitive behavioural therapy for psychosis,” says Tracey.
Bethany also notes the value of wider knowledge-sharing. “If we have a challenge here at Ontario Shores, we reach out directly to Scarborough Health Network to say hey, have you ever had this? What do you do? We’re sharing learning, and we feel we’re not on our own, which I think is really great.”
Another key accomplishment, foundational to the program’s ongoing success, is the improved collaboration between the four organizations. According to Michelle Rehder, CMHA Toronto’s Chief Clinical Officer, “seamless care delivery, quality standards implementation, improved information transfer, and shared advocacy efforts” are some of most important benefits of the four-way partnership. She adds that these factors are key to achieving the project’s aims to “enhance the quality and continuity of care, advocate for the social determinants of health, and improve outcomes for people with schizophrenia.”
“I think it’s such a success to have our four organizations working together. We meet on a regular basis. People are very keen and engaged. Everyone is so busy in healthcare, and there’s so much going on that to take on an additional project like this is a real testament to the program’s value. We have a shared purpose that really drives us,” says Bethany. In so many ways, she concludes, “providing the right care at the right time in the right place is a game changer.”
Learn More About the Integrated Care Pathway for People Diagnosed with Schizophrenia
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.
Learn more about patient steps, community programs and services, frequently asked questions and about our partners on our dedicated page.