Participants
Our study is implementing the TDM within 9 hospitals across Ontario and 9 CSI member organizations.
| Participating Hospitals | Participating Consumer Survivor Initiative Organizations |
|---|---|
| Centre for Addiction and Mental Health | Centre for Addiction and Mental Health Internal Peer Support (Toronto) |
| Hôpital Montfort | Psychiatric Survivors of Ottawa |
| London Health Sciences Centre | Connect for Mental Health Inc. (London) |
| Providence Care | Mental Health Support Network South East Ontario |
| Baycrest | Krasman Centre (Richmond Hill) |
| St. Joseph’s Healthcare, Hamilton | Peer Support Services (Hamilton) |
| St. Joseph’s Healthcare, London | Can-voice (London) |
| Thunder Bay Regional Health Sciences Centre | People Advocating for Change through Empowerment (Thunder Bay) |
| Ontario Shores | CMHA Durham (Whitby) |
The TDM supports the successful community integration of people diagnosed with a mental illness and aims to reduce length of stay, readmission rate and improve the quality of care for this population. The TDM is based on the provision of therapeutic relationships to ensure a seamless safety net exists for patients throughout the discharge and community reintegration processes. The TDM has two components to assist patients in the transition from hospital to community:
Peer Support: Support from a person who has experienced a mental illness, is living successfully in the community, and has completed a peer training program. This includes regular contact on a schedule that suits both parties, for the purpose of providing social support and shared learning from the experience of someone who has lived through a similar transition; and
Staff Support: Continued support from a staff person from the hospital program, or a community program (the patient identifies the staff person as someone who they have a therapeutic relationship with) until a therapeutic relationship has been established or re-established with a community mental health care provider.
The three basic assumptions of the TDM are:
- People heal in relationships (including staff and peer relationships);
- Transitions in care are vulnerable periods for individuals with mental illness; and
- A network of relationships provided during transitional periods assists in recovery.
The TDM employs a groundbreaking, collaborative, relationship-focused approach to discharging patients that has the potential to revolutionize care at CAHO hospitals across Ontario.
Why is this important?
The transition from hospital to community is complex and can be challenging for many patients. For example, a study of 85 long-term psychiatric patients showed that 25% met the criterion for relocation trauma when moved from hospital to community (Farhall, Trauer, Newton, & Cheung, 2003). Recent research also shows that the first days and weeks following discharge are particularly high-risk periods, with 43% of psychiatric patient suicides occurring within the first month post-discharge (Hunt et al., 2009).
The period following discharge is also a particularly vulnerable period for readmission. With usual care, there can be a significant gap between the discharge date and the time individuals are seen by community agencies. As well, some psychiatric patients are discharged to emergency shelters or no fixed address; these environments do not tend to facilitate recovery from mental illness (Forchuk, Russell et al., 2006). 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 supports the successful community integration of people with mental health challenges, thus decreasing unnecessary in-patient and emergency room hospital visits for this population.
What is the evidence?
In 1992, a Canadian participatory action project called the Bridge to Discharge project (Forchuk, Chan et al., 1998; Forchuk, Jewell et al., 1998) designed and implemented TDM on a long-term ward that was part of the schizophrenia service at the former Hamilton Psychiatric Hospital in Ontario. All 38 pilot participants were successfully “bridged” to the community. In the first year, this resulted in in-patient savings of almost $500,000 while improving patients’ quality of life (Forchuk, Chan et al., 1998).
The pilot project’s success was replicated in other studies. Reynolds et al. (2004) introduced the model in Scotland,UK to four acute care programs. Psychiatric patients were randomized on the day of discharge into an intervention group that employed the TDM or a usual care control group. In this study the control group was more than twice as likely to be readmitted in the 5 months following discharge compared to the TDM group.
Forchuk, Martin, Chan and Jensen (2005) also demonstrated the effectiveness of the TDM in 26 Ontario tertiary care psychiatric wards at four geographic locations. The length of stay for participants on the intervention wards was reduced by an average of 116 days, freeing up 12 million dollars worth of bedspace. The intervention group also consumed on average $4,400 less hospital and emergency room services per person in the year after discharge compared to the control group. Recent studies (described below) have also identified facilitators and barriers to TDM implementation (Forchuk, Martin et al., in press-a; in press-b).
What are the facilitators and barriers to implementing the TDM?
Despite the strong evidence supporting the TDM, there are several barriers that may disrupt implementation.Throughout this project, the project team will assist in identifying and addressing these potential barriers with you.
Forchuk, Martin et al. (in press-a; in press-b) implemented the TDM on 40 psychiatric wards in three different waves. The researchers compared three groups of wards; Group A wards had already adopted the TDM, Group B wards implemented the TDM in year one, and Group C wards implemented the TDM in year two. Strategies were suggested by the A and B wards to enhance implementation on the B and C wards, respectively. This research revealed that the most commonly cited barriers to adoption of the TDM are:
- Resistance to procedural changes (e.g. hospital staff feeling swamped with new information and processes)
- Team dynamics (e.g. some hospital staff being supportive of TDM, while others resist; collaborating successfully with CSI groups)
- Changes in ward champions, which can disrupt the implementation process
The implementation strategies developed for this project are a direct reflection on the known barriers and were created to mitigate them. According to Forchuk, Martin et al. (in press-a; in press-b), specific strategies that aid in the implementation of TDM include:
- The use of educational modules for on-ward hospital staff training and peer support training
- Presence of on-site champions
- Supportive documentation systems.
All of these best practices are used in the current implementation.