The Ontario Federation of Community Mental Health and Addiction Programs is pleased to announce "Through the Door", a Mental Health and Addictions Working Group Report created by LHINC (Local Health Integration Networks Collaborative).

 "Through the Door" is a crucial report that acknowledges challenges with transitions of care for people with mental health and addiction issues in Ontario. Inadequate transitions of care for people with mental health and addictions can result in re-hospitalization, homelessness, adverse events, and other difficulties. These challenges are highlighted in recent literature and also in a vast number of national and provincial reports.

Effective transitions of care are critical to delivering high quality and safe care.

 To address the challenges associate with transitions of care, the LHINC Working Group has provided several practical recommendations for Ontario's Local Health Integration Networks and Health Service Providers to further improve transitions for clients in each region across the province.

Central to the Working Groups recommendations is the establishment of a regional mental health and addictions Network as suggested by the Minister's Advisory Group Report entitles "Respect, Recovery, Resilience: Recommendations for Ontario's Mental Health and Addictions Strategy, Report to the Minister of Health and Long-Term Care". The Network would act as the platform that supports other changes to improve transition experiences at the Regional, Organizational and Client levels.

 Each region will have its own approach to these recommendations based on local circumstances and priorities. To reflect this, the Working Group has proposed not only recommendations, but also a high-level implementation plan showing how the different recommended activities could roll out across a given LHIN region.

The recommendations are as follows:

Regional Level

1.      Each LHIN should have in place a regional mental health and addictions Network that has a mandate to improve transitions for mental health and addictions clients.

2.      Steps should be taken at the board, executive, front-line staff and client levels to build and maintain trust between participants in the Network.

3.      Each Network should pick one or two small, high-needs target populations as the main focus of their initial collaborative work.

4.      Each Network should undertake concrete activities to ensure its sustainability.

5.      Each LHIN should have in place someone designated to improving transitions for mental health and addictions clients by acting as a system resource for system work as decided upon by the Network.

6.      Each Network should have in place a transition-driven performance management process.

Organizational Level

7.      Every mental health and addictions provider should have an after-hours strategy

8.      Every mental health and addictions provider should have a protocol for urgent level of response.

9.      The Network should support every mental health and addictions service provider to develop agreements with other providers to support client transitions along the journey of recovery that ensure alignment between intensity of services provided and acuity of client needs.

10.  The LHIN should consult the Network on decisions related to mental health and addictions resources based on the Network's understanding of system capacity, effectiveness of existing services in generating positive outcomes, and transition-related needs of clients.

Client Level

11.  Each Network should take concrete steps to reinforce the renewed focus on client care.

12.  Each Network should review the Alliance of Information and Referral Systems (AIRS) Standards and determine which ones are most relevant to improving transitions in its region.

13.  Each Network should support the use of information and communication tools to facilitate effective transitions.

14.  The Network should build on existing tools with mental health and addictions providers to ensure that care plans travel with the patient across organizational boundaries.

15.  Based on existing infrastructure, each Network will ensure availability and use of an up-to-date, comprehensive list of mental health and addictions services for referring individuals and organizations in its community.

16.  The Network should assess the effectiveness of current intake practices to mental health and addictions services and make recommendations to the LHIN and providers on how to improve their coordination.

17.  The Networks should work with the appropriate provincial partners and academic experts to undertake practical knowledge exchange.

 “Through the Door” presents an opportunity for providers and consumers.  It will demonstrate that mental health and addiction providers can improve access, integration, and meet provincial health priorities.

 Please see the attached report.  Please do not hesitate to send any comments concerns or questions to David Kelly.