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Transforming Mental Healthcare

A Collaborative Journey
Transforming Mental Healthcare
Published Date

Dear colleagues, partners, and friends,

I am delighted to share an inspiring story of collaboration and transformation in mental healthcare. At Ontario Shores Centre for Mental Health Sciences, we have always been committed to delivering the highest quality of care to individuals facing the challenges of schizophrenia. Our mission, however, extends beyond the walls of our institution.

In the fall of 2022, we embarked on an extraordinary journey, a journey that unites four distinct groups: Scarborough Health Network, Ontario Shores Centre for Mental Health Sciences, and the Durham and Toronto branches of the Canadian Mental Health Association. Together, we set out to address the inefficiencies and fragmentation in our healthcare system, focusing on improving the lives of individuals diagnosed with schizophrenia.

The Integrated Care Pathway for People Diagnosed with Schizophrenia pilot project was born out of a desire to provide seamless transitions to the right care, at the right time, and in the right place. This initiative was grounded in the understanding that our patients don't access care in silos; their journey often takes them through multiple healthcare providers. Unfortunately, this journey was marred by repetitive assessments and an emotional toll on our patients. Our challenge was clear, how could we change this landscape and, in the process, enhance the patient experience?

Bethany Holeschek, an occupational therapist at Ontario Shores, emphasizes the importance of this project by stating, "Our healthcare system is designed the way it is, but how can we still work together and maybe overcome some of those barriers in a way that's meaningful and improves the experience? The driving factor was that patient experience."

As we delved deeper into this initiative, it became evident that the key to its success lay in coordinated care along a continuum. The creation of the role of the integrated care coordinator was a pivotal step. These coordinators work across all four partner sites, ensuring that individuals don't fall through the cracks and that referrals are never missed. They advocate for our most vulnerable individuals and help prevent them from slipping through the gaps.

Emily Willchuk, one of the integrated care coordinators, passionately explains the importance of their role, "Long hospitalizations and disjointed care lead patients to lose their trust in the system and feel less in control of their recovery. 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."

Our commitment doesn't stop at coordinated care. We believe in clinical best practices and standards of care. Our goal is not just seamless transitions but also ensuring that everyone is following the same standards. This includes evidence-based psychotherapy and prescribing practices. We want people to have access to the established best practices at every step of their journey.

As we move forward, our successes are becoming more apparent. The first Integrated Care Pathway handled 113 referrals in its first year. The second, implemented in August 2023, has already seen 16 referrals along this pathway. These numbers exceed our expectations and highlight the pressing need for change.

We are measuring our impact through various metrics, including improvement in symptoms, time to improve symptoms, and adherence to clinical best practices and quality protocols. Most importantly, we're focused on the time spent in the hospital versus the community. We understand that individuals who can be well in the community for longer periods have a higher quality of life, and we are committed to achieving this outcome.

Our patients' voices are at the center of our efforts. Their experiences have improved, and they have expressed the value of seamless transitions and a single point of contact in their journey. This is a testament to the transformation we are fostering.

In conclusion, I want to emphasize the importance of collaboration. The success of this project lies in the unity of our four organizations, all working towards a shared purpose – providing the right care at the right time in the right place. We are on a mission to ensure that individuals do not fall through the cracks and that they can achieve better outcomes in the community. I invite you to join us on this remarkable journey of transformation and unity.

Thank you for your unwavering support and commitment.

To learn more about how the Integrated Care Pathway brings the collective expertise of Ontario Shores, Scarborough Health Network, and the Durham and Toronto branches of the Canadian Mental Health Association together to provide seamless care for individuals with schizophrenia visit here.


Sanaz Riahi 
Vice President, Clinical, Practice and Chief Nursing Executive Ontario Shores Centre for Mental Health Sciences

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