Mental Health Patients Getting Extra Care Post Discharge


Windsor Team Care Centre

A new program is demonstrating positive results in supporting mental health patients after they’ve been discharged from the hospital.

“It was really nice to know someone out there cared. They would reach out to me just to follow up, outside of appointments,” says an anonymous patient who recently went through the program. “It made me realize how valuable I might actually be to people.”

Initially launched as a pilot project, the transitional care pathway provides access to follow-up care for mild to moderate mental health patients after they’ve been released from Windsor Regional Hospital’s Mental Health Assessment Unit.

Between December 2021 and March 2022, the partnership between WRH and the Windsor Family Health Team - Windsor Team Care Centre program, saw 55 patients referred to the Post Hospitalization Mental Health Pathway with 96% not seeking further treatment after taking part in the program.

”The health care system can be hard to navigate on a good mental health day,” explains WTCC Nurse Practitioner Caitlin Haugh. “This collaboration helps to prevent clients from falling through the cracks when they may not be in the best position to follow up or advocate for themselves.”

The program ensures eligible patients receive a ‘wellness call’ within 72 hours of discharge to go over the next steps in their treatment plan. WTCC Practice Facilitator Diane Quadros is the first point of contact for patients.

“Patients have indicated they knew I was going to call, which is great to hear because it confirms the process is working well and they are often surprised how fast I call them post-discharge,” says Quadros. “It’s rewarding to check in with individuals and answer any questions they may have regarding the next steps.”

Quadros says the main focus is to open up the lines of communication with patients, especially those navigating the mental health system for the first time.

“Stigma continues to exist around mental health and the follow-up call allows an open conversation regarding this and is a safe opportunity to ask any questions.”

If needed, a consult with a nurse practitioner is scheduled when appropriate, patients are referred to WTCC or Family Services Windsor-Essex where a number of counseling services are available.

“I can clarify and describe the types of services offered and how they may help the patient on their journey,” explains WTCC Nurse Practitioner Malikah Bader. “We educate folks about their medications, and how to take them appropriately. It also gives the patient an opportunity to ask questions which may not have crossed their mind during the discharge process, which can often be overwhelming.”

Patients involved in the program were asked to participate in an anonymous feedback survey. Of 10 responses, all were satisfied with the support they received from the WTCC with 90% feel supported in managing their condition and working toward achieving wellness post-hospitalization. The wellness calls were acknowledged as being helpful by all respondents as well.

Our anonymous patient had gone through the mental health system in the past but says this time felt very different.

“The first time was very daunting and I felt very alone through the process of trying to get better. This time around, it felt like I had a whole team behind me. If you want to get better, they will help you. They care about you. Feeling alone and secluded isn't normal and they really help make you feel supported.”

With patient feedback validating the many benefits of the pathway and with minimal resources needed to make the transitional support available, WRH and WTCC will continue to offer the program beyond its pilot period.

“There’s something to be said about having someone tell you, ‘You can do it!’ or ‘You’re not the only one,’ when you’re suffering from a mental illness which causes your brain to tell you the exact opposite,” says Bader. “Call it motivation, call it empowering, call it cheerleading, call it whatever you want - it fosters hope and courage during what is likely one of the worst periods of a person’s life.”

More information about mental health services can be found on the Windsor Regional Hospital and Windsor Team Care Centre websites.