Integrated Care Pathway for People Diagnosed with Schizophrenia

After admission, our dedicated patient care team engages in a conversation with the patient, gathering information about their condition and determining the level of support required. This assessment allows us to identify the most suitable services tailored to the individuals' unique needs.

Patients on this pathway receive the best possible medications to support their treatment. Our clinicians may recommend the use of long-acting medication or Clozapine, depending on the patient's response to previous treatments. These medications have demonstrated effectiveness in helping individuals with schizophrenia. Each treatment option will be thoroughly discussed.

Approximately two weeks after admission, the patient consults with our care team to determine if their symptoms are improving and to make any necessary adjustments to their treatment plan.

If the patient responds positively to treatment at SHN, we will facilitate their transfer to outpatient community services at SHN, CMHA Toronto or CMHA Durham. Ontario Shores may provide specialized inpatient care when needed. Our care coordinators will guide the patient through this process and discuss available options.

Ongoing communication with the patient's care team is crucial. We continually monitor progress, allowing adjustments to medications and other support as needed. Our goal is to find the most effective treatment for each patient.

Once the patient is coming to the end of their stay at Ontario Shores or SHN, they will meet with their care coordinator to discuss next steps in their recovery goals. This may mean being referred into Ontario Shores or SHN outpatient services, or community services at CMHA Toronto or CMHA Durham.

When the patient is connected to the appropriate community services and making progress toward recovery, a meeting with the patient's care coordinator will be scheduled to discuss exiting the care pathway. This decision will be made collaboratively with the patient and their support person(s).

Adults with schizophrenia or schizoaffective disorder enrolled in the Assessment and Reintegration Program (ARP) or Integrated Community Access Program (ICAP) at Ontario Shores or SHN. Also, individuals admitted to and/or discharged from settings where partnerships have been established and inclusion criteria have been met.

Ontario Shores is a tertiary mental health hospital specializing in providing care in a short amount of time. It offers both inpatient and outpatient services. The Assessment and Reintegration Program at Ontario Shores is provided by an interprofessional team of assessment and treatment specialists. This team collaborates with patients and families to develop a care plan with the goal of reintegrating the patient into the community.

SHN is a network of three hospitals and community clinics that provide a range of services to the Scarborough community. Inpatient mental health services are available for patients living with mental illness who require hospitalization. An interprofessional team offers assessment and treatment while focusing on collaboration and patient/family-centered care.

The Canadian Mental Health Association (CMHA) provides community mental health services through its 135 branches. CMHA Durham and CMHA Toronto, two local branches, are involved in the integrated care pathway with Ontario Shores and SHN. This collaboration ensures close cooperation in identifying the best treatment(s), programming, and support for individuals living with schizophrenia in the community.

Yes. A member of the patient's care team will discuss the pathway with the patient, and they have the option to decline participation. The pathway aims to provide superior care to people living with schizophrenia compared to standard treatment. By participating, the patient will receive seamless, integrated care regardless of where it is received. To address any concerns about the sharing of personal health information, please contact the patient's care team.

The duration of the pathway can vary depending on individual needs and progress. It is designed to provide comprehensive care throughout the recovery journey. The care team will work closely with the patient to determine the appropriate length of time for their involvement in the pathway.

Yes, family members or support persons are encouraged to be involved in the care pathway. Their participation and support play a vital role in the patient's recovery. The care team values collaboration with family members and supports their inclusion in decision-making and planning.

Yes, the integrated care pathway acknowledges that individuals diagnosed with schizophrenia may have other mental health needs or comorbid conditions. The care team takes a holistic approach and works to address all relevant mental health concerns to provide comprehensive care.

After exiting the care pathway, patients will be connected with appropriate community services and resources to support their ongoing recovery. The patient's care coordinator will assist in making these connections and ensure a smooth transition to continued care and support.

Yes, individuals who have previously received treatment for schizophrenia can join the integrated care pathway. The pathway is designed to support individuals at any stage of their recovery journey, whether they are newly diagnosed or have received treatment in the past.