Transitioning from Hospital-Based Care to Community-Based Models of Care

Abstract

Collaborative mental health-care services have been designed and implemented nationally and internationally for a little over three decades now, and much has been reported in the literature about lessons learned over the years. Most of these services have been for general mental health population groups. For the serious mental illness (SMI), there is limited data and experience on transitioning patients from hospital-based care to primary care. The few programs described in this chapter deal with collaboration in mental health patients with SMI. In most of these programs, the fundamental principles of sharing/collaborating care were followed within an interdisciplinary context with few differences. Experiences from these models of collaboration contribute valuable information for individuals with SMI and the health-care system. The authors describe clinical application of the service concept through case examples and real-life experiences in delivering services through collaborative care. This form of care provides enhanced access to good-quality mental health care, utilizing the patient-centered concept even after being transferred to primary care. Family physicians are able to overcome difficulties in accessing, communicating, and negotiating referrals that are often barriers to delivery of optimal mental health care, facilitating better integration of mental and primary care reform. The health-care sector benefits include a seamless, accountable, transparent, more integrated system resulting in reduced wait times and contribution of valuable information for others to replicate.