Search
Close this search box.
Search
Close this search box.

Right care, right time, right place for people diagnosed with schizophrenia

In a fragmented health care system, four groups have come together to reduce inefficiencies, prevent people from falling through the gaps, and align practitioners around a best-practice approach to care for people diagnosed with schizophrenia, their families, and their care teams.

Launched in fall 2022, the Integrated Care Pathway for People Diagnosed with Schizophrenia pilot project is a collaboration between Scarborough Health Network (SHN), Ontario Shores Centre for Mental Health Sciences, and the Durham and Toronto branches of the Canadian Mental Health Association.

“The driving factor was to improve the experience of people who access services across the continuum of care,” says Bethany Holeschek, an occupational therapist on the professional practice team at Ontario Shores. “We know that people don’t just come to Ontario Shores or to one of the CMHAs or to Scarborough Health Network. They often will access all of us at some point along their journey. The challenge right now is we are all siloed, we’re all separate entities,” Bethany adds.

It was a welcome opportunity to work together more collaboratively. That’s one of the things that I am so excited about, because tertiary and acute hospitals and community, we all work very differently. Working in coordination will have tremendous benefits for our clients.”

TRACEY HARDINGE, SENIOR DIRECTOR, CLINICAL OPERATIONS, CMHA DURHAM

As Tracey Hardinge, Senior Director of Clinical Operations at CMHA Durham, says, “one of the things that we looked at is what we can do better to support people as they navigate through the different levels of hospital care and then into the community. Ultimately, we don’t want people in the hospital. We want them in the community. It’s been really exciting watching the two levels of hospitals and community come together to create this pathway to support people.”

COORDINATING CARE ALONG A CONTINUUM

While the teams at Scarborough Health Network, Ontario Shores and the Toronto and Durham CMHA branches regularly referred people to each other, there was no seamless transfer that took advantage of a single intake assessment. As a result, clients were forced to “start over each time. They’re being asked the same 20 questions over and over. So there’s a lot of extra effort, misdirected time, and that affects the person’s spirit,” says Bethany.

“One of the things that was really important was having people not have to retell their story, because it’s so evident the trauma that it brings each time,” adds Tracey.

The onerous and often retraumatizing process hampers access to “the right care at the right time” and can discourage clients from seeking care at all.

Dr. Ilan Fischler, Chief of Psychiatry and Medical Director of the Mental Health & Addiction Program at SHN, explains that “individuals with schizophrenia are often placed on waitlists for the services and treatments that we know will help them recover or keep them well in the community. People may relapse while they are waiting. One the key wins for the pathway is that individuals can be seamlessly connected to the services they need when they need them.”

 

Our healthcare system is designed the way it is but how can we work together and overcome some of those barriers in a way that improves the experience?

BETHANY HOLESCHEK, ONTARIO SHORES

A KEY ROLE: THE INTEGRATED CARE COORDINATOR

To ensure seamless transitions across organizations, the pilot project created a key role: the integrated care coordinator. “They work across all four sites to facilitate timely access through seamless transitions from one organization to another. They’re able to advocate and make sure people don’t fall through the cracks or that a referral doesn’t get missed,” explains Bethany, whose role involves supporting the work of the care coordinators.

There are currently two coordinators based out of Ontario Shores and working with all four partners. “We are working to advocate for some of the most vulnerable folks in our community,” says integrated care coordinator Emily Willchuk. In these instances, people often become more difficult to reach, treat, and support. “Long hospitalizations and disjointed care lead patients to lose their trust in the system and feel less in control of their own recovery,” Emily adds. “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.”

Coordinators also play a role in creating a better experience for members of the care team. They know about the client’s overall situation and can share that information with members of the care team at any site and any point on the client’s recovery journey. “They help demystify what each organization does,” adds Bethany, who says that, with a bird’s-eye view of what’s available, the care coordinator can help the team find resources and develop solutions to best meet the client’s needs.

“We are making a difference to our clients’ lives by connecting them with allied staff across different sites,” adds integrated care coordinator Shane Mammen. “We see this time and time again as they are supported throughout every stage of their recovery journey. It is exciting to be a part of a program that aims for these successes and is growing every day.”

CLINICAL BEST PRACTICES & STANDARDS OF CARE

“The HQO (Health Quality Ontario) standards are guiding us to do evidence-based care,” says Bethany. “It’s one thing to have seamless transitions, but if everyone is not following the same standards, it erodes the quality of care and the outcomes we can achieve,” she says. This refers both to evidence-based psychotherapy (cognitive behavioural therapy for psychosis) and prescribing practices. “Ultimately, we want people to have access to the established best practices,” says Tracey, which includes making sure that “all the psychiatrists that are prescribing are on the same protocols.” And especially, says Tracey, “we want to reduce readmissions to hospital and visits to ER.”

By streamlining their admission and access, we build a wrap-around level of support that empowers patients to live their best lives with a safety net to prevent crisis.

EMILY WILLCHUK, INTEGRATED CARE COORDINATOR, ONTARIO SHORES

SUCCESSES SO FAR

The first Integrated Care Pathway implemented – from acute care at Scarborough Health Network to tertiary care at Ontario Shores to community care at CMHA Toronto or CMHA Durham – handled more than 100 referrals in the first year. The second – from Scarborough Health Network directly to one of the CMHAs – was implemented in August 2023, and there have already been 15 referrals along this pathway from acute to community care.

While referrals fluctuate from month to month, the rates have often been higher than predicted. “We realized people hadn’t been referring from one setting to another because the wait is so long, sometimes up to two years. Now people are at least getting referred to an appropriate service in a timely way and we’re working towards reducing the barriers and those wait times even further,” says Bethany.

As the program completes its first year, a comprehensive evaluation is underway to measure its impact. The multi-agency team, led by Frank Sirotich, Chief Research Officer with CMHA Toronto, is looking at metrics such as improvement in symptoms, time to improved symptoms, and adherence to clinical best-practice and quality protocols. Ilan Fischler notes that “all four of our organizations are committed to measuring clinical improvement and functional recovery using validated rating scales. Care is then individualized to provide the highest-quality treatments and optimize people’s recovery.”

Another metric the team is tracking is time spent in hospital versus in the community. “We know people who are able to be well in the community longer most likely have a higher quality of life and we want to improve and provide that,” says Bethany. “We’re also measuring quality of life and the client’s experience from what they tell us and we can already see that we’ve improved the experience,” she adds.

“The piece that hits home for me quite often is the value of those seamless transitions, of sharing communications, and clients not having to start from scratch at each organization,” Bethany adds. “Clients see the value of that single point of contact. As an example, one of the families reached out to their care coordinator and wanted to make sure that the coordinator would come to all their care team meetings because they really felt supported and advocated for by them. It’s such a nice experience to learn that clients feel that way. They wouldn’t have had that before. They would have had to learn a whole new team every time they transitioned from one place to another.”

 We’re doing this to provide people with better care, so they don’t fall through the cracks. That’s the most important thing and we don’t ever want to lose focus on that.

TRACEY HARDINGE, CMHA DURHAM

A SOLID FOUNDATION TO BUILD ON

The project team is proud of the foundations they’ve laid and the capacity building that has been achieved. The team has learned together and shared those learnings in a way that simply didn’t happen before.

For example, “we looked at what people were getting in a hospital setting that they weren’t getting from the community because we didn’t have the capacity or training [within CMHA Durham]. One of our successes has been training some of our staff in cognitive behavioural therapy for psychosis,” says Tracey.

Bethany also notes the value of wider knowledge-sharing. “If we have a challenge here at Ontario Shores, we reach out directly to Scarborough Health Network to say hey, have you ever had this? What do you do? We’re sharing learning, and we feel we’re not on our own, which I think is really great.”

Another key accomplishment, foundational to the program’s ongoing success, is the improved collaboration between the four organizations.  According to Michelle Rehder, CMHA Toronto’s Chief Clinical Officer, “seamless care delivery, quality standards implementation, improved information transfer, and shared advocacy efforts” are some of most important benefits of the four-way partnership. She adds that these factors are key to achieving the project’s aims to “enhance the quality and continuity of care, advocate for the social determinants of health, and improve outcomes for people with schizophrenia.”

“I think it’s such a success to have our four organizations working together. We meet on a regular basis. People are very keen and engaged. Everyone is so busy in healthcare, and there’s so much going on that to take on an additional project like this is a real testament to the program’s value. We have a shared purpose that really drives us,” says Bethany. In so many ways, she concludes, “providing the right care at the right time in the right place is a game changer.”

Like this article?

Share on Facebook
Share on Twitter
Share on LinkedIn
Share via Email

Sheryl Wedderburn

Courtice, Ontario – Chief Executive Officer/Officer of the Board

Sheryl Wedderburn is the Chief Executive Officer at the Canadian Mental Health Association (CMHA) Durham. Since her appointment in 2021 she has led the organization through innovative key milestones. The transformation and modernization of housing programs for people with serious mental illness; attaining Accreditation with exemplary standing and raising the profile of the organization within the mental health and addictions sector by co-partnering with lead service providers to support an integrated care model for people living with Schizophrenia. Sheryl has a proven track record in removing barriers between providers and designing client-centred systems while championing the expansion of the traditional catchment areas moving towards equitable access to care. The former CEO and Principal Consultant for Bernard Consultancy, Sheryl has worked dutifully with Chief Executive Officers and Chief Operating Officers, inspiring them to cultivate inventive strategic plans, conducting quality-driven operational reviews and advancing the development, mentorship and successioning of their leadership teams. As a seasoned Governor, Sheryl has served on various Boards since 1986, from hospital sector to community. In addition to her role as Officer of the esteemed CMHA Durham Board of Directors, she serves on the Board of the Alzheimer Society Durham Region, where she advocates for enhanced services to meet the growing diverse needs of people living with Alzheimer and associated dementias. She is the Founding President for JCAN, a registered not-for-profit charity serving the Afro-Caribbean population. A life-long learner, Sheryl holds a Bachelor of Science in Nursing, Master of Health Sciences and Certified Health Executive designation from the Canadian College of Health Leaders. Past cross-appointments include Adjunct Faculty for the Nursing Degree Program at University of Toronto and Ontario Tech University.

Board Photo Sarah Moore 1 14

Kerrie Wriker

Colborne, Ontario – Chief Operating Officer/Board Secretary

Kerrie has over 20 years of experience working in the community-based mental health and addictions sector and has held various leadership roles throughout her career. She attained formal education in Recreation and Leadership (Ontario Tech University), Professional Management (York University), and Harm Reduction. She is also a Green Belt in leading process improvement methodology Lean Six Sigma and holds a Change Management Practitioner certification. In her current role as CMHA Durham’s Chief Operating Officer, she effectively fulfills layered reporting obligations to numerous levels of government and ensures all services are integrated, planned, delivered, and evaluated in accordance with professional standards.
As a caregiver to a loved one with a severe mental disorder, Kerrie is a firm believer that connected and caring communities promote wellness. To that end, Kerrie volunteers as a panel member with the Ontario Caregiver Organization, member of an Advisory Board within her township, and is a Board Trustee with CMHA National Pension Plan in addition to her work with CMHA Durham.

Board Photo Sarah Moore 1

Sarah Moore

Ajax, Ontario – Board Member

Sarah is an accessibility advocate with a passion for cultivating inclusion, standing up to stigma, and breaking down barriers alongside people with visible and invisible disabilities. She is an Accredited Municipal Professional with more than 15 years of local government experience. Her portfolio includes specialties in public administration, accessibility compliance, diversity, equity, and inclusion (DEI), as well as volunteer management. Sarah is an Honours graduate of the University of Toronto and obtained a certificate in Accessibility Practices from Toronto Metropolitan University. With both a personal and professional connection to mental health, supporting family members, friends, and colleagues with mood disorders, Sarah is eager to contribute to the promotion and enhancement of positive mental health within the Region as a member of the CMHA Durham Board of Directors. Outside of work, Sarah’s hobbies and interests include film, language studies (French and Spanish), baking, and spoiling Riley, her Shih-Tzu.

Nicole Seymour

Whitby, Ontario – Board Member

Nicole Seymour is currently the Chief Regulatory and Compliance Officer for a global property and casualty insurance organization. She has over 20 years of regulatory compliance experience in the insurance and financial industries and has held Chief Compliance Roles at insurers, mutual fund dealers, and life insurance MGAs. Throughout her career, Nicole has implemented successful compliance and regulatory risk management programs at multiple institutions. Continuously committed to her professional development, she holds a bachelor’s degree from the University of Waterloo and has recently completed the Cambridge Business Sustainability Management Certificate and the Certificate in Regulatory Compliance and Legal Risk Management for Financial Institutions from Osgoode Hall. Nicole lives in Whitby with her husband and four children. She enjoys traveling and being a hockey/soccer mom.

Board Photo Sarah Moore 1 13

Katie Cosway

Courtice, Ontario – Board Member

Over the past 15 years, Katie has dedicated her career to guiding organizations to build strong cultures that create inclusive and successful business outcomes. After completing her Honours BA at McMaster University and a post-graduate certificate in Human Resources at Durham College, Katie spent 10 years in organizational and career management consulting, delivering services across North America. She later took on a leadership role within the energy sector, where she focused on learning and development to support the growing demands of that industry. A certified Change Management Practitioner and Human Resources Leader (CHRL), Katie also has experience serving on a non-profit board within the financial sector and brings a governance/policy strength that has resulted in increased performance of the teams and projects she’s worked on. Growing up in Durham Region, and currently residing in Courtice with her family, Katie has a deep appreciation for community services such as the ones provided by CMHA Durham.

Jason Langley

Clarington, Ontario – Board Member

Jason is a Senior Strategy & Innovation leader at a large North American financial institution. With a cross border mandate, Jason has built a brand rooted in strategic thought leadership and has a track record of driving multi-dimensional transformation focused on growth and the customer experience. Jason is passionate about coaching and developing future leaders and is a staunch advocate for mental health in both his professional and personal life. He holds both an MBA and Certificate in Responsible Leadership from Queen’s University, a Bachelor of Commerce from Ontario Tech University, and is a Certified Change Management Practitioner. Having grown up in Oshawa, Jason now lives in Clarington with his wife and daughter. In his spare time, he enjoys being outdoors and is an avid fisherman.

Duncan Kerr

Brooklin, Ontario – Board Member

Duncan Kerr is an experienced executive currently serving as the Director of Sustainability and Training with Toronto Hydro. He is responsible for developing and managing short- and long-term sustainability, training, and workforce skills development strategies, as well as directing and managing the organization’s sustainability and training systems, processes, and programs. Duncan also drives change in the pursuit of compliance and continual improvement of environment, social, and governance (ESG).  Prior to Toronto Hydro, Duncan held professional and leadership roles in both health and safety and operations at General Motors in Canada, the United States, and Australia. His impact is supported by a diverse education, including a Bachelor of Kinesiology from McMaster University, a Master of Science in Biomechanics from the University of Guelph, and a Master of Business Administration from Wayne State University.  He is also a Canadian Registered Safety Professional (CRSP) and an Environmental Professional (EP). Duncan has lived in Brooklin for the last 15 years, with his wife of over 20 years and their two sons.

Elizabeth McSavaney

Pickering, Ontario – Board Member

Elizabeth is currently a Human Resources (HR) Executive for a leading global insurance organization.  Elizabeth has obtained her Canadian Human Resources Leader (CHRL) designation and carries a certificate in Alternative Dispute Resolution from the University of Windsor. Over the course of her career, she has led teams in both the private and public sectors across North America.  She has driven complex transformational change projects in corporate and manufacturing environments and has worked in a variety of HR disciplines. In addition to her HR qualifications, Elizabeth has served as a professor at Algonquin College’s School of Business. Beyond work, Elizabeth is a passionate health advocate, with a Bachelor of Science (Honors) in Human Kinetics from the University of Ottawa. She keenly understands the value that focused strategies can bring to the health outcomes of individuals, organizations, and the broader community. When Elizabeth is not at work she enjoys CrossFit, running, traveling, and spending time with family and friends.

Board Photo Sarah Moore 1 2

Earlene Worrall

Blackstock, Ontario – Board Member

Earlene seeks to leverage her knowledge and skills in ways that make a meaningful difference for others, both professionally and personally. With expertise in brand-building, marketing, and strategy, she has spent the last fourteen years working with healthcare clients in a trusted advisor role to help them tackle their toughest strategic challenges. As a Partner with Ipsos Healthcare Advisory, Earlene deeply understands the underlying drivers of behaviour, uncovers the insights that matter, and unfailingly pulls through to actionable strategy – ultimately helping to improve the lived experience of patients, their loved ones, and the healthcare providers who treat them. Earlene is equally committed to contributing to her community. Her volunteer roles over the past two decades have spanned her interests in the environment, the arts, social services, and healthcare. Earlene holds a Bachelor of Commerce from Queen’s University. She and her husband live in Blackstock.

Board Photo Sarah Moore 1 6

Melissa Beaucaire

Oshawa, Ontario – Board Member

Melissa has a rich background in the non-profit sector with more than 25 years of experience. Tapping into her formal education in Sociology (BA, University of Ottawa) and Early Childhood Education (Honours Diploma, Algonquin College), she is currently a Manager for Children’s Services in the Durham Region. Melissa has also previously served on the board of non-profit organizations as secretary and treasurer. A lifelong learner, Melissa has prioritized her professional development in the areas of mental health, diversity, special needs, addiction, management, and leadership. She recognizes the importance of the work that CMHA Durham does to provide services for the community and those living with mental health challenges, and she is honoured to support the mission. Besides Melissa’s personal and professional pursuits, family is integral to her life. Melissa and her family are long-time residents of the Durham Region. 

Board Photo Sarah Moore 1 3

Jim Hunt

Nestleton, Ontario – Board Member

Jim Hunt is a retired management professional, whose career touched many essential business operations, from manufacturing to customer satisfaction. He is an outside-the-box thinker with a Mathematics degree from the University of Waterloo (whose handbook he co-authored). An effective problem solver, Jim was one of a few people in North America to successfully manage the implementation of operation scheduling software. Jim also served on the boards and advisory committees of several noteworthy organizations, including Sir Sandford Fleming College and the Canadian Mental Health Association Ontario, where he was a board member for nine years. Jim’s investment in accessible and effective mental health care is inspired by the experiences of his loved ones who live with mental disorders. As a resident of Scugog, Jim’s work with CMHA Durham is a testament to his commitment to ensuring care is available to those in his community who need it most.

Dave Wheeler

Whitby, Ontario – Board Chair

Dave Wheeler is a passionate advocate for mental health, and a trusted advisor to CMHA Durham. He has brought his empathetic and effective approach to professional and organizational advancement to roles at several notable companies, including his current position as senior manager of sales and operations at one of Canada’s leading financial institutions. Dave’s expertise is backed by a Master of Business Administration from Queens University and a Bachelor of Arts in Political Science from York University. As CMHA Durham Board Chair, Dave effectively develops strong relationships with stakeholders, while ensuring the appropriate processes are in place to monitor and measure the organization’s performance and efficacy outcomes. Beyond his professional endeavours, Dave enjoys travelling, golf, hockey, baseball, running, and coaching sports.

Preya Singh-Cushnie

Ajax, Ontario – Board Member

Preya Singh-Cushnie is deeply committed to making a positive impact and has accumulated more than 23 years of leadership experience across various financial services organizations, from global giants to mid-sized firms, both internationally and domestically. She currently holds a senior leadership role at the Ontario Medical Association, overseeing the insurance division serving 45,000 physicians in Ontario and Atlantic Canada. In addition to her insurance responsibilities, Preya actively supports the association’s advocacy efforts, contributing to physician and patient care initiatives.

Preya approaches leadership with a focus on empathy, transparency, and a clear sense of purpose. She has a knack for facilitating positive changes by collaborating effectively with internal and external partners, committees, and the OMA Insurance Board to advance the organization’s programs and advocacy work. Preya is also a Licensed Life Insurance Agent and holds a Bachelor of Arts in Psychology from York University.

Her dedication extends to promoting Equity, Diversity, and Inclusion, with a special focus on supporting mental wellness initiatives. This commitment has led her to serve as a Director and Treasurer for CMHA Durham. Before her involvement with CMHA Durham, Preya spent four years as a member and Vice Chair of the Town of Ajax Diversity and Community Engagement Committee.