Project Overview

The Mental Health and Addictions Hospital to Home Program strengthens the transition from hospital to home or community-based care for adults requiring mental health and addictions support.

This initiative focuses on improving discharge planning, enhancing post-discharge supports, and connecting individuals to coordinated community-based services. By ensuring patients receive the right care after leaving hospital, the program improves patient flow, reduces unnecessary emergency department visits, and decreases Alternate Level of Care (ALC) days.

The goal is simple: safer transitions, stronger community supports, and better outcomes.

Purpose

The transition from hospital to home is a critical moment in the care journey for individuals living with mental health and addiction-related conditions. Without coordinated discharge planning and timely community follow-up, patients are at higher risk of readmission, prolonged hospital stays, and gaps in care.

This initiative addresses those challenges by strengthening partnerships across hospital and community providers to ensure individuals receive appropriate, ongoing support once they leave hospital.

Key Objectives

• Ensuring seamless transitions from hospital care to home or community settings, minimizing avoidable readmissions
• Providing timely access to community-based mental health and addictions services, including case management, peer support, and home care
• Supporting aging in place by equipping individuals with the resources needed to manage their conditions outside of hospital
• Reducing hospital dependency and improving bed availability for patients requiring acute care

Intended Impact: Improved continuity of care, stronger community supports, reduced hospital utilization, and better patient outcomes.

Who This Initiative Supports

• Adults admitted to hospital with mental health or addiction-related conditions
• Individuals requiring structured transition support following discharge
• Patients with stable housing or access to a residence post-discharge

Strategic Alignment

• Transforming the health and wellness system so people receive the right care, at the right time, and in the right place
• Integrating services across health and social care partners to better serve community needs
• Collaborating with community organizations to address social determinants of health, including housing stability
• Optimizing care coordination and system navigation across providers and services
• Streamlining processes to reduce service wait times and system bottlenecks
• Building innovative partnerships that strengthen integrated care delivery
• Implementing new models of coordinated home and community care

Project Leadership & Collaboration

Lead Organization:
Waterloo Regional Health Network (WRHN)

Partners & Collaborators:

• Bayshore HealthCare
• Community Care Concepts
• Community Support Connections
• Ontario Health atHome
• Thresholds Homes and Support
• Community member representatives

This program reflects a shared commitment across hospital and community partners to provide integrated, person-centered care.

Related Resources

Resources and supporting materials are currently in development.

Contact

For more information about this initiative:
info@kw4oht.com