Photo: From left, Danielle Rai, Clinical Manager, Adult Inpatient Mental Health, meeting with Rechelle Jesso and Catherine Bowser, Transitional Case Management Outreach staff.
May 5, 2026
The Adult Mental Health and Addictions program at London Health Sciences Centre (LHSC) offers mental health assessments and treatment, crisis intervention, and stabilization. Services are for those aged 18 and over and are conducted individually or in groups, depending on the patient’s treatment plan.
Once stabilized, an individual may need continued support once discharged from hospital into the community.
Bringing community services into the hospital setting enhances patient support and overall well-being by creating continuity between hospital and community care where appropriate.
Inpatient mental health
There are a number of community partners that inpatient mental health programs are connected with, as noted by Danielle Rai, Manager, Adult Inpatient Mental Health & Addictions. “Community partners play an important role in supporting adults with mental health concerns by helping maintain stability after discharge and reducing the risk of readmission.”
Rai continues, “While hospital teams focus on acute stabilization, community programs provide practical, ongoing support in real-world settings.”
Community partners, such as the Canadian Mental Health Association (CMHA), are onsite and allow staff to meet patients where they are at in their recovery journey. One of the most robust partnerships with CMHA and LHSC is the Transitional Case Management Outreach (TCMO) program.
TCMOs are staff that assist individuals as they transition from high-acuity inpatient units back into the community, particularly those returning to environments that may lack consistent support. TCMOs help coordinate follow-up care, connect patients to groups and community agencies, support access to income and housing resources, and provide short-term guidance during the adjustment period from inpatient to outpatient care.
“This approach reduces barriers to access, such as transportation challenges, long waitlists, stigma, or lack of awareness about services available to patients,” shares Rai. “Early connection to community resources while the patient is still admitted allows for timely referrals, collaborative discharge planning, and a smoother transition to outpatient supports.” This model has proven to reduce the number of readmissions for patients who have been connected prior to discharge.
Rai also notes that discharge from hospital can be a vulnerable period, and without adequate follow-up and structured supports, patients are at a higher risk for relapse, crisis, or readmission.
Rai says that “Strong community supports – such as outpatient mental health teams, addiction treatment programs, peer support groups, housing services, and case management – help maintain stability and reinforce the progress made during hospitalization. When discharge planning includes established community connections, patients are more likely to feel supported, maintain treatment engagement, and sustain recovery.”
Integrating community-based supports such as TCMOs and acute inpatient services is considered best practice for the individuals served.
Ambulatory mental health
Within the General Adult Ambulatory Mental Health Services (GAAMHS) at LHSC, the Traumatic Stress Services team partners with St. Thomas Elgin General Hospital, Parkwood Institute, Thames Valley Family Health Team, Woodstock General Hospital, and CMHA to ensure there is not any duplication of services and there are minimal barriers to getting the patient into the most appropriate treatment for them.
Robin Ferguson, Manager, Adult OP Mental Health & Addictions, notes that these partners enhance support and well-being for patients of this program by creating a continuity of care in and out of hospital settings with each program enhancing the other with the services and expertise provided.
Since the Traumatic Stress Services team only provides consultation services, the team needs community partners to provide that crucial ongoing support to ensure patients do not have to return to hospital.
“Our community partners are integral to excellent patient care and ongoing support for our program,” Ferguson says.
Addiction Medicine Consult Service (AMCS)
The AMCS team at LHSC is comprised of employees from partner organizations. This service is available because of collaboration between LHSC, CMHA Thames Valley - Addiction and Mental Health Services (CMHATV), and Regional HIV/AIDS Connection (RHAC).
“This team offers treatment and support to patients in hospital who use substances,” explains Michele Murray, Manager, Adult Mental Health & Addictions, LHSC. “The support is nonjudgmental and meets patients where they are at, ensuring they feel heard and seen through their participation in this voluntary consultative service.”
The team members, many of whom are peer harm reduction workers, help connect, or reconnect, patients to services outside of the hospital. The peer harm reduction workers are a testament to how change is possible, offering patients hope through each interaction.
Within the AMCS team, community partners play a vital role in patient support by connecting with patients through peer support and providing connections to services in the community and helping them navigate the system. The team meets patients with genuine empathy and openness.
Murray says, “I truly believe the success of our AMCS team is due to our collaboration with CMHATV and RHAC. Their passion and commitment to support this marginalized population is a driving force to improving patient care for those in hospital who use substances.”
Community involvement is a protective factor in promoting long-term mental health, reducing readmissions, and improving overall quality of life and the Adult Mental Health and Addictions team at LHSC is committed to maintaining and growing community connections for the benefit of patients.