In their lifetime, every Canadian will experience a transition in care, whether as a client, patient,  caregiver, family member, and/or as a member of a community with challenges to access care. Successful care transitions require multi-disciplinary communication and coordination, comprehensive planning, including patient/caregiver education and clinician involvement, and shared accountability during all points of transition. When gaps occur in care transitions, individuals are susceptible to fragmentation in care, poor quality of care, unfavorable experiences, compromised patient safety, and adverse medical events.

The Canadian Institutes of Health Research (CIHR) invested in a multi-Institute initiative is to improve the health and wellness of Canadians by supporting research that transforms the health system to optimize the outcomes of patients experiencing transitions in care. Our team was fortunate to receive a Transitions in Care (TiC) Team Grant: “Digitizing Stepped Mental Health Care: A Pragmatic Trial.

Funding Source: CIHR


The demand for mental healthcare services is escalating and there is widespread recognition across Canada that an accessible system of care is needed to provide timely and ongoing mental health assessment and treatment, for the right person at the right time. Unfortunately, access to mental health care in Canada is delayed compared to other countries; a finding which is due, in part, to an under supply of services and protracted wait lists. This study will evaluate a new mental health care service model called Stepped Care 2.0  on mental health and wellness outcomes at 15 sites in Newfoundland and 15 sites in Nova Scotia.

We have partnered with the governments of Nova Scotia and Newfoundland and Labrador, as well as a technology partner GreenSpace.  Together, we will develop a stepped-care management platform to integrate mental health tools with traditional practices. The goal of the platform is to improve care by providing a framework through which to systematically organize, monitor and administer various levels of mental health treatment. Mental healthcare providers at 15 sites in each province will undergo training in stepped mental healthcare and use of the digital management platform.  Once implemented, this new approach to organizing and delivering care will be compared to treatment as usual.

We expect stepped mental healthcare will improve the quality of care, reduce wait times and increase access to care, especially for people living in remote areas and those whose changing life circumstances require a more flexible kind of care tailored to their unique challenges. This new approach to care includes a wider range of treatment options, including psychiatric care, individual and group counselling, online treatment programs with built in professional support, self-help resources and peer support. The management system will make it easy to tell quickly when treatment is working well or when a transition in care is required. The program will also allow patients to be more involved in care planning and decision making.


To follow…