A short-term service offering intensive follow-up (typically two to three weeks) for individuals requiring support during transition from hospital discharge to community mental health, with a focus on ensuring timely connection to a mental health services or additional referral coordination.
The Integrated Transition Care Team (ITCT) supports adult mental health and substance use clients who are being discharged from a hospital requiring short-term support during transition from hospital to community. This is a short-term, intensive service provided for typically two to three weeks after a client is discharged. It is designed to ensure a safe and supported transition back into the community.
ITCT provides comprehensive assessments, individualized care planning, psychiatric monitoring and crisis management. The services help clients connect to community mental health and substance use teams, primary care providers and other essential services such as, substance use supports and social resources. The team works closely with clients to stabilize their care, prevent hospital readmission and bridge them to longer-term supports.
Clients can expect:
- Comprehensive assessment with individualized care plan.
- Intensive case management, psychiatric monitoring, risk assessment and crisis management.
- Referral coordination to other resources such as housing, community services and substance use resources.
- Guiding and support through services.
- Assistance with medication administration, monitoring and management.
- Help finding a primary care practitioner if they do not already have one.
- Helping clients attend a follow-up psychiatric assessment with a psychiatrist at ITCT.
- Helping clients transition to services within the mental health centre if they require ongoing support beyond two to three weeks.
Access
Eligibility
- Clients not receiving mental health services through Fraser Health or in a hospital
- Open referral to community mental health and substance use service
- Suicide risk assessment completed
- Require immediate enhanced services until connected to a community mental health and substance use team
- Stable housing (shelter bed accepted)
- Psychiatric consult completed
- Discharged from hospital
- Connected to counsellor, recovery home or treatment centre where psychiatrists are not available will be accepted
- Resides in the communities of New Westminster, Tri-Cities, Mission, or Abbotsford
This service may not be suitable for clients who are already connected to a psychiatrist (such as from mental health teams, private practices, mental health centres, Assertive Community Treatment service and Bed-Based Treatment services).
Referral
Referrals are accepted from the in-patient psychiatry unit within Fraser Health for clients being discharged from the hospital in need of support from the ITCT team. As well, referrals can be received from the Chilliwack General Hospital Emergency Department.