01 / UNDERSTAND THE GAP
This campaign focuses on adults discharged home from psychiatric emergency care, before a receiving service has accepted their referral.
The person is assessed. A decision is made about what happens next.
The person goes home. A referral is sent to a follow up service.
Who tracks the referral, stays in contact and acts if it is declined?
The receiving service confirms acceptance. A care plan can move forward.
WHAT THIS QUESTION MEANS
“Owner” means a named administrative role that stays responsible for coordinating the transition. Clinical decisions remain with clinicians.
That role should know whether the referral was received, whether it was accepted, what happens next and what to do if the plan breaks down.
A person may already have a family physician, a specialist or a bridging program. The question is how the handoff works when they do not, when contact fails or when short term support ends.
WHAT THE NOVEMBER REPLIES ADD
PPAO identified Ontario Health’s Transitions Between Hospital and Home standard. It describes transition planning, follow up and a point of contact. The standard covers transitions home after hospital admission. Its scope section says it does not address the specifics of transitions from the emergency department to home or from inpatient mental health settings to home. Read the standard ↗ · Scope on page 2 ↗
CAMH said it assigns no specific role to ensure referrals made in its emergency department are followed up. It described a notification route when a referral is declined, starting with the referring provider and potentially involving primary care. Read the CAMH reply ↗
WHAT THE PUBLIC RECORD SHOWS
Different measures tell different stories. We keep their populations and limits attached.
ICES reports a gradual decline in physician follow up within 7 days after mental health and addictions hospital discharge.
This measure is about hospital discharges. It is not an ER discharge follow up rate. Data to March 2025.
ICES · December 2025 ↗ICES reports a gradual rise in mental health and addictions ER revisits within 30 days of an ER visit.
A different group from the hospital discharge measure. Provincial trends do not establish the cause of a particular revisit. Data to December 2024.
ICES dashboard · December 2025 ↗Ontario Health’s major depression standard calls for a scheduled clinician appointment within 7 days after acute care discharge.
Condition specific. A quality standard, not a universal legal entitlement. Applicability to ER visits without admission needs clarification.
Ontario Health · reviewed in brief October 10, 2026 ↗WHAT ALREADY EXISTS
CAMH describes short term care for people referred from its emergency department or crisis inpatient units, with follow up for up to 3 months. Its current page requires attendance within 6 weeks of referral. That is a local pathway with eligibility limits.
CAMH Bridging Clinic · checked November 2, 2026 ↗CPSO expects referring physicians to explain their role during referrals and to track urgent referrals. Consultants must acknowledge referrals no later than 14 days, urgently when needed, and communicate acceptance or refusal. Its detailed home discharge section applies to inpatients.
CPSO Transitions in Care · checked November 2, 2026 ↗The campaign’s October evidence brief records the Mahoney inquest jury’s 2022 recommendations on treatment wait reporting and assessing a coordinating advocate role. These are recommendations. Their implementation has not been verified in this campaign.
See the source and its limits ↗ONE QUESTION. A BETTER STANDARD.
Ask your elected representative who stays accountable until follow up care accepts the person.
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