Collaborative Care Relationship Between Seven Oaks Tertiary Care Facility and Seven Oaks ACT Team

The Seven Oaks Assertive Community Team (ACT) is linked with the Seven Oaks Tertiary Care Facility for the provision of respite and short term admissions (2 or 3 days) with relapse, thereby preventing acute care access and improved quality of care for clients. This model is unique and requires excellent team dedication and the coordination of care. This collaboration has provided hope and opportunities to many patients who were previously thought to require lifelong “asylum” level care. It has given them the chance to live far more independently in the community, often in their own apartments, supported intensively by an outpatient team sponsored by the same facility. As a direct result of the Seven Oaks Facility and the local ACT teams working under the same clinical director, the vision, administrative leadership, and governance of both have been efficient with a patient-centred focus. There is as seamless an orientation as possible during discharge planning or the return of patients to the facility. This approach has helped severely ill and refractory patients, as well as the staff, become more comfortable addressing the clinical implications of moving from a hospital-based to a community-based service model. Detailed community service plans, that are electronically stored and available to all Seven Oaks staff, provide transparent and accountable service collaboration. This enables a majority of patients to be supported in independent living arrangements in their own apartments, or in public mental health housing apartments provided by the health authority and other community agencies. An evaluation framework was developed and the collaboration’s effectiveness was demonstrated using performance measures such as a reduction in emergency room visits, inpatient admissions, and costs in acute care.