One in six people in hospital don’t need to be there.
This startling reality reflects Ontario's hospital capacity crisis, made worse by staff shortages and delays in care. Many of these patients have nowhere else to go. They are designated as Alternate Level of Care (ALC) patients, meaning they no longer require hospital care but cannot leave due to a lack of suitable placement, such as a long-term care or rehabilitation facility.
To address this issue, CAMH, Reena, and Surrey Place have partnered to launch a new program that moves low-income ALC patients with developmental disabilities and mental illnesses—a dual diagnosis—out of hospitals and into specialized supportive housing. CAMH provides mental health support, Reena offers specialized housing and developmental services, and Surrey Place delivers comprehensive care for individuals with autism and developmental and sensory-related concerns.
By combining expertise and resources, the program creates a streamlined pathway for people to access affordable, specialized housing and wraparound support services tailored to their unique needs.
People with dual diagnoses are among the most vulnerable to becoming ALC patients. Because the mental health and developmental services they require are spread across different sectors and rarely offered in the same place, finding appropriate housing that meets their complex needs is a significant challenge. This program fills that gap by emphasizing community integration—moving people out of hospitals and into homes where they can rebuild their independence and quality of life.
Since welcoming its first patients in August 2023, the program has successfully moved eight ALC patients into accessible and affordable housing.
"A hospital is not a home. People with complex needs deserve a place where they can live with dignity—where they can build skills, form connections, and work toward greater stability," says Willie Thorman, Case Manager within CAMH’s Forensic Outpatient Services. "By creating a clear path from hospital to home, this program helps patients take back their lives while also relieving pressure on our health care system by freeing up much-needed hospital beds."
At the heart of the program is a commitment to personalized, trauma-informed care. Patients and families are actively involved in the transition process—from selecting housing to shaping support plans— ensuring that services reflect the full scope of a person’s physical and mental health, cognitive, social, and cultural needs. Each residence is chosen with the person in mind and features personalized adaptations such as lockable storage, reinforced furniture, and window modifications to enhance privacy and security. These thoughtful changes help patients feel safe, comfortable, and empowered in their new homes. Our organizations were actively involved throughout the transition process leading up to discharge. Reena's staff visited inpatient units daily to meet with patients and collaborated with teams to ensure a smooth discharge to the community.
"This place is good for my son—it is a home, not a hospital. Now that he's closer to me in Woodbridge, I'm able to see him every weekend," said a family member of a patient.
As the partnership evolves, it aims to set a new standard for improving patient transitions from hospital to community living. Future objectives include expanding the availability of housing placements, enhancing care coordination, and advocating for systemic changes that better support people with dual diagnoses. In line with these goals, our organizations and other key stakeholders participated in a 'Think Tank Day' last week. This event focused on understanding and strengthening services and care pathways for the dual diagnosis population through shared insights, innovative practices, and strategic action planning.
About Our Partners
Reena is a non-profit organization that promotes dignity, individuality, independence, personal growth and community inclusion for people with diverse abilities within a framework of Jewish culture and values. Learn more about Reena at: https://reena.org/.
Surrey Place is a not-for-profit organization that helps people of all ages with autism-, developmental-, and sensory-related concerns push the boundaries of what’s possible to achieve new victories. With a holistic circle of care approach, Surrey Place brings together caring clinicians, staff, valued partners and other experts to collaborate for the client’s best interests. Learn more about Surrey Place at: https://www.surreyplace.ca/.
