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Bridging the Gap Between Hospital and Community Mental Health Services for Frequent Emergency Department Visitors

Inappropriate emergency department (ED) use is costly. A system navigation service was developed to connect individuals with repeated ED presentations due to mental health or substance use to community services. Management, staff, and clients (n = 37) participated in interviews or focus groups to identify implementation challenges and associated solutions. Referrals were improved through ED staff support and automating the process. The outreach process, decreased service duration, and prompt support with connection to services facilitated program delivery. Two newly funded programs addressed the limited capacity of other services, and technology facilitated communication. Attention to partnerships and flexibility in the design were essential.