Photo caption: One of three transitional supportive housing sites that are part of the CREATE program.
By: Camille Quenneville, Chief Executive Officer, Canadian Mental Health Association (CMHA) Ontario
As Ontario continues to redesign health care around increasingly complex needs, partnerships between hospitals and community mental health and addictions organizations offer a blueprint for the future. Connecting specialized hospital care with specialized community mental health and addictions services strengthens system capacity to meet demand, while improving outcomes for individuals through seamless pathways to care. These partnerships demonstrate what this approach can look like in practice, with models that bridge hospital and community care to support people with complex needs.
An example of this collaboration is the Collaborative Residents Enabling Assisted Transitional Engagement (CREATE) program in Durham Region, a partnership between Ontario Shores Centre for Mental Health Sciences (Ontario Shores) and the Canadian Mental Health Association, Durham. The program provides supportive housing and ongoing care for people with complex mental health needs, helping reduce hospital readmissions and Alternate Level of Care (ALC) pressures while improving hospital bed flow.
For people with complex mental health needs, hospital care provides stabilization and specialized treatment, and community services offer supportive housing, connections to care and the life skills needed for long‑term success.
Community mental health organizations like CMHA Durham have established networks of support for their clients, including relationships with landlords, peer support workers, case management services and affordable housing providers. Hospitals and other health care partners work in collaboration with community mental health and addictions providers for crisis services, acute mental health supports, intensive case management, rehabilitation, supportive housing and other specialized services. Care pathways co-designed with the combined expertise of hospitals and community-based providers improve system capacity, strengthen transitions and ensure continuity of care.
What is the Intervention?
The CREATE program begins before patients leave the hospital, with discharge planning and referrals made by their hospital care team. Patients then transition to one of three transitional supportive housing sites, where residents receive ongoing clinical care delivered in partnership between Ontario Shores and CMHA Durham.
As part of the program, residents have access to around-the-clock supports with activities of daily living, such as medication administration, budgeting, hygiene and meal preparation. Together with residents, Ontario Shores and CMHA Durham establish progress milestones toward independent or less intensive housing placement, usually within two years of entering the program. When clients have progressed through the program but aren’t yet ready for independent living, the CREATE program offers step-down units with less intensive supports to create capacity for new hospital discharges.
A defining feature of the CREATE program is the integration of supportive housing into the care pathway. Supportive housing, including transitional housing, combines affordable housing with ongoing mental health services and daily living supports, helping residents remain stable in the community and connected to care. For many people living with complex mental health needs, supportive housing prevents crises, enables successful discharge from hospital and constitutes essential health infrastructure.
For clients like J.F., CREATE provides an important stepping stone in her mental health journey. “I love my CREATE home,” she says. “The staff here are very helpful. I’m now better at organizing my room thanks to staff. Staff even help me learn to cook as well. There are so many good things I can say. [...] Thank you for giving me a place to call home.”
In 2025, 40 per cent of CREATE participants achieved independent or supported housing outcomes and the program boasts a zero per cent readmission rate to the hospital within 30 days of transitioning out of the hospital.2
Solving a Shared System Challenge Together
ALC pressures are a shared health system challenge. The success of the CREATE program reminds us that improving health system capacity goes beyond strictly clinical spaces; it also depends on the community-based services and infrastructure that allow individuals to receive care in community and thrive outside of hospitals.
Investing in both community mental health care and hospital care is essential to building a high-performing, integrated health system. CMHA Durham and Ontario Shores demonstrate what is possible when hospitals and community organizations work as equal partners, with supportive housing recognized as a core component of care. Hospitals and community mental health organizations championing innovative, locally responsive models like CREATE will be essential to building the connected mental health system Ontarians need and deserve.
To learn more about the CREATE model, read the peer-reviewed article Preparing for Independent Living Following Psychiatric Hospitalization and see the CMHA Durham CREATE program webpage.