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. 2026 Mar 10;20(3):e70161. doi: 10.1111/eip.70161

Enabling Successful Transitions From Hospital Back to Campus: An Example of an Innovative Navigator Service for Post‐Secondary Students With Acute Mental Health Needs

Kristin Cleverley 1,2,3,✉, Sarah Brennenstuhl 4, Andrea J Levinson 3,5, Chris Bartha 4, Carole‐Anne Chiasson 3, Lexi Ewing 3, Melissa Griffin 3, Rosalind McManus 3, Saba Nasir 3
PMCID: PMC12973351  PMID: 41804945

ABSTRACT

Introduction

Increasing numbers of post‐secondary students (PSS) are reporting mental health problems, and service needs often outweigh campus capacity, especially among PSS with acute issues. Stronger pathways linking campus and hospital‐based care have therefore been recommended. In collaboration with Canada's largest university and largest mental health and addictions hospital, a Navigation Service for PSS accessing the emergency department (ED) was launched in 2022. The service provides developmentally appropriate, trauma‐informed transition support to PSS following hospital discharge to prevent recurrent crises. This paper describes service development, design, and usage.

Methods

Health administrative data from the first 2 years of service use were analysed to describe the population of PSS using the ED. Factors associated with service referral, service registration and ED return after service discharge were examined using logistic regression and Fisher's exact tests.

Results

Six hundred and forty‐nine PSS used the ED between September 2022 and August 2024 and of these 331 (51%) were referred to the service. Referrals were significantly associated with younger age, female gender, lack of provincial health insurance, and suicidal ideation; lower odds of referral were associated with substance use. ED return after discharge from the service (11.8%) was significantly lower than among those never referred (22.1%, p = 0.02).

Conclusion

The service fills an essential gap in the landscape of student mental health services by ensuring PSS requiring hospital intervention can safely return to campus. Two years of data provide important insights regarding who is getting a referral and what can be done to improve service access.

Keywords: acute care, emergency room visits, mental health, navigation, post‐secondary institution, post‐secondary students

1. Introduction

Increasing numbers of postsecondary students (PSS) disclose having a mental health disorder (Hong et al. 2022; Linden et al. 2021; Lipson et al. 2018; Wiens et al. 2020) with reports of some conditions such as anxiety and depression nearly twice as high as compared to 10 years ago (Wiens et al. 2020). Data from the World Health Organization International College Student Survey shows 35% of PSS globally have at least one common mental health disorder (Auerbach et al. 2018). Unsurprisingly, the steep rise in reported mental health concerns has been accompanied by increasing demand for services among PSS (Linden et al. 2021; Lipson et al. 2019). For those with acute and complex needs, limited assessment and psychiatric care available on campus suggests increased demand often exceeds local capacity (Read et al. 2022). Increased and potentially unmet mental health needs come with a continuum of risks from dropout of academic studies (Auerbach et al. 2016) to attempted or completed suicide (Lageborn et al. 2017; Uchida and Uchida 2017). Some data suggests up to 25% of PSS have considered suicide (Ogrodniczuk et al. 2021). Sadly, however, the mental health needs of a majority of students who attempt, or complete suicide have been shown to go largely unrecognised on campus (Moghimi et al. 2023; Uchida and Uchida 2017).

For many young people, the emergency department (ED) is the first point of contact for mental health care (Gill et al. 2017). Local hospitals have been the default option for managing mental health crises among PSS (Gorman et al. 2020). Several studies suggest ED use by PSS for mental health purposes has increased over time (Clements et al. 2023; Hong et al. 2022), mirroring the broader rise in mental health problems in this population (Lipson et al. 2018; Wiens et al. 2020). For students using the ED, however, the transition back to campus is often poorly coordinated, and a shared plan is rarely present (Neilson et al. 2020; Ontario College Health Association 2009). As the risk of adverse events, such as suicide, is heightened after psychiatric hospital discharge, this period has great significance for ensuring PSS receive the supportive care needed (Chung et al. 2017).

Higher demand for mental health services exacerbated by tragic instances of suicide among PSS has put enormous pressure on post‐secondary institutions (PSI) to manage increasingly complex mental health needs on campus (Duffy et al. 2019; Mancini and Roumeliotis 2019). PSI have begun to meet this challenge by redesigning the delivery of mental health services (University of Toronto 2019). In recognition of students' increasing use of hospitals for mental health needs, there have been multiple calls for the development of stronger pathways linking campus and hospital‐based care (Carleton University 2016; Duffy et al. 2019; University of Calgary 2015; University of Toronto 2019; Western University 2018). Linkage to acute care has been formalised within Stepped Care Models for post‐secondary environments that organise care to meet the needs of students from the least to most intensive options (Cornish et al. 2017).

System navigation inclusive of discharge planning and linkage to appropriate care has been shown to decrease 30‐day hospital readmissions (Sfetcu et al. 2017; Vigod et al. 2013) and reduce mental health impairment in the general population (Steffen et al. 2009). While system navigation models designed specifically for youth show great promise in reducing ED use and increasing transition readiness (Cleverley et al. 2021; Cleverley, Salman, et al. 2025), a scoping review suggests no models exists for PSS specifically (Cleverley, Rowland, et al. 2020). To address the need for formal pathways between campus and hospital‐based care, a model originally designed to support transitions from hospital‐based child and youth mental health services to community‐based services (Cleverley, Gore, et al. 2018) was adapted to the post‐secondary environment (Cleverley et al. 2023; Levinson et al. 2023). This was achieved in partnership with students using Expedited Experience Based Co‐Design (Green et al. 2020; Springham and Robert 2015). Based on shared decision making, the Post‐Secondary Navigation Model works to facilitate successful transitions by collaborating with the PSS to: (1) outline and prioritise transition goals, (2) assess transition readiness and (3) communicate with clinicians and service providers to determine the level and type of care needed post‐acute care discharge (Cleverley et al. 2023; Levinson et al. 2023).

This paper reports on the implementation and use of an innovative post‐secondary Navigation Service in partnership between Canada's largest university and psychiatric hospital.

1.1. Service Development

The University of Toronto (UofT) is the largest university in Canada with 99 794 students across three campuses and serves a diverse domestic and international student population (Facts and Figures, n.d.). Each campus has a dedicated health centre, delivering primary care and mental health services, with mental health concerns representing approximately 50% of visits, equalling over 50 000 visits annually. The Centre for Addiction and Mental Health (CAMH) is the largest mental health and addictions academic health science hospital in Canada and is geographically co‐located with the largest of the three UofT campuses. The two institutions recognised the opportunity to partner to develop a dedicated Navigation service to better meet the needs of PSS.

In 2020, Executive Leadership at CAMH and UofT established a joint governance structure to design and implement the University of Toronto Navigation Service (UTN) consisting of an Advisory Table and two Planning Tables. The Advisory Table was responsible for tracking the planning process and included operational and clinical leaders from both institutions. The Planning Tables focused on clinical pathway/model development and the evaluation framework, respectively. A key enabler of this work was access to resources from both hospital and post‐secondary environments. For example, hospital project management resources supported changes to the Electronic Health Record (EMR). This enabled ‘UofT Student’ to be added to the standard hospital registration form and for the first time the identification of PSS for data collection purposes. Project management also supported process mapping and building forms within the EMR to enable further data collection. Funding for two new clinical navigator positions was provided by the university as prioritised through a new office of Student Mental Health within the Vice Provost Students office. The collaboration of university and hospital subject matter experts established a team with a comprehensive skillset spanning clinical, operational, research and data analytics expertise.

1.2. Service Design

The UTN service was designed to prioritise the needs of PSS by providing developmentally appropriate, trauma‐informed transition support when discharged from hospital, to prevent recurrent crises, and unnecessary repeat ED visits. Many UofT students are new to the city, if not the province or country, and lack family or other local support systems. Many are also dealing with the complexity of the health care and post‐secondary systems for the first time. Lack of support and systems knowledge, combined with undiagnosed or undertreated mental health concerns, further exacerbated by academic and other stressors, place student populations at additional risk. The UTN service was designed specifically to address the conditions creating unique vulnerability and manage risk using developmentally appropriate care. Through provision of a Navigator, the UTN service ensures each student is provided with dynamic and highly customised support and linked to university resources (e.g., housing, Accessibility) and mental health services (e.g., outpatient psychiatry, counselling), enabling transition goals to be met, whether they return to university studies, arrange for an academic leave, or go back to their family home. All students accessing CAMH, enrolled at the university and living in the province are eligible for the service.

Two referral pathways were designed and built into the EMR order system. One pathway is for students discharged from the ED (or ED overflow clinic) and a second is for students discharged following inpatient admission. Detailed process mapping enabled the development of a clear workflow to guide decision making. See Figure 1 for the ED referral pathway workflow. To optimise identification of students presenting to a very busy ED environment, the Navigators spend time in the ED and attend rounds to build relationships and engage in case finding. For high‐risk students without support in place, a co‐referral model was enacted in collaboration with the Bridging Clinic, a low barrier, walk‐in service at CAMH, to provide interim psychiatric and therapeutic care post ED or inpatient discharge until the student can be formally connected.

FIGURE 1.

FIGURE 1

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ED referral pathway workflow.

The Navigator role is built on core competencies of clinical social work practise (occupational therapists and registered nurses may be well suited to the role too) to assess students' transitional support needs, establish navigation goals, and identify potential barriers to recovery and academic reintegration (Cleverley, Gore, et al. 2018). The Navigators work collaboratively with the university health centres, university crisis teams, and community partners. The Navigation work is divided into three phases: (1) Intake and assessment; (2) Navigation support and connection to services; (3) Navigation service discharge. See Figure 2 for a description of the Phases, with examples of key activities. A critical early activity unique to this service involves seeking consent from the student to share information across institutions; the consent process was co‐designed with students to ensure it worked for them. Role clarity has been essential, requiring ongoing education to ensure understanding and collaboration across both institutions. Clinical supervision is provided by a psychiatrist cross‐appointed to CAMH and UofT and a clinical psychologist at CAMH.

FIGURE 2.

FIGURE 2

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Navigation phase, timing and examples of key activities.

2. Materials and Methods

A robust evaluation framework was integrated into the service design from the beginning, facilitated by a planning table dedicated to this goal. The key to evaluation has been leveraging existing data sources, including the hospital EMR, and integrating Equity, Diversity and Inclusion (EDI) data. This project was approved by the Quality Project Ethics Review at CAMH.

2.1. Participants

The PSS in the evaluation dataset included all those identified in the CAMH EMR as UofT students who presented to the ED, and all inpatient and outpatient UofT students who received a referral for UTN during the first 2 years of the service implementation (September 2022 to August 2024). As CAMH's ED provides psychiatric assessment and treatment for mental health and substance use concerns, all participants' presenting issues will fall within these domains. While minor physical health issues are addressed at CAMH as part of comprehensive mental health care, individuals presenting with a primary physical health emergency are transferred to a local hospital equipped to manage acute physical illness.

2.2. Measures

UTN service use data included ED visits, referral to the UTN service, service registration, discharge from service, use of ED within 6 months of discharge and service use year (2022/23 or 2023/24). Demographics included age (16–20, 21–25, 26+), gender identity (woman, man, another gender identity, prefer not to answer), and presence of provincial health insurance (yes/no). In Canada, each province or territory provides a single‐payer system that covers medically necessary hospital and physician‐based care (Canada 2016). Presence of provincial insurance coverage, therefore, acts as a proxy for whether the student is international or from out of province. Ethnicity was not included in the overall models due to high levels of missing data but is presented in the sample description. Previous hospital use data included previous outpatient visit (past year), previous inpatient visit at CAMH (past year), and previous ED visit at CAMH (past year). Clinical information included Canadian Triage and Acuity Scale (CTAS) (Bullard et al. 2008) score and presenting problem.

2.3. Analysis

Descriptive statistics were used to summarise the sample using the ED and stratified by UTN service referral (yes/no). All variables are categorial and described using frequency counts and percentages. For those with multiple ED visits (n = 207), data from the first relevant visit was used, defined as either their first ED visit if they never received a UTN referral or the ED visit where they received the UTN referral. The prevalences of receiving a referral, registering with the service, and returning to the ED within 6 months of discharge were calculated. Logistic regression was used to identify variables associated with receiving a UTN referral from ED, inpatient or outpatient service (Model 1), and registering for the service among those with a referral (Model 2). Potential predictors included: age, gender identity, presence of provincial insurance, past year ED use, past year inpatient admission, past year outpatient visit, CTAS score, and presenting problem(s). Model findings are visualised using forest plots. All predictors were left in the model regardless of p‐value. Model diagnostics were used to test assumptions before a final model was selected. Fisher's Exact Test was used to identify variables associated with returning to the ED within 6 months among those discharged from the service due to the small sample sizes. In addition, a two‐proportion z test was conducted to compare the 6‐month ED return rates between PSS discharged from UTN (the ‘intervention’ group) and PSS who never received a UTN order (the ‘non‐intervention’ group). All tests are two‐sided; a p‐value of 0.05 was used to assess statistical significance.

3. Results

3.1. Referrals to UTN

A total of 649 PSS used the ED between September 2022 to August 2024; of these students, 331 (51%) received a UTN order. Characteristics of PSS using the ED, and those who did and did not receive a UTN order are shown in Table 1.

TABLE 1.

Characteristics of Post‐Secondary Students Presenting in the CAMH ED according to Whether they Received a Referral for the University of Toronto Navigation Service.

Overall, N = 649 No UTN referral, N = 318 UTN referral, N = 331
Year of ED visit
2022–2023 351 (54%) 194 (61%) 157 (47%)
2023–2024 298 (46%) 124 (39%) 174 (53%)
Age
16–20 103 (16%) 34 (11%) 69 (21%)
21–25 369 (57%) 155 (49%) 214 (65%)
26+ 177 (27%) 129 (41%) 48 (15%)
Gender
Woman 373 (57%) 161 (51%) 212 (64%)
Man 224 (35%) 123 (39%) 101 (31%)
Non‐binary 13 (2.0%) 10 (3.1%) 3 (0.9%)
Trans Woman/Trans Man 5 (0.8%) 4 (1.3%) 1 (0.3%)
Prefer not to answer 24 (3.7%) 13 (4.1%) 11 (3.3%)
Do not know 10 (1.5%) 7 (2.2%) 3 (0.9%)
Ethnicity
White 163 (29%) 92 (35%) 71 (24%)
Black 45 (8.1%) 28 (11%) 17 (5.8%)
Asian 221 (40%) 87 (33%) 134 (46%)
Indigenous 4 (0.7%) 3 (1.1%) 1 (0.3%)
Middle Eastern 29 (5.2%) 15 (5.7%) 14 (4.8%)
Latin 23 (4.1%) 13 (5.0%) 10 (3.4%)
Other ethnicity not listed 7 (1.3%) 4 (1.5%) 3 (1.0%)
Prefer not to answer 39 (7.0%) 12 (4.6%) 27 (9.2%)
Do not know 25 (4.5%) 8 (3.1%) 17 (5.8%)
Presence of provincial health plan 434 (67%) 238 (75%) 196 (59%)
Previous inpatient visit 93 (14%) 38 (12%) 55 (17%)
Previous outpatient visit 231 (36%) 106 (33%) 125 (38%)
Previous ED visit 205 (32%) 87 (27%) 118 (36%)
CTAS score
CTAS 1 2 or 3 287 (45%) 125 (40%) 162 (49%)
CTAS 4 or 5 356 (55%) 188 (60%) 168 (51%)
Presenting problem: Anxiety 146 (22%) 67 (21%) 79 (24%)
Presenting problem: Depression 152 (23%) 68 (21%) 84 (25%)
Presenting problem: Mania 19 (2.9%) 9 (2.8%) 10 (3.0%)
Presenting problem: Psychosis 50 (7.7%) 26 (8.2%) 24 (7.3%)
Presenting problem: Substance use 53 (8.2%) 40 (13%) 13 (3.9%)
Presenting problem: Suicidal ideation 260 (40%) 106 (33%) 154 (47%)
Presenting problem: Self‐harm 10 (1.5%) 4 (1.3%) 6 (1.8%)
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Abbreviations: CTAS, Canadian Triage and Acuity Scale; UTN, University of Toronto Navigation Service.

As shown in Figure 3, PSS who received a UTN referral were more likely to have visited the ED in 2023–2024 compared to 2022–2023, be younger in age, identify as female, and not have a provincial health insurance number (i.e., be an out‐of‐province or international student). Students presenting with suicidal ideation were more likely to receive a UTN referral whereas students presenting with substance use were less likely.

FIGURE 3.

FIGURE 3

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Odds ratios predicting University of Toronto Navigation Service referral with 95% confidence intervals.

3.2. Service Registration

Of the 331 PSS who received a UTN referral, 249 (75%) registered with the service. PSS who registered were more likely to have visited the ED in 2023–2024 (compared to 2022–2023), had a past year outpatient visit, and presented with suicidal ideation than those who did not register with the service (see Figure 4).

FIGURE 4.

FIGURE 4

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Odds ratios predicting University of Toronto Navigation Service registration with 95% confidence intervals.

3.3. Discharge and ED Return

Of the 110 students discharged from the UTN Service who were followed for at least 6 months for ED return, 11.8% (n=13) returned to the ED in this timeframe compared to 22.1% for students who never received a UTN referral. This difference was statistically significant, χ2(1, N = 377 = 5.33, p = 0.021, 95% CI [0.0246, 0.1809]). There was a significant positive association between ED return and past year inpatient visit (OR = 4.78, 95% CI [1.04, 20.44]; p = 0.022). All individuals who returned to the ED had a prior outpatient visit, resulting in an undefined odds ratio due to complete separation.

4. Discussion

Two years of service use data demonstrate the extent to which PSS are using a single ED to address their mental health problems. This reinforces calls for better pathways linking campus and hospital‐based services and the need for navigation services such as the one described. Despite nearly universal eligibility criteria for UTN, the referral rates were 50% for the 2 years. Integrating a new service into a very established ED is a major change, so while we are working to increase the rate of referrals, we consider 1 in 2 students receiving a referral a good outcome at the 2‐year mark. In addition to the challenges of integrating the service, analysis of the data suggests student‐level factors may also influence the decision to refer.

4.1. Student Referrals and Service Engagement

Younger age predicted receiving a referral suggesting a bias toward those presenting more ‘student‐like’. Given the age range of PSS accessing the service and the knowledge that graduate students may not be youth (Government of Canada 2014), it is important to remind physicians that referrals ultimately should reflect student status and need, not age or student‐like appearance. Women PSS had a higher likelihood of referral compared to men and those reporting another gender identity. There is some research on adolescents indicating that young women may be more aware of referral pathways (Haavik et al. 2019), which in the context of the UTN service could mean they engage in greater self‐advocacy for further mental health services. Women are also more likely to consult with mental health professionals, especially for suicidal ideation (Cox 2014), and therefore may be over‐represented in the ED to begin with, as our data suggests. The high proportion of PSS using the service without provincial health insurance (33%) also underscores the role the service plays in catching those who may otherwise fall through the cracks of the Canadian health care system, such as international students. Certain presenting problems were associated with a higher likelihood of referral, such as suicidal ideation, and others with lower, such as substance use. Just under half of all ED presentations by PSS were associated with a presenting problem of suicidal ideation, underscoring the heightened risk of suicidality in younger populations (Lui et al. 2023), and PSS in particular (Mortier et al. 2018). This more frequently observed student presentation may make treating psychiatrists more likely to consider referral to services like UTN. Finally, referrals were more likely in the second year of service, probably due to several strategies introduced to increase referral rates. These included: (1) active case finding including greater collaboration with inpatient teams to identify students; (2) regular education for new staff and residents; (3) retrospective file reviews to identify why students did not receive a referral and (4) improved visibility of service by ensuring a Navigator was available on site 5 days a week. To further improve referral rates, UTN referrals could be integrated in the ED order set as an opt‐out option versus an elective referral.

In addition to not receiving a referral, it is possible that some students decline the referral. Anecdotal information suggests that some PSS are fearful of having the university know about their mental health status, worrying that it might affect their academic standing. While we do not have data to substantiate these anecdotal reports, a funded research study called NavigateCAMPUS began recruiting from CAMH in 2024. Students will be followed from intake into UTN to 6 months after discharge. Importantly, qualitative data will be collected to better understand student perspectives on the service (Cleverley, Brennenstuhl, et al. 2026).

We found some attrition between receiving a referral and registering for the service (i.e., booking first appointment). Part of this drop‐off may be explained by administrative reasons, such as cancelled referrals and changing eligibility (e.g., student moved out of the province); however, loss to follow up also appears to play a role demonstrated by repeated unreturned calls to students by the Navigators. PSS who received a referral and registered for the service were more likely to have accessed outpatient services at CAMH before. This suggests familiarity with the hospital may predispose students to service engagement. We also found increased registration with the service in the second year, perhaps indicating greater proficiency with approaching students regarding use of the service.

4.2. Return to the ED After Service Use

Providing an initial indication of service effectiveness, we found that only 11.8% of students discharged from the UTN service returned to the ED within 6 months. This is significantly lower than the 22.1% with repeated ED use within 6 months who were not referred to UTN. Returning to the ED among those discharged from UTN was associated with past year inpatient admission, which is consistent with other research on return ED use among youth (Roberts et al. 2018). The lower ED return rate after UTN service use is a provisional indicator of service efficacy that will need to be tested more formally in future research.

4.3. Model Scalability

While all UofT students are eligible for the UTN service (and students have accessed the service from all three geographically separated campuses), those living near the west‐ and east‐end campuses may be less likely to use the downtown CAMH ED given the geographical inconvenience. To enable more equitable access to Navigation for students, adaptation and scaling of the model to hospitals near the west‐ and east‐end campuses are currently planned or underway. The adaptation process must consider community hospital environments, which manage more than just mental health concerns, and how existing hospital navigation resources can be leveraged. To ensure PSS Navigation does not exceed service capacity at local hospitals, in the adapted model, navigation roles and tasks related to the university will be integrated within the campus health centres. Successful post‐secondary Navigation models based on hospital partnerships require a flexible approach that enables feasibility across different contexts to support scalability.

4.4. Limitations

We could not link the hospital‐based data with university‐based data to verify that students are indeed returning to their studies and accessing care on campus. While measurement‐based care data is being collected as part of the evaluation framework to explore symptom‐based changes across the Navigation period, low response rates at discharge due to system‐ (e.g., patient data collection sites not working) and student‐ (e.g., lack of compliance) based factors has limited our ability to use this data from the earlier service implementation period. Finally, this evaluation was not designed to test service efficacy. While we found initial evidence of effectiveness based on the lower rate of ED return among those discharged from the UTN service, future research will be needed to confirm this finding using more sensitive outcome measures to demonstrate successful transition, such as attending a mental health appointment within 30 days of discharge (Cleverley, Brennenstuhl, et al. 2026).

5. Conclusions

The University of Toronto Navigation Service fills an essential gap in the landscape of student mental health services by ensuring those who require hospital intervention can safely return to campus and, hopefully, continue their studies. Two years of data provide many insights about how students engage with the service and how it can be fully optimised.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

We are grateful to the students, clinicians, and staff at the University of Toronto and CAMH who generously shared their time and expertise to inform the adaptation of the Post‐Secondary Navigation Model and support its implementation at CAMH.

Data Availability Statement

Research data are not shared.

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