The HUB and the Spoke

Bill MacEwan, MD, FRCPC

Head, Department of Psychiatry, St. Paul's Hospital, Providence Health Care

It’s an average weekday at St. Paul’s Emergency Department, and Dr. MacEwan stands in the crowded hallway while physicians and staff whizz by. On this date, 29 of the 30 inpatient beds in the emergency department are being used by patients with mental health illnesses.

A mental health emergency can be just as urgent as those at risk of life or limb. Dr. MacEwan and his colleagues believe there is a better way to help patients in a crisis and, more importantly, reach them before their health concerns reach an emergency state.

Dr. Bill MacEwan, Head, Department of Psychiatry | Change the Labels | 2:12 The Hub and the Spoke

When it’s a broken bone or chest pains, most people know to head for the nearest hospital emergency department. But for those experiencing a mental health issue—depression, anxiety, or psychosis—it can often be difficult to recognize your health needs, or find the right care you need.

To confront these issues, Providence Health Care and Vancouver Coastal Health (VCH) are re-imagining how people access mental health care through three important initiatives: the HUB and the Rapid Access Addictions Centre (RAAC) at St. Paul’s Hospital, and the VCH’s Access and Assessment Centre (AAC) at VGH.


The HUB at St. Paul’s Hospital aims to divert mental health and substance use patients out of the regular flow of Emergency Department (ED) traffic, and redirect them to a new dedicated care setting, built on a model of rapid response and the co-location of acute and community resources.

This out-of-the-box solution comes in the form of state-of-the-art modular care spaces, which will allow St. Paul’s to co-locate services without any structural changes to the hospital.

The HUB will be comprised of two sites—a state-of-the-art clinical unit and a transitional centre—and support a transformation in access, care and follow-up for people with mental illness and problematic substance use. By providing quicker, integrated service in a culturally appropriate, trauma-informed way, the HUB will connect the care and expertise provided in a clinical setting to the housing, social and continuing care resources and supports that are already in place in the communities and neighbourhoods where patients live and are most familiar.

"The new St. Paul's HUB will provide the ED with the desperately needed space and resources to better serve a rapidly growing subset of our patient population, namely those with mental health and or substance use-related issues,” says Dr. Dan Kalla, head, Emergency Medicine, SPH and MSJ. “It will allow those patients to be treated with more dignity and privacy in an area more specialized to deal with their specific needs, while freeing up space in the rest of the department to deal with patients suffering from other medical conditions.”

The HUB is expected to redirect up to 6,000 emergency department visits annually, representing approximately 54% of emergency room volume for mental health and substance use. A large part of this redirecting will be seen through the introduction of the Rapid Access Addiction Center (RAAC).

Rapid Access Addictions Center

“The RAAC will provide addiction services from medical specialists, nursing, and social work in an outpatient setting located right in St. Paul’s Hospital,” says Nancy Chow, clinical nurse leader, RAAC. “These services are made accessible in a timely a manner, which is an integral approach to help stabilize the population presenting to the HUB.”

Closely allied with the ED, RAAC staff will serve as a source of expertise in addiction medicine for those with concurrent addiction, mental health and health issues. The clinic will not only provide a spot where patients are referred to, but staff at the RAAC will follow and support patients discharged from SPH who have been started on treatments for addiction during their hospitalization. In this way, RAAC will begin to divert of patient traffic out of the ED and into more specialized care, and also model the support services offered by the HUB’s transitional centre.

Transforming Care, Transitioning Care

The creation of a transitional centre at St. Paul’s will create a bridge for patients who are returning to challenging environments, enabling care providers to establish relationships to provide further support and reduce future visits to Emergency.  It will provide discharged patients with a safe space, after care, and connection to community services, through support by Integrated Case Management (ICM) teams, Assertive Outreach Teams (AOT) and Community Transition Teams (CTT).

“Coming into an emergency department is very overwhelming – it’s disruptive from patients’ normal support systems and it breaks down connections because of the step out of someone’s normal approach to care,” explains says Dr. MacEwan, head, Department of Psychiatry at St. Paul’s. “A lot of people come to emergency because they're in distress or having a crisis but if you can go right into the community and help people where they live, it’s preferable to them continually coming to the ED.”

In the same way, VCH’s Access and Assessment Centre takes pressure off of emergency departments by providing pathways for people and families to access mental health and substance-use services through a single point of access, which any adult in Vancouver with a non-life threatening mental health and or substance-use problem can access either in-person, or over the phone.

“We want to have the patient journey be improved so people can feel like they were shown a better way to move forward with their mental illness,” says Dr. MacEwan. “We also want our emergency staff to be able to fully attend to and care for the urgent patient cases that present in a space dedicated to emergency care. And ultimately, want to see better care for our patient.”

The HUB at St. Paul’s is the result of unique partnerships led by St. Paul’s Health Innovation, St. Paul’s Foundation, Vancouver Police Foundation, Vancouver Police Department, the City of Vancouver, Vancouver Coastal Health and the Ministry of Health.

Mental Health Hub Partners