November 4, 2025

Mental Health’s Missing Link: Why Care Coordination Is Central to Canada’s Preventive Strategy

Coordinated care management is the missing link in Canada’s mental health strategy; offering a proven, preventive approach that connects people to timely, equitable, and effective support.

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Latifa Soobedar

Mental health and wellbeing challenges in Canada are no longer just personal struggles or isolated crises. Exacerbated by the unprecedented challenges of 2020 and the pressures of our hyper- connected world, they have evolved into a collective concern, that touches millions of people, disrupts families, tests workplaces and stretches public systems to their limits. For federal, provincial and municipal governments, this growing need has become one of the defining health and social policy challenges of the decade.

Coordinated care management offers a practical, evidence-based way to reset the balance: recognizing problems early, keeping people connected with effective support, reducing inequities and easing pressure on acute services.

The Canadian Picture: Prevalence, Declines and Unmet Need

The scale of mental health challenges in Canada remains significant. The Mental Health and Access to Care Survey (2022) found that more than five million Canadians aged 15 and older met diagnostic criteria for a mood, anxiety or substance-use disorder in the previous year. Among young women aged 15–24, the 12-month prevalence of generalized anxiety disorder nearly tripled between 2012 and 2022, while major depressive episodes nearly doubled.

These concerns have not lessened. The Canadian Mental Health Association’s State of Mental Health in Canada 2024 report shows that one in four Canadians say symptoms of mental illness affect daily functioning. Among men aged 19–29, 43 percent report moderate to severe depression, with even higher rates among racialized men (Canadian Men’s Health Foundation, 2024).

Older adults are also affected: in late 2024, Statistics Canada reported that six percent of Canadians aged 65 and older live with a diagnosed anxiety disorder, with prevalence higher among women (7.5 percent) than men (4.2 percent).

Need for care continues to outpace availability. The Canadian Institute for Health Information (CIHI) reported in 2024 that 15 percent of adults said they did not get needed mental health services in the past year because of cost. Cost, awareness and fragmentation remain among the biggest barriers to access.

The Pan-Canadian Health Inequalities Reporting Initiative (2024) found that people experiencing food insecurity, unstable housing, or unemployment are far more likely to report poor mental health and less likely to access timely care. Youth face similar pressures: the Canadian Health Survey on Children and Youth (2023) found that 21 percent of young people rated their mental health as “fair” or “poor.”

The Role of Mental Health Care Coordination

People experiencing mental health concerns often describe the system as fragmented and overwhelming. A single person may interact with family physicians, psychiatrists, psychologists, counsellors, crisis teams, housing agencies and peer support groups—often without anyone ensuring those pieces fit together. This lack of integration leads to duplication, delays and missed opportunities for early intervention.

A 2024 study published in PubMed found that caregivers of people with serious mental illness described navigating services as a “second full-time job” and said coordinated care management reduced both their stress and the risk of loved ones falling through the cracks.

Mental health care coordination provides organized, proactive support that helps people access, navigate and stay engaged in a continuum of services. It includes:

  • Connecting to resources such as peer groups, drop-in clinics or group counselling—supports that often go unused simply because people don’t know they exist.
  • Facilitating provider communication so that information is shared and duplication avoided.

Preventive interventions only work when they are consistent and supported. Coordinators raise awareness, sustain engagement and identify risks early, thus reducing the risk of crises before they start.

The Measurable Impact of Mental Health Care Coordination

Canadian evidence confirms what clinicians and caregivers have long known: coordinated care management improves outcomes. Fragmented systems leave people cycling between waitlists and emergencies, while coordinated support helps them connect sooner, stay engaged longer and avoid unnecessary suffering. Some of the measurable impacts of mental health coordination we’ve seen recently include:

Together, the research makes clear that coordinated care management is far from a marginal add-on—it is rather, essential infrastructure for a fairer, more effective mental health system.

How Mental Health Care Coordination Bridges Gaps

Mental health care coordination changes how people find and maintain support. Instead of leaving individuals to navigate complex systems alone, coordinators provide direct, ongoing guidance.

Function of Care Coordination Benefit of Care Coordination in Mental Health Evidence That Care Coordination Works
Navigation and linkage to resources Helps people find free or low-cost supports such as peer groups, drop-in counselling and group programs, reducing dependence on costly private care. Family Health Team pilots show that many Canadians are unaware of available supports until a coordinator connects them (PubMed, 2024).
Transition support between care settings Prevents people from falling through the cracks after hospital discharge or crisis care by ensuring follow-up and continuity. CIHI reports that lack of post-discharge follow-up often leads to relapse and re-admission.
Reminders, monitoring and check-ins Regular follow-ups catch early warning signs such as disrupted sleep or worsening anxiety before they escalate into crises. Coordinated telehealth and primary care models are linked with fewer emergency visits and improved outcomes (BioMed Central (BMC) Primary Care, 2025).
Support for preventive practices Reinforces healthy sleep, physical activity and social connection—all core elements of mental wellness. National data link good sleep and physical activity with stronger mental health outcomes (PHAC, 2023).
Equity and cultural competence Makes care more accessible and relevant for Indigenous, rural, low income and newcomer populations. The Pan-Canadian HealthInequalities Reporting Initiative documents persistent mental health gaps that narrow when culturally safe, coordinated programs are in place.

These examples show that coordinated care management is not abstract policy—it is a set of proven, practical steps that improve outcomes and equity.

Building Care Coordination into Canada’s Mental Health System

Expanding mental health care coordination requires deliberate policy action. Federal, provincial and municipal governments all have roles to play in embedding coordination within health systems: setting expectations, funding sustainable roles and aligning incentives with prevention. The most impactful recommendations for government agencies include:

  • Formalize roles with committed funding. Coordinators need secure mandates in community, primary care and hospital settings. Predictable, multi-year funding and clear responsibilities are essential.
  • Build integrated networks across sectors. Housing, employment, social supports and justice all influence mental wellness. Integrated networks reduce silos and improve continuity.
  • Expand access to preventive community services. Peer groups, drop-in counselling and wellness programs remain underfunded. Mapping, subsidizing and integrating these supports strengthens early intervention.
  • Measure what really matters. Beyond wait times or hospitalizations, metrics must capture time from first symptom to support, participation in preventive services and whether people feel their needs are met.
  • Support workforce and cultural safety. Coordinators need training in trauma-informed, culturally competent care. Remote and Indigenous communities benefit from flexible delivery models such as virtual or mobile clinics.
  • Align funding models with prevention. When funding flows only to crisis response, systems stay reactive. Blended or outcome-based models that reward prevention and coordination shift incentives.

These steps make the system easier to use, more preventive and more equitable, replacing short-term fixes with sustainable improvements in mental health outcomes.

Barriers to Scaling Mental Health Care Coordination

Even with strong evidence, scaling coordination across Canada isn’t easy. Promising programs can falter when practical barriers are ignored. The most common challenges include:

  • Pilot fatigue and short-term funding. Many programs show promise but fail to expand when initial funding ends.
  • Lack of role clarity. Overlapping responsibilities between navigators and coordinators create confusion for patients and caregivers.
  • Cultural relevance and geographic diversity. Indigenous, rural and low income populations face significant access gaps.
  • Difficulty measuring prevention. Preventive outcomes are harder to quantify than crises.
  • Duplication and overload. Launching similar roles without coordination risks inefficiency.

These barriers are design challenges, not reasons to hesitate. With foresight, cultural humility and sustained investment, governments can scale coordination sustainably and equitably.

Measuring Success: Indicators That Count

Governments need clear indicators to show that clinical coordination is improving mental health outcomes. Success must be measured not only by crisis response but also by prevention, continuity and equity.

Key indicators include:

  • Proportion of people with anxiety, depression or other mental health symptoms whose needs are met or unmet
  • Time from first symptom to first intervention
  • Participation in community and preventive supports
  • Number and quality of care transitions with follow-up
  • Rates of emergency department visits or hospitalizations for mental health crises
  • Patient and caregiver satisfaction with support and connection
  • Long-term outcomes such as improved screening scores, quality of life and social connectedness

From Crisis Response to Coordinated Care: A Path Forward

Canada deserves a mental health system that does more than respond to emergencies—one that helps people feel supported early, stay engaged through ups and downs, and avoid crises where possible.

Mental health care coordination may be the missing link, turning what we know works into what people can actually access. Policymakers at every level of government have a chance to formalize roles, integrate sectors, fund prevention, measure what matters and support the workforce.

Already in 2025, 31 percent of Canadians report that mental health challenges are significantly affecting their work or studies (Mental Health Research Canada). Without coordinated solutions, both cost and suffering will continue to grow.

With thoughtful design and compassion in policy, Canada can move toward a system that is less reactive, more humane and truly supportive of everyone.

Join Us in Building a Better System

At Serefin Health, we believe coordinated care management has the power to transform how Canadians experience mental wellbeing. We invite leaders at all levels of government to work with us in building a more connected, preventive and compassionate mental-health system.

Latifa Soobedar

Latifa Soobedar leads Serefin's expansion across the Middle East and Africa, blending clinical psychology expertise with a vision for transformative corporate wellness. With over 18 years in psychology and a Master’s from the University of Stellenbosch, she is a specialist in EMDR, Clinical Hypnotherapy, and CBT.

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