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Assess post-discharge risk and activate the appropriate follow-up

• Use an evidence-based risk assessment tool to assess risk for rehospitalization
  Process measure: Percent of patients who have a risk assessment done prior to discharge
  LACE online risk assessment tool by the Health System Performance Research Network
• Consider referring patients with multiple chronic conditions and complex needs to Health Links
  Process measure: Percent of patients with multiple chronic conditions and complex needs referred to Health Links
  Health Links Resources by Health Quality Ontario
• Provide a warm handoff from hospital to home care (e.g., by having home care coordinators in place in hospital and holding care conferences before discharge that involve the care coordinator and the community interdisciplinary team)
  Process measure: Percent of patients identified to be at risk for rehospitalization who were offered a pre-discharge care conference with interdisciplinary team, including the home care coordinator

Provide patient education and encourage self-management

• Use the teach-back method to ensure patients and caregivers understand the conditions of their care and what is required post-discharge
  Always Use Teach-Back! Toolkit by UnityPoint Health, Health Literacy Iowa, and Des Moines University
• Create a coordinated approach to support patients, caregivers and providers with self-management
  South West Self Management Program by the South West LHIN

Use specialized teams of practitioners and technology to enable care at home

• Use technology such as the Ontario Telemedicine Network or e-notifications about patient discharge
  Process measure: Percentage of eligible patients who receive care via the Ontario Telemedicine Network