Patient transfers between different care settings (e.g.,
hospital, primary care, community care) and between different clinicians during
an acute or chronic illness are critical and vulnerable points in the provision
of health care, especially for older adults and people with complex needs.
Across Ontario Health programs, teams are using the updated
Transitions Between Hospital and Home quality standard to align quality improvement, digital enablement, and home
and community care coordination to make transitions more reliable, informed,
and person-centred.
We are pleased to share some examples of how the Transitions
Quality Standard is being implemented to inform and support your ongoing work.
Hospital Clinical Quality Programs – DASH / GeMQIN / ONSQIN
Current focus includes strengthening delirium screening and assessment and
expanding education and supports for families and care partners. In 2025/26,
family and caregiver engagement in delirium prevention and early recognition
was added as a specific change concept to build shared understanding of
baseline function, reduce barriers to recognition, and support earlier
response.
Evidence-to-Practice (E2P) Program
E2P’s digital enhancements embed multiple transitions quality statements into
day-to-day acute care workflows. Standardized order sets, medication
reconciliation processes, and patient/provider discharge summaries (e.g.,
PODS-like tools) support more consistent transition planning, communication,
and education across sites.
Enhanced In-Home Remote Care Monitoring (RCM)
This model emphasizes continuity immediately after discharge, often with
same-day outreach paired with home-based assessment, medication reconciliation,
and follow-up with primary and specialty care. Virtual monitoring and shared
communication across teams help identify issues early and support patient- and
caregiver-defined goals during recovery at home.
Ontario Health Team (OHT) Implementation
OHTs continue to advance coordinated, community-based care that supports
transitions across sectors. Current work focuses on building awareness of the quality
standard and supporting the spread of leading practices through regions and OHT
partners where feasible.
Ontario Health at Home (OHaH)
OHaH supports earlier and more coordinated transition planning through timely
patient/family engagement, standardized assessment processes, and care
coordination for hospital discharges. Near-term priorities include expanding
e-notifications across hospitals, testing and scaling standard automatic
data-sharing (testing in spring 2026, with broader roll-out targeted for fall
2026), and strengthening access to timely medication lists to support
post-discharge medication review.
Looking Ahead
Work will continue in 2026/27 to strengthen admission and discharge workflows,
align digital tools with clinical practice, and clarify cross-sector roles and
responsibilities so patients experience smoother, safer transitions between
hospitals and home.
Connect With Us
Teams working on transitions of care, discharge communication, remote care monitoring,
or hospital-to-home coordination are encouraged to comment below to share what
is working, where challenges persist, and opportunities to spread and scale
effective approaches.
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