Transitions between different sectors of the health care system (e.g., from hospital to home) can be stressful for patients and caregivers, who must navigate the system while dealing with health issues.
Good transitions in care require effective communication among patients, their caregivers, and the health care providers at each organization involved. When transitions go poorly, they can result in negative outcomes (e.g., readmission to hospital) and poor patient experience.
Improving transitions in care requires organizations in all sectors of the health care system to come together to ensure that patients are getting the care and support they need, when and where they need it. Although much attention has been devoted to improving transitions in care over the past several years, there has been a lack of progress provincially in improving key measures of transitions.
Through the Quality Improvement Plans (QIPs), organizations assess their progress toward improvement on key provincial priorities by monitoring their performance on a set of quality indicators. Timely and efficient transitions in care is a key theme in the QIP Priorities for 2019/20. Through the QIPs, organizations across the province and in different sectors of the health care system can work together to improve transitions in care.
This series of posts will:
- Introduce the QIP transitions indicators and how they align with one another
- Outline an approach to addressing these indicators and link to the resources, tools and templates to support this work
- Present a case study to show how transitions can be addressed using partnerships among organizations as well as with patients
What matters to patients during transitions in care?
To improve transitions in care for patients and caregivers, we needed to hear from them about what issues need to be addressed.
In 2018, a province-wide consultation was conducted with people with lived experience of transitions from hospital to home. The goal was to find out what matters most to them during this time. Here is what they said:
- Not enough publicly funded home care services to meet the need
- Home care support that is not in place when arriving home from hospital
- Having to advocate to get enough home care
- Not being involved in discharge planning
- Once home, having no contact numbers for people to call if there is a problem
- During discharge planning, the assumption by hospital staff that family and friends will provide care
- Long waits for follow-up appointments with family doctors and specialists
- Unclear or inconsistent communication about health status in preparation for going home
Although some of these issues will require increased funding or capacity, many are within the control of health care organizations and can be improved in collaboration with other local organizations and patients.
Key resources to improve transitions in care
Transitions Between Hospital and Home Quality Standard
Read this quality standard, developed by Health Quality Ontario (now Ontario Health [Quality]), to learn what quality care looks like for people transitioning between hospital and home. This quality standard was developed in partnership with an advisory committee of health care providers and patients and caregivers with lived experience. It incorporates some of the QIP indicators related to transitions in care
Transitions Between Hospital and Home Playbook
Review this playbook to learn how the Transitions Between Hospital and Home Quality Standard can support the new Ontario Health Teams in providing seamless, fully coordinated care.
Posts about effective transitions on Quorum
Follow the Effective Transitions tag on Quorum to read the latest posts related to transitions in care.