Care transitions occur when patients transfer between different care settings (e.g., hospital, primary care, long-term care, home and community care) and between different health care providers during an acute or chronic illness. Transitions are critical and vulnerable points in the provision of health care. Transitions between hospital and home are complex, multiple-step processes that require communication and coordination among the patient, their caregivers, the hospital team, primary care, and home and community care providers.
When patients’ care transitions are not managed well, patients and caregivers may suffer harm from errors and delays in care. Either can result in avoidable hospital admissions, emergency department visits, and increased health care costs.
At maturity, Ontario Health Teams (OHTs) will support high-performing integrated care delivery systems across Ontario and seamless transitions for patients. To help OHTs (and any organizations working to integrate care) achieve this, Health Quality Ontario has published a final draft of the Transitions Between Hospital and Home quality standard that outlines how your team can achieve a seamless discharge from hospital to home and community using the best available evidence.
To complement the release of this quality standard, Health Quality Ontario has published a playbook, which describes how the Transitions Between Hospital and Home quality standard supports OHTs in providing seamless, fully coordinated care—a key success factor in integrated care delivery systems. Playbook users will learn how the quality standard can benefit an OHT and help meet the OHT's year 1 expectations, as well as tips, tools, and resources to support the implementation of each statement.