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NOW UPDATED: Ontario Health’s Transitions Between Hospital and Home Care for People of All Ages (originally released in 2020) addresses care for people of all ages transitioning (moving) between hospital and home after a hospital admission. This includes people who have been admitted as inpatients to any type of hospital, including complex continuing care facilities and rehabilitation hospitals. The transition from hospital to home is commonly referred to as a “hospital discharge.” “Home” is broadly defined as a person’s usual place of residence and includes personal residences, retirement residences, assisted-living facilities, long-term care facilities, hospices, and shelters. This update aligns the quality standard with the most recent clinical evidence and with current practice in Ontario. For a summary of updates, please see pages 7–8 of the quality standard.

Transitions are critical and vulnerable points in the provision of health care. When care transitions are poorly managed, patients may suffer harm from errors and delays in care. These issues can lead to avoidable hospital admissions, emergency department visits, and increased health care costs while negatively affecting patient experience. In addition to potential patient harms, family members and care partners may also experience distress during poorly managed transitions owing to anxiety and burnout from the sudden responsibility of having to provide complex care without adequate training or support. Ontario has significant opportunities to improve transitions between hospital and home. Below are some tools that may help you put the quality statements into practice. Many of these tools support multiple quality statements and are therefore grouped by general theme.

Are there other tools or resources you use to support high-quality transitions? Do you have experience implementing these tools? If so, please let us know in the comments section below!

Comprehensive Resources Related to the Transitions Between Hospital and Home Quality Standard

Discharge and Care Planning:

• interRAI Implementation Toolkit—a collection of practical resources for health care organizations to use when implementing an interRAI assessment system (from the Canadian Institute for Health Information)
• Patient-Oriented Discharge Summary (PODS)—a hospital discharge process and package codesigned by patients and staff to improve follow-up care (from OpenLab, a member of the University Health Network)
• Supporting Transitions from Acute/Community Into Long-Term Care—a checklist to support transitions for older adults with responsive behaviours or personal expressions to long-term care from a hospital or the community (from Behavioural Supports Ontario)

Hospital Readmission Risk Assessment:

• LACE Index—a tool to assess a patient’s risk of hospital readmission (from the Health System Performance Network)

Medication Reconciliation:

• Best Possible Medication Discharge Plan—a tool to help manage a patient’s medications after hospital discharge (from the Institute for Safe Medication Practices Canada)
• Hospital to Home – Facilitating Medication Safety at Transitions —a toolkit to support medication safety throughout transitions (from the Institute for Safe Medication Practices Canada)
• Medication Reconciliation in Acute Care: Getting Started Kit—a toolkit to help interdisciplinary teams improve medication safety for their patients (from the Canadian Patient Safety Institute and the Institute for Safe Medication Practices Canada)
• Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation —a toolkit to detect and prevent medication discrepancies (from the Agency for Healthcare Research and Quality)
• Ontario Primary Care Medication Reconciliation Guide—a guide for primary care teams to reconcile patient medications (from the Institute for Safe Medication Practices Canada)

Resources for Patients, Families, and Care Partners

For Patients:

• Quality Standard Patient Guide—A guide for patients and care partners that helps people know what to ask for in their care and provides helpful resources (from Ontario Health)
• 5 Questions to Ask About Your Medications—a quick-reference guide for patients and care partners about what to ask clinicians about their medications (from the Institute for Safe Medication Practices Canada)
• CO-Health app—a digital app that helps patients with self-management tasks recommended by their clinicians and with managing their medications (from CO Health)
• MedRec:M—a digital app that helps patients keep track of their personal health information (from the Institute for Safe Medication Practices Canada)
• Shared Plan of Care (SPoC)—a tool to help parents and guardians share information about their children with members of their care team (from Family Voices)
• thehealthline.ca—a resource to find local health and community services across Ontario (from thehealthline.ca Information Network)
• AdvantAge Ontario—an organization that provides information and guidance related to managing care for older adults

Local Programs and Supports for Patients:

• Home at Last—a free program that provides older adults with up to 12 weeks of additional at-home support following hospital discharge (referral required) (from One Care Home & Community Support Services)
• Ocean eReferral Network—An EMR-integrated, cloud-based technology for health care referrals (from OceanMD)
• Ontario eConsult Program—enables doctors to consult with specialists across the province to get faster access to advice for patient care (from Ontario Health)
• OntarioMD eNotifications—Near-real-time electronic notifications that alert primary care clinicians when their patients are discharged from the emergency department or are admitted or discharged from inpatient units (from OntarioMD)

Related Quality Standards:

• Behavioural Symptoms of Dementia: Care for People in Hospitals and Long-Term Care Homes
• Dementia: Care for People Living in the Community
• Hip Fracture: Care for People With Fragility Fractures
• Major Depression: Care for Adults and Adolescents
• Medication Safety: Care in all Settings
• Palliative Care: Care for Adults With a Serious Illness
• Schizophrenia: Care for Adults in Hospitals