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The Transitions Between Hospital and Home Quality Standard by the Quality business unit of Ontario Health provides guidance for the care of people of all ages transitioning from hospital to home (commonly called “hospital discharge”). This quality standard provides guidance for the care of people of all ages transitioning from hospital to home (commonly called “hospital discharge”).

The quality standard includes 10 quality statements addressing areas that have high potential for improving the quality of care for people in Ontario transitioning from hospital to home.

Below is a sample of tools and resources that may help you with the implementation of the quality statements into practice.

Are there other tools or resources you use? Do you have experience implementing these tools? If you have feedback about any of these tools, please use the comments section below to share!

Clinical Practice Supports

Discharge and Care Planning:

• interRAI Implementation Toolkit—a collection of practical resources from the Canadian Institute for Health Information that health care organizations can use when implementing an interRAI assessment system
• Patient Oriented Discharge Summary (PODS) —a hospital discharge process and package codesigned by patients and staff to improve follow-up care
• Supporting Successful Transitions into Long Term Care Report and Checklist —a report and checklist launched by Behavioural Supports Ontario to support transitions of older adults with responsive behaviours/personal expressions into long-term care homes

Hospital Readmission Risk Assessment Tools:

• LACE index tool —a tool to assess a patient’s risk of hospital readmission
• Hospital Admission Risk Prediction [HARP] —a tool to assess a patient’s risk of readmission from the Canadian Institute for Health Information

Medication Reconciliation:

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

Digital Health Solutions

Electronic Communication Systems:

• eNotifications—a tool from Ontario MD that sends a near real-time electronic message sent through Health Report Manager to primary care providers to notify them when their patients are discharged from the emergency department or are admitted to, or discharged from, in-patient units
• Ocean eReferral Network—a network that allows health care providers to securely send electronic referrals in real-time while keeping patients informed
• Ontario eConsult Program—a tool from the Ontario Telemedicine Network that allows doctors to consult with specialists across the province to get faster access to advice for patient care

Developing and Sharing of Coordinated Care Plans:

• Client Health and Related Information System (CHRIS)—a tool that supports the delivery of care at home and in the community, allowing patients to get the right care, at the right time, at the right place
• Shared Health Integrated Information Portal (SHIIP) —a custom web application to help direct care from hospitals to the community and to prevent hospital readmission

Resources for Health Care Professionals

• Bringing Care Home—a report of the Expert Group on Home and Community Care that proposes a number of recommendations to improve home and community care
• Continuity of Care: Transitions in Care—a policy by the College of Physicians and Surgeons of Ontario that sets out their expectations of physicians when patient care is transferred between physicians, or between physicians and other health care providers
• Managing Transitions: A Guidance Document—a guidance document developed by the Ontario Hospital Association that helps health care providers comply with legislative and regulatory requirements, and highlights the important role of health care providers, patients, families, and caregivers in facilitating patient flow across the continuum of care
• Single Point of Care (SPOC) Document—a tool that can help keep track of complex medical information for pediatric patients
• Team-Based Transition Management: A Hospital Discharge Follow Up Process —a slide deck developed by the Tilbury District’s Family Health Team that supports the effective management of patient transitions from hospital to home in the primary care setting
• Thriving at Home: Levels of Care Framework—a report of the Levels of Care Expert Panel that provides a levels of care framework to improve the quality and consistency of home and community care for people in Ontario

Resources from the Quality business unit at Ontario Health:

• bestPATH: Transitions of Care—an evidence-informed improvement package that highlights change concepts and tools designed to improve transitions of patients from hospital to home and community
• Hospital Overcrowding Webinar (Part I)—Timely and Efficient Transitions webinar series (part 1 of 2) to support the 2019/20 quality improvement plan indicators related to improving transitions in care
• Hospital Overcrowding Webinar (Part II)—Timely and Efficient Transitions webinar series (part 2 of 2) to support the 2019/20 quality improvement plan indicators related to improving transitions in care
• Quorum Post—a post entitled “Timely and Efficient Transitions: Addressing hospital overcrowding in the 2019/20 QIPs”
• Quorum Indicators and Change Ideas—a tool explaining the quality indicators being tracked by health care organizations in Ontario through Quality Improvement Plans (QIPs), and evidence-based change ideas to help improve them
• Transitions Between Hospital and Home—a summary of innovative practices to support transitions between hospital and home

Resources for Patients, Caregivers, and Families

For Patients:

• 5 Questions to Ask About Your Medications—a quick reference guide for patients and caregivers about the questions they should ask about their medications when seeing their doctor, nurse, or pharmacist
• CoHealth App—a digital app that allows patients to keep track of self-management related tasks that have been recommended by their health care providers, as well as the management of their medications
• MyMedRec—a digital app developed by the Institute for Safe Medication Practices Canada that allows patients to keep track of their own personal health information

Local Programs and Supports for Patients:

• Home at Last—a free program from OneCare Home & Community Support Services that works collaboratively with hospitals, community support service agencies, and community care access centres to the ensure smooth transitions of patients and caregivers from hospital to home
• Home First Philosophy—a partnership program among the Central East region, hospitals, home and community care, and community support services that facilitates timely discharge from hospital following an acute care stay
• Integrated Comprehensive Care (ICC)—a program at St. Joseph’s Healthcare Hamilton that supports the seamless transition of patients from hospital to home by ensuring access to a care coordinator, a single contact for patients can call for information, and leveraging the expertise of an interprofessional team and virtual care
• Priority Assistance to Transition Home (PATH)—a partnership program between the Canadian Red Cross and Timiskaming Home Support that helps patients make the transition from hospital to home safely, smoothly, and comfortably
• thehealthline.ca—a resource to find local health and community services across Ontario

For Family and Caregivers:

• Better Together Campaign—an initiative from the Canadian Foundation for Healthcare Improvement that called on hospitals and health care delivery organizations across Canada to implement family presence policies as an important step toward delivering more patient and family-centred care
• CaregiverExchange.ca—a mini-site of the thehealthline.ca that provides information about services, articles, and videos specifically for caregivers, along with an online caregiver forum, where caregivers can ask questions and support each other
• Guides and Checklists for Family Caregivers—resources for family caregivers about navigating medical visits, hospital and discharge planning, rehabilitation, and home care
• The Ontario Caregiver Organization—resources from an organization that raises awareness of the caregiving role and provides information and support to family caregivers

For Senior Patients:

• AdvantAge Ontario—an organization that provides information and guidance related to managing care for seniors
• My Way Home—a program in the Mississauga Halton region that provides in-home and community health care services for patients who are currently in the hospital but have health care needs that could be met in the community

Tools and Initiatives to Support Health Equity

• Guide to Requirements and Obligations Relating to French Language Health Services —a guide from the Ontario government intended to help strengthen health system accountability and performance and support services for Ontario’s Francophone communities
• Health Equity Impact Assessment—a decision support tool developed by the Ministry of Health and Ministry of Long-Term Care that walks users through the steps of identifying how a new program, policy, or similar initiative will impact population groups
• Non-Insured Health Benefits for First Nations and Inuit—a national program through the Government of Canada that provides coverage to registered First Nations and recognized Inuit for a specified range of medically necessary items and services that are not covered by other plans and programs
• Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Implementation and Action Toolkit —a standardized risk assessment tool that accounts for social determinants of health
• The Everyone Project Toolkit—a health screening tool to help family physicians address social determinants of health in their practices and communities

Comment below to describe your experience with these tools or share any others you have found useful!