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Dr. Joshua Tepper and Dr. Tara Kiran

Transitions in Care: Telling the Patient Story

Often marked by uncertainty and anxiety, the transition from hospital to home can be a confusing time for patients and their caregivers.

These transitions from one health care team or organization to another have long been recognized as challenging times in a patient’s journey through the health care system.

In fact, references to needing to deal more effectively with transitions appears throughout Health Quality Ontario’s, Quality Matters: A Plan for Health Quality, the organization’s blueprint for creating a higher quality health care system in the province.

“Transitions are indeed a challenge: a patient can be under the care of a provider who, in essence, disappears before someone else assumes responsibility,” says the report. “Patients get lost in the shuffle. They can be unsure of whom to call when they need information about their medical condition.”

From the patient perspective, the report notes: “When you are discharged from hospital and require follow up, you want aftercare to be available without having to chase it down. You want the “system” to just work efficiently so that you don’t have to wait so long for appointments.”

Because transitions is an important quality issue, Health Quality Ontario has just launched an initiative in which patients and their caregivers are being asked through a survey to tell us about what stood out for them – good or bad—about their care experience during the transition from hospital to home. Home could include supportive housing, shelters, long-term care facilities and nursing homes.

Health Quality Ontario is also partnering with other organizations to host conversations about this topic in their communities. The aim is to hear directly from patients -- and their caregivers -- across Ontario who have had a lived experience of being discharged home from hospital.

Some of the most common notable experiences will be summarized and patients will be asked to rate how important these factors are to ensure a good experience. We realize that what matters to patients may differ depending on where they live or their background.

The findings from this work will directly inform many activities at Health Quality Ontario including future indicators to measure health system performance on transitions and a future quality standard outlining what quality care should look like for people as they transition from hospital to home.

Response to this outreach has been positive so far with a number of people responding to the survey. Common themes both positive and negative are already emerging.

What is unique about this particular initiative is that it focuses on patient experience rather than outcomes or cost savings. Input from patients will be used to directly influence what the improvement priorities should be in this area.

The survey is just part of the work being done to try to enhance quality care during the transition process. Health Quality Ontario is also working to add patient-reported transitions experience questions to existing provincial surveys. Transitions in care was also one focus of Health Quality Ontario’s yearly Measuring Up report on how the health care system is performing.

Health Quality Ontario has also recently partnered with the Council of Academic Hospitals of Ontario to help spread to 27 hospitals throughout the province the Patient Oriented Discharge Summary (PODS) - a standardized yet adaptable tool that provides patients with a set of clear and easy-to-understand instructions to follow after they are discharged from hospital.

If you have experienced a transition from hospital to home as a patient or caregiver in the last three years, you are invited to complete the survey or consider hosting a conversation on this topic in your community.

Dr. Joshua Tepper is President and CEO of Health Quality Ontario. Dr. Tara Kiran is Quality Improvement Program Director and Board Chair for the St. Michael’s Hospital Academic Family Health Team and Health Quality Ontario project lead of the Transitions in Care patient initiative.


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