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Evidence to Improve Care

Transitions Between Hospital and Home

Care for People of All Ages

This quality standard addresses care for people of all ages transitioning (moving) between hospital and home after a hospital admission. The transition from hospital to home is commonly referred to as a “hospital discharge.” This includes people who have been admitted as inpatients to any type of hospital, including complex continuing care facilities and rehabilitation hospitals. “Home” is broadly defined as a person’s usual place of residence and may include personal residences, retirement residences, assisted-living facilities, long-term care facilities, hospices, and shelters.

The scope of this quality standard includes all clinical populations, including groups that often face challenges with transitions, such as people with complex care, mental health, addictions, palliative, or end-of-life care needs. The scope also includes all health care providers.

Although many of the statements may apply to them, this quality standard does not address the specifics of:

  • Transitions between inpatient mental health settings and home

  • Transitions from the emergency department to home

  • Postnatal care for healthy, stable mothers and infants returning home

  • Patients with an Alternate Level of Care (ALC) designation

This quality standard does not address:

  • Transitions from children’s to adults’ services

  • Inter- and intra-hospital transitions

Thank you for your comments and feedback. Based on all the feedback received we have updated the draft quality standard, patient guide and added additional resources.

The updated guides and resources below are in draft form. Please check back here in a few months for the finalized versions.

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Quality Standard

Clinicians: Know what quality care looks like, based on evidence and expert consensus

Download the Draft

Quality Standards Draft

Patient Conversation Guide

When getting ready to leave the hospital: Know what to ask for in your care

Download the Draft

Quality Standards Draft

Case for Improvement (slide deck)

Share why this standard was created and the data behind it, to get the support you need to put it into practice

Download the Draft

Quality Standards Draft

Data Table

Identify where there are gaps in care in your region, to inform resource planning and improvement efforts

Download the Draft

Quality Standards Draft

Measurement Guide

See the technical specifications for the indicators within the quality standard

Download the Draft

Quality Standards Draft

In early 2018, Health Quality Ontario asked Ontarians about their transitions from hospital to home. Over 600 patients and caregivers shared their stories with us – some of success and others about the gaps in care they experienced. We heard simple stories, moving stories, and stories that were complex (see our report on these stories here).

What we heard was only the beginning.

Next, we wanted to understand what parts of transitions back home are most important to Ontarians. What should be priorities when it comes to improving transitions in care?

Later in 2018, we asked once again and you responded.

This is what we learned.

Read the report

Thank you to Dr. Tara Kiran at St. Michael's Hospital and the 600+ patients and caregivers who shared their experiences transitioning from hospital to home. This work has informed the development of a quality standard for Transitions Between Hospital and Home.

This project started in September 2017.

Health Quality Ontario thanks the following individuals for their generous, voluntary contributions of time and expertise to help create this quality standard:

Amir Ginzburg (co-chair)
Chief and Medical Director, Medicine Program, Trillium Health Partners
Clinical Quality Lead, Mississauga Halton Local Health Integration Network and Health Quality Ontario

Lianne Jeffs (co-chair)
Research and Innovation Lead and Scholar in Residence, Sinai Health System
Nursing and Health Disciplines Senior Clinician Scientist, Lunenfeld-Tanenbaum Research Institute

Carole Ann Alloway
Cofounder, Family Caregivers Voice
Lived Experience Advisor

Chantal Backman
Assistant Professor, University of Ottawa

Tanya Baker
Clinical Practice Manager, Bayshore HealthCare

Carole Beauvais
Chief Executive Officer, Nucleus Independent Living

Lara de Sousa
Vice-President, Client Services, Circle of Care, Sinai Health System

Julie Drury
Lived Experience Advisor
Minister’s Patient and Family Advisory Council, Ministry of Health and Long-Term Care

Laurie Hebert
Patient Flow, Discharge Planner, Health Link Coordinator, Arnprior Regional Health

Helen Janzen
Manager, Integrated Community Service Programs
Lead, Long-Term Care and Placement, Waterloo Wellington Local Health Integration Network

Helene LaCroix
Vice-President, Clinical Innovations, Saint Elizabeth Health

Brenda Laurin
Co-chair, Health Quality Ontario Patient, Family and Public Advisors Council
Lived Experience Advisor

Joanne Maxwell
Senior Director, Collaborative Practice, Holland Bloorview Kids Rehabilitation Hospital

Susan McKenna
Clinical Lead Pharmacist, Pharmacy Services, Kingston Health Sciences Centre

Jennifer Mills
Executive Director, Quinte and District Rehabilitation

Andrea Moser
Associate Medical Director, Long-Term Care and Chief Medical Information Officer, Baycrest Health Sciences
Clinical Quality Lead, Health Quality Ontario
Quality Table Chair, Health Quality Ontario

Shailesh Nadkarni
Regional Director, Patient Care and Partnerships, Hamilton Niagara Haldimand Brant Local Health Integration Network

Elly Nadorp
Care Coordinator Coach, Western Ottawa Health Link
Social Worker, Pinecrest Queensway Community Health Centre

Diana Nichol
Registered Nurse and Quality Improvement and Effective Transitions Lead, Tilbury District Family Health Team

Michael Nickerson
Lived Experience Advisor

Karen Okrainec
Clinician Scientist, University Health Network, University of Toronto

Thuy-Nga (Tia) Pham
Physician Lead, South East Toronto Family Health Team

Suzanne Saulnier
Director of Behavioural Support Services, LOFT Community Services

For more information, contact

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