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Evidence to Improve Care

Transitions Between Hospital and Home

Care for People of All Ages

These quality statements describe what high-quality care looks like for people as they transition between hospital and home.

See below for a summary of the quality standard or download it for more detailed statements.

Download the Quality Standard

Quality Statement 1: Information-Sharing on Admission
When a person is admitted to hospital, the hospital shares information about the admission with their primary care and home and community care providers, as well as any relevant specialist physicians, soon after admission via real-time electronic notification. These providers in the community then share all relevant information with the admitting team in a timely manner.

Quality Statement 2: Comprehensive Assessment
People receive a comprehensive assessment of their current and evolving health care and social support needs. This assessment is started early upon admission, and updated regularly throughout the hospital stay, to inform the transition plan and optimize the transition process.

Quality Statement 3: Patient, Family, and Caregiver Involvement in Transition Planning
People transitioning from hospital to home are involved in transition planning and developing a written transition plan. If people consent to include them in their circle of care, family members and caregivers are also involved.

Quality Statement 4: Patient, Family, and Caregiver Education, Training, and Support
People transitioning from hospital to home, and their families and caregivers, have the information and support they need to manage their health care needs after the hospital stay. Before transitioning from hospital to home, they are offered education and training to manage their health care needs at home, including guidance on community-based resources, medications, and medical equipment.

Quality Statement 5: Transition Plans
People transitioning from hospital to home are given a written transition plan, developed by and agreed upon in partnership with the patient, any involved caregivers, the hospital team, and primary care and home and community care providers before leaving hospital. Transition plans are shared with the person’s primary care and home and community care providers and any relevant specialist providers within 48 hours of discharge.

Quality Statement 6: Coordinated Transitions
People admitted to hospital have a named health care professional who is responsible for timely transition planning, coordination, and communication. Before people leave hospital, this person ensures an effective transfer of transition plans and information related to people’s care.

Quality Statement 7: Medication Review and Support
People transitioning between hospital and home have medication reviews on admission, before returning home, and once they are home. These reviews include information regarding medication reconciliation, adherence, and optimization, as well as how to use their medications and how to access their medications in the community. People’s ability to afford out-of-pocket medication costs are considered, and options are provided for those unable to afford these costs.

Quality Statement 8: Coordinated Follow-Up Medical Care
People transitioning from hospital to home have follow-up medical care with their primary care provider and/or a medical specialist coordinated and booked before leaving hospital. People with no primary care provider are provided with assistance to find one.

Quality Statement 9: Appropriate and Timely Support for Home and Community Care
People transitioning from hospital to home are assessed for the type, amount, and appropriate timing of home care and community support services they and their caregivers need. When these services are needed, they are arranged before people leave hospital and are in place when they return home.

Quality Statement 10: Out-of-Pocket Costs and Limits of Funded Services
People transitioning from hospital to home have their ability to pay for any out-of-pocket health care costs considered by the health care team, and information and alternatives for unaffordable costs are included in transition plans. The health care team explains to people what publicly funded services are available to them and what services they will need to pay for.

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