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Evidence to Improve Care

TRANSITIONS FROM HOSPITAL TO HOME

Care for People of All Ages


This quality standard addresses care for people of all ages transitioning (moving) from hospital to home, commonly referred to as “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, and shelters.

The scope of this quality standard includes all clinical populations, including groups that often face challenges with transitions (e.g., people with mental health, palliative, or end-of-life care needs), and applies to all health care providers.

The quality standard offers guidance on the continuum of care from being in hospital to preparing for a successful discharge (i.e., discharge planning and process, timely services and support after discharge) and returning to the community (i.e., coordination of home care and follow-up medical care in the community, out-of-pocket costs, and the limitations of funded services).


Thank you for your comments and feedback. The consultation period has now ended.

The two guides below are in draft form. Please check back here in a few months for the finalized guides and for a variety of other resources related to this standard.

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Quality Standard

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

Learn More

The clinical guide cover



Patient Conversation Guide

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

Read more

Patient conversation guide cover

In early 2018, Health Quality Ontario asked Ontarians about their transitions from hospital to home. Over 1,000 patients and caregivers shared their stories with us – some of success and others about the caps 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 1,000+ patients and caregivers who shared their experiences transitioning from hospital to home. This work has informed the development of a quality standard for Transitions from Hospital to 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
Caregiver
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, Baycrest Health Sciences
Chief Medical Information Officer, Toronto Central Local Health Integration Network
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 Sauliner
Director of Behavioural Support Services, LOFT Community Services

For more information, contact QualityStandards@HQOntario.ca.

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