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Quality Improvement

Transitions between Hospital and Home

Patients who have multiple conditions and complex needs may require care across different health care settings (e.g., hospitals, family physicians, specialists etc.), which could potentially pose serious risks to their safety and quality of their care. Incomplete or inaccurate transfer of information, lack of comprehensive follow-up care, and/or medication errors at the time of transition could be very dangerous and cause serious, preventable harm to patients. Furthermore, the impact of these risks may be intensified by patients and families who feel unprepared for self-management, and are unsure of how to access appropriate health care providers for follow-up.

The figure below is an outline of both innovative practices and evidence-informed best practices that are designed to improve transitions between hospital and home.

Please click on the image for more information.

Early in the Hospital Admission

Throughout the Hospital Stay and Transition Process

Close to Time of Discharge

In the Community After a Hospital Stay


The use of these practices varies significantly across the province. Teams are encouraged to prioritize the implementation of evidence-informed best practices before adoption of the innovative practices outlined in these documents. When considering the adoption of innovations, recommended practices should be considered first, followed by promising practices, and then emerging practices.

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