Readmissions
Improving care transitions from acute to community settings can reduce unplanned readmissions and improve the overall quality of healthcare. In Ontario, a number of best practices and innovative interventions have been undertaken recently. These changes promise to improve integration within our healthcare system.
Articles
Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community 
Carl van Walraven et al., CMAJ 182(6): 551-557. The Ottawa hospital created the LACE Index, which predicts the risk of unplanned readmissions or death after discharge. 
Hospital Readmissions for Patients with Mental Illness in Canada 
Nawaf Madi et al., Healthcare Quarterly 10(2): 30-32. This article review, conducted by the Canadian Institute for Health Information (CIHI), describes the patterns found in readmissions to hospital during 2002–2003 for patients whose most responsible diagnosis was a mental health issue.
Integrated Complex Care Model: Lessons Learned from Inter-organizational Partnership
E. Cohen et al., Healthcare Quarterly 14 (sp): 62-70. This article describes the lessons learned from an inter-organizational partnership to improve outcomes for medically complex children.
Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety
Kim Alvarado et al., Healthcare Quarterly 9 (sp): 75-79. This article describes the development of evidenced-based Transfer of Accountability (TOA) guidelines at Hamilton Health Sciences, the results of a pilot study of these guidelines and the ongoing project implementation.
Presentations
Reducing the 30-Day Readmission Rate at Trillium Health Centre
Amir Ginzburg and Susan Bisaillon, Trillium Health Centre, June 2011. This presentation describes the work that has been done at Trillium Health Centre to reduce the 30-day readmission rate as of June 2011.
A Virtual Ward to prevent readmissions after hospital discharge
Irfan Dhalla, Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, November 2010. This presentation describes the use of a virtual ward to prevent hospital readmissions in Toronto.
Virtual Ward Program: Improving Transitions in Care
Thuy-Nga Pham and Kavita Mehta, South East Toronto Family Health Team, 2010. This presentation outlines the experience of the South East Toronto Family Health Team, Toronto East General Hospital, Toronto Central LHIN Community Care Access Centre and the Ontario Telemedicine Network at improving the transitions in care through the use of a virtual ward program.
Reports
Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
Boutwell, A. et al., The Institute for Healthcare Improvement (IHI), 2009. This article looks at a sampling of effective programs underway to reduce avoidable rehospitalizations across the United States.
Enhancing the Continuum of Care: Report of the Avoidable Hospitalization Advisory Panel
Ministry of Health and Long-Term Care (MOHLTC), November 2011. MOHLTC’s Avoidable Hospitalization Advisory Panel’s advice and recommendations on appropriate measures, targets and timelines to help reduce hospital readmissions.
The Use of Virtual Wards to Reduce Hospital Readmissions in Canada
Canadian Agency for Drugs and Technologies in Health (CADTH). This report evaluates the use of virtual wards to reduce hospital readmissions in Canada.
Checklist to Meet Ethical and Legal Obligations to Critically Ill Patients at the End of Life
Robert W. Sibbald et al., Healthcare Quarterly 14(4): 60-66. An end-of-life checklist designed to improve communications and avoid common mistakes and errors in end-of-life care.
How-to Guide: Creating an Ideal Transition Home
GA Nielsen et al., Institute for Healthcare Improvement (IHI), 2009. This guide supports individuals and organizations in their work to improve transitions of care and reduce avoidable rehospitalizations.
IHI Improvement Map: Improving Transitions to Reduce Readmissions
Institute for Healthcare Improvement (IHI). The IHI Improvement Map is an interactive tool that helps hospital leaders in the United States improve quality outcomes by guiding their improvement efforts.
Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard
Rosmin Esmail et al., Healthcare Quarterly 9 (special issue): 80-86. This tool, developed by the Calgary Health Region, is designed to determine ICU patients’ readiness for transport.
Roadmap to Better Care Transitions and Fewer Readmissions
U.S. Department of Health and Human Services, 2011. This resource lists the elements of safe, effective and efficient care transitions, and provides tools to support improved care transitions.
Trillium 30-Day Readmission Driver Diagram, Draft 2
Trillium Health Centre, 2011. Driver diagrams are a type of structured logic chart with three or more levels. They provide a “theory of change” to help an individual or organization achieve a specific goal.
