Care transitions occur when patients transfer between different care settings (e.g., hospital, primary care, long-term care, home and community care) and between different health care providers during the course of an acute or chronic illness.
Transitions are critical and vulnerable points in the provision of health care. Transitions between hospital and home are complex, multiple-step processes that require integrated communication and coordination among the patient, their caregivers, the hospital team, primary care, and home and community care providers.
The transition process is further complicated by the complexities of the health system because care is delivered by multiple providers with various levels of accountability.
As a result, there are many points at which communication and care processes can break down. These include, but are not limited to:
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Preparing family and caregivers for the person’s return home
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Communicating the person’s care plan to the health care providers taking over the person’s care
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Performing medication reconciliation and checking post-discharge medication adherence
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Arranging for transportation and equipment needs at home
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Coordinating appropriate follow-up care (e.g., medical appointments, home and community care services)
When patients’ care transitions are not managed well, patients may suffer harm from errors and delays in care. Either can result in avoidable hospital admissions, emergency department visits, and increased health care costs. They can also negatively affect patients’ experiences. Some patients may feel emotional distress and worsening of symptoms, and family and caregivers may also experience distress.
There are opportunities for improvement in Ontario to ensure seamless transitions between hospital and home. For example, recent reports and surveys found that:
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About 25% of respondents reported that their primary care providers were not aware of the care they had received in hospital
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Only 59% of people discharged from hospital were aware of which danger signs to look out for at home, and only 52% knew when to resume their usual activities
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Although 80% reported knowing how to take their medications, 36% did not know what side effects to watch for
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One-third of people discharged from hospital for a mental health or addictions condition did not have a follow-up visit with a physician within 7 days after discharge
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Less than half of people hospitalized with serious chronic conditions had follow-up visits with a doctor within 7 days of leaving hospital; this is an important finding, given that about 20% of people with serious chronic conditions are readmitted to hospital within 30 days after discharge
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As many as 44% of patients in Ontario do not attend suggested post-discharge appointments for follow-up medical care because of issues such as mobility limitations, low health literacy, financial concerns, and a lack of social supports
Further, information is not consistently transferred between health care providers.
The Change Foundation reports that many community-based service providers regularly rely on patients and informal caregivers to pass on relevant information to other providers. Addressing these gaps in information flow can help people stay safe at home and avoid unnecessary return visits to hospital.
A 2017 report highlighted systemic barriers that family doctors in Ontario often face when coordinating care for their patients in home and community care:
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Less than a third of family doctors say their practice routinely communicates with their patients’ community case managers or home care providers about their patients’ needs and services
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About 30% of Ontario family doctors say they sometimes, rarely, or never receive a notification when their patient is discharged from hospital
A 2017 report from the Ontario Patient Ombudsman identifies several opportunities to improve the quality of patients’ experiences as they prepare for discharge and transition between hospital and home, and states that the key to improvement is accurate, timely communication and engagement with patients and their caregivers. Patients and their families and caregivers are the constant in transitions and are crucial to any strategies that support safe and effective transitions.
Some patients transitioning between hospital and home are particularly vulnerable and at increased risk of hospital readmissions, such as people with complex care needs (including children and older people with multiple comorbidities or cognitive impairment). The needs of children and youth—especially those with complex medical conditions or mental health and addiction issues—are different from those of adults, and their special needs must be taken into consideration when planning transitions between hospital and home.
Those who are medically underserved, have low socioeconomic status, or are members of specific populations (e.g., Indigenous Peoples, newcomers to Canada, refugees, and the homeless) face several barriers to care, including few programs and resources in preferred languages and a lack of culturally safe care. Some of these populations are also disproportionately affected by poverty, trauma, and social isolation, which can, in turn, reduce the effectiveness of care transitions. These people may need access to additional resources and increased collaboration with community partners and social services.
To support the development of this quality standard on transitions between hospital and home, our organization partnered with health care and community organizations to conduct a province-wide consultation through broad engagement with people with lived experience of transitions from hospital to home. What we heard from patients is summarized in Appendix 4.