Quality Statement 14: Transitions in Care - Health Quality Ontario (HQO)

Resources Quality Statements Advisory Committee About

14

Transitions in Care

People living with dementia and symptoms of agitation or aggression who transition between settings have a team or provider who is accountable for coordination and communication. This team or provider ensures the transmission of complete and accurate information to the family, caregivers, and receiving providers prior to the transition.

Background

Transitions between settings can pose problems in continuity of care for people living with dementia. Untimely or uncoordinated transition processes may delay treatment and increase the risk of behavioural symptoms being triggered. People living with dementia and their caregivers should be involved in the transition preparation process so their needs and questions are addressed. When they are aware of what will happen during the transition, they are empowered to play an active role. In addition, the most up-to-date information should be documented in the care plan by all providers. A provider or team should be accountable to ensure the accurate and timely transition of information to the proper recipients, to achieve a seamless transition process. Ultimately, transitions should be limited to only those that are beneficial or necessary.

What This Quality Statement Means

For Patients

You should have a smooth transition between care environments.

For Clinicians

Ensure that people moving between providers or care settings have a person or team responsible for coordinating their care and transferring information among providers. Keep people living with dementia and their caregivers involved in and informed about their transition process.

For Health Services

Ensure that hospitals and long-term care homes have systems, processes, and resources in place to enable smooth transitions between care settings for people living with dementia.

Quality Indicators

Process Indicator

Percentage of people living with dementia and symptoms of agitation or aggression whose information is received by the new facility prior to their transition

Denominator: total number of people living with dementia and symptoms of agitation or aggression who transition to a new facility
Numerator: number of people in the denominator for whom complete and accurate transmission of information is received by the new facility prior to their transition
Data source: local data collection

Percentage of people living with dementia and symptoms of agitation or aggression whose information is incomplete or inaccurate when received by the new facility

Denominator: total number of people living with dementia and symptoms of agitation or aggression who transition to a new facility that has received information regarding their care and treatment
Numerator: number of people in the denominator whose care and treatment information is incomplete or inaccurate during the transition process
Data source: local data collection

Definitions Used Within This Quality Statement

Information

The following should be communicated to the patient, family, caregivers, and receiving providers prior to the transition:

Approaches to care
Updated care plan
Treatment history, including treatment options that have failed
Potential triggers for behavioural symptoms
Contact information for discharging and receiving providers

Evidence to Improve Care