Quality Statement 12: Transitions in Care - Health Quality Ontario (HQO)

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12

Transitions in Care

People with major depression who transition from one care provider to another have a documented care plan that is made available to them and their receiving provider within 7 days of the transition, with a specific timeline for follow-up. People with major depression who are discharged from acute care have a scheduled follow-up appointment with a health care provider within 7 days.

Background

Transitions between care providers can increase the risk of errors and miscommunication in a person’s care. It is important for people with major depression who are moving from one care provider to another to have a care plan that is shared with them and between providers. Optimal communication and coordination of treatment with other health care professionals lessens the risk of relapse and can reduce side effects. If the person is being referred to a new provider, it is important to ensure that the new provider accepts the patient before transferring them. A follow-up appointment after hospitalization helps to support the transition to the community. It can allow for the identification of medication-related issues; it also helps to maintain clinical and functional stability and aims to prevent readmission to hospital. It is especially important for people with major depression who are admitted to hospital with a high risk for suicide to be followed up soon after discharge. If the person’s consent is obtained, their family or caregivers should be notified of their potential risk for suicide.

What This Quality Statement Means

For Patients

If you move on to a new health care professional, you should each receive a written copy of your care plan from your previous health care professional and your first appointment should be scheduled within a specific timeline. For example, if you have major depression, you should see your new health care professional within 7 days of being discharged from hospital.

For Clinicians

When handing over a person’s care to another health care provider, ensure that the new provider accepts the patient, and that the patient and the new provider have a documented care plan within 7 days, as well as a scheduled follow-up with the new provider. When discharging a patient from hospital, ensure they have a scheduled follow-up appointment with a provider within 7 days of discharge.

For Health Services

Ensure systems, processes, and resources are in place to facilitate communication and the sharing of information between clinicians during care transitions. Ensure the system can accommodate the appropriate follow-up timelines.

Quality Indicators

Process Indicator

Percentage of people with major depression who transition from one care provider or care setting to another and have a documented care plan

Denominator: total number of people with major depression who transition from one care provider or care setting to another
Numerator: number of people in the denominator who have a documented care plan
Data source: local data collection

Percentage of people with major depression who transition from one care provider or care setting to another whose care plan specifies a timeline for follow-up

Denominator: total number of people with major depression who transition from one care provider or care setting to another who have a documented care plan
Numerator: number of people in the denominator whose care plan specifies a timeline for follow-up
Data source: local data collection

Percentage of people with major depression who transition from one care provider or care setting to another and have their care plan made available to the receiving provider within 7 days

Denominator: total number of people with major depression who transition from one care provider or care setting to another who have a documented care plan
Numerator: number of people in the denominator whose care plan is made available to the receiving provider within 7 days
Data source: local data collection

Percentage of people with major depression who are discharged from hospital who see a psychiatrist or primary care physician within 7 days of discharge

Denominator: total number of people with major depression who are discharged from hospital
Numerator: number of people who within 7 days of discharge of index hospitalization have at least one psychiatrist or primary care physician visit
Data sources: Discharge Abstract Database, Ontario Mental Health Reporting System, Ontario Health Insurance Plan Claims Database

Definitions Used Within This Quality Statement

Documented care plan

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

Depression symptoms at the time of transition
Risk for suicide or self-harm, if any
Treatment history, including treatment options that have failed
Goals for treatment

Evidence to Improve Care