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Home to Hospital to Home Transitions

Primary Health Care Integration Network

Alberta’s first provincewide Home to Hospital to Home Transitions Guideline for adult patients will help healthcare providers and teams in acute, primary and community care operate as a singular entity with patients and their loved ones as equal partners — where people and communities, not diseases, are at the centre of the system. Join us on the journey!

D’Arcy & Vicki’s Story

Why do we Need a Guideline?

A 2012 Canadian Institute for Health Information report found that 1 in 12 patients are readmitted within a month of leaving hospital which costs the Canadian healthcare system a reported $1.8 billion.

Evidence shows that we can help reduce readmissions, length of hospital stays and emergency department encounters with transitions initiatives that coordinate across different points on a patient’s journey.

Our Primary Goals: Coordination & Information Sharing

How do we, as the health system, ensure that our patients move along on their healthcare journey in a coordinated way, with important information following them?

Who is the Guideline Designed For?

The guideline is for healthcare providers and teams working in hospital, primary care and community settings and to partner with patients, families and caregivers.

Which Patient Populations Does the Guideline Support?

The guideline is for adult transitions from hospital only at this time. Other services and demographics may be added to the guideline in the future.

How Were Patients Involved in the Development of the Guideline?

More than 15 patient advisors were involved in development of the guideline. These patient advisors also made recommendations on resources for patients and families to support safe transitions. Read about our Patient Discovery Day.

What’s Included in the Guideline?

To assist providers and teams within Alberta, this guideline presents leading operational practices, change management tips, tools and resources and additional information for the following sections:

  • Confirmation of the Primary Care Provider
  • Admit Notification
  • Transition Planning
  • Referral and Access to Community Supports
  • Transition Care Plan
  • Follow-Up to Primary Care

How can you Monitor & Assess Transition?

A set of recommended monitoring measures, both system and strategic, was developed at the same time as the guideline. These measures are aligned with the guideline as well as the transitions in care measures of the Provincial Primary Care Network Committee.

Do you want to Connect with Others Doing Transitions Improvement Work?

Join a new community of practice (CoP) to network with others who are striving for the same goal: person-centred transitions.

Do you Have Questions About Implementing the Guideline in your Area?

Email us: PHC.IntegrationNetwork@ahs.ca

“If there is better planning and better familiarization with the situation (around transitions of care), many of these patients will be able to cope and understand what they are going through, and that will be beneficial to them both in the confidence they have in the outcome of the situation and also in their confidence of the healthcare system in general.”

– John, patient/family advisor