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?

Currently, 30 per cent of patients in Alberta experience a gap in care during their transition from hospital to home. Gaps in care can result in accelerated progression of disease, hospital readmissions and suboptimal health system costs.

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.

The guideline helps ensure that patients move along 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.

What Do Patients Have to Say?

More than 15 patient and family advisors have been involved in different aspects of the Home to Hospital to Home Transitions Guideline initiative.

One team, co-led by patient and family advisors, explored what patients and families need for safe, patient-centered transitions and created a report called “Transitions through Patients Eyes: Recommendations to Support Patients and Families.” The report outlines recommendations for Alberta’s health system leaders to use in implementation of the guideline.

The report reflects key themes from patient stories and gathering feedback from their transitions experiences, as well as identifying/analyzing current transition tools in the province.

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:

  • 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.

Guideline in Action: ADAPT Grant

ADAPT stands for A DiseAse-Inclusive Pathway for Transitions in Care.

The ADAPT project is a $1.3 million grant that will create a common transition in care pathway for Albertans with complex chronic conditions. This pathway will be for patients with heart failure, COPD, cirrhosis, end-stage kidney disease and stage 3-4 cancers. The pathway will be rolled out in three waves across five acute care sites between 2021-22. The project will implement three components of the Home to Hospital to Home Transitions Guideline: admit notification, transition planning and follow-up to primary care.

ADAPT is a Partnership for Research and Innovation in the Health System grant by Alberta Innovates.

Grant Updates:

Learn more, visit ADAPT Study.

Have Questions about Implementing the Guideline?

  • When planning transition initiatives, use the guideline to understand what processes and partnerships need to be in place to create safe, reliable and effective transitions.
  • Transitions of care committees in each zone are developing implementation plans. More information will be shared by your zone in the coming months.
  • Review this one pager for an overview of the initiative.

Email: 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