Home to Hospital to Home Transitions

What is ADAPT?| Approach| Project Objectives| Improving Transitions| Benefits of ADAPT

Support and empower patients, families and providers throughout the transition journey.

What is ADAPT?

A DiseAse-inclusive Pathway for Transitions in Care (ADAPT) is a grant-funded embedded implementation initiative for the Home to Hospital to Home Transitions Guideline (H2H2H).

In April 2020, the Alberta Health Services’ (AHS) Primary Health Care Integration Network (PHCIN) received a Partnership for Research and Innovation in the Health System (PRIHS) grant by Alberta Innovates. This 3-year grant will provide $1.2 million to improve transitions in care for patients in Alberta.

The ADAPT study is focused specifically on implementing 3 of the 6 H2H2H Guideline elements (admit notification, transition planning & follow-up to primary care) to support transitions in care for Albertans with the following 5 complex chronic conditions: heart failure, chronic obstructive pulmonary disease, cirrhosis, end-stage kidney disease and/or stage 3-4 cancers. Implementation of the 3 Guideline elements will be tested in 5 acute care sites and Primary Care Networks across Alberta.


The ADAPT project will standardize patient transitions by integrating, spreading, and scaling current disease-specific transitions in care pathways work across Alberta for patients with chronic disease. ADAPT aims to strengthen the hospital admission, transition planning, and follow-up to primary care processes. This project will also assess whether such a pathway adapted to local settings is an efficient and cost-effective intervention within the Alberta healthcare system.

The ADAPT project team is collaborating closely with other provincial transitions in care initiatives, including H2H2H Transitions and One:Carepath initiatives.

Project Objectives

  • Create A DiseAse-inclusive Pathway for Transitions in care
  • Strengthen hospital admission, transition planning, and follow-up to primary care processes for patients with chronic conditions
  • Assess efficiency and cost-effectiveness within the Alberta healthcare system

Why is Improving Transitions Important?

Patients who have complex, chronic diseases often have extensive unmet care needs as they transition between hospital and home and regularly return to hospital due to a flare-up or progression of their medical condition.  Many re-admissions to hospital can be prevented with appropriate primary care and community supports. Most interventions to address care gaps during transitions in care tend to be disease-specific (e.g., heart failure, cancer) without addressing multimorbidity and have been developed in hospitals by specialists; they are not necessarily optimized for family doctors who may not have the tools and resources to support the shared care needed by these patients.

Opportunities exist to enhance healthcare system integration in Alberta and improve transitions in care.

The Benefits of ADAPT

What does this study offer Albertans?

  • Integrated approaches for home to hospital to home transitions in Alberta
  • Improved patient and provider experiences
  • Enhanced community care
  • Care that aligns with patient preferences
  • Increased health systems efficiency

What does this study offer primary care physicians and team members?

  • Standardized processes for patients with chronic conditions transitioning from home to hospital to home
  • Structured processes for timely and comprehensive transition planning, including patient care planning and follow-up
  • Change management and evaluation support
  • Enhanced community capacity by empowering family physicians and supporting the patient’s medical home

What does this study offer hospital physicians and team members?

  • Change management and evaluation support
  • Supported shared care planning across providers, health teams and the care continuum
  • Supported transitions for high-risk patients from hospital to primary care
  • Ongoing analytics support at a provincial, zonal, and site level
  • Reduced health system costs

Quick Reference

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Co-Designers Needed

ADAPT is seeking input from primary care physicians and multidisciplinary team members to co-design a standardized post-discharge follow-up process in primary care for transitioning patients with chronic disease. Broad perspectives are needed to ensure optimal design and usability across the province.

Read more about participating in the co-design of this process, Transitions and Care Planning in the Patients Medical Home If you would like more information on the project, contact