​​​​​Seamless Transitions: Hospital to Home​​

Seamless Transitions: Hospital​​​ to Home is a Mississauga Halton LHIN-funded, partnership initiative with ​Trillium Health Partners (THP) to improve patient and carer experiences through the development of a consistent, integrated, person-centered approach for hospital to home transitions. The approach eliminates duplication in processes and gaps in communication and care that put patients at risk.

Using insights from patients, families, our staff, THP staff, physicians, community providers and a leading practice review, a dedicated team of interdisciplinary professionals from both organizations developed a new approach to hospital transitions. It was tested for nine months in the THP-Credit Valley Hospital (CVH) Medicine program, following patients from admission through to discharge and recovery at home.

 
Key components of Seamless Transitions approach:
  • ​Integrated, mobile care team
  • Transition planning starting on admission (patients streamed into pathways based on post-hospital care coordination needs
  • Enhanced care coordination (Transition Coordinator role) - one person as key contact between patient and care team who oversees transition plan
  • Individualized, comprehensive, written transition plan (My Story and My Care Guide for patients; Plan of Care for providers)
  • Daily discharge rounds
  • Post-discharge phone calls and/or visits
  • Timely, accurate information flow from community providers, amongst hospital teams, and back to community providers

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Findings from the test phase are phenomenal. Results indicate a significant reduction (52%) in readmission rates for patients discharged using the Seamless Transitions approach, compared to all other patients in the THP-CVH Medicine program, saving 0.9 bed days for every patient. Patient experience improved measurably as well, with many patients commenting they felt better prepared to leave hospital, "I left knowing what I was doing. Everything was explained to me in my care plan. And I didn't have to repeat myself at my family doctor, I just brought my booklet."

 
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The enhanced coordination and communication between providers and patients in this new approach enabled patients to remain at home and out of hospital, helping to improve patient experience, hospital flow/capacity and relationships between hospital and community providers.

 
Opportunities for spread

 
The key components of Seamless Transitions are grounded in leading practice and insights from patients and practitioners, which enables effective, cross-sector application. A comprehensive guidebook provides summary of partnership journey and design process. It serves as a blueprint for action for other hospitals and community organizations seeking to implement a patient-centred, integrated hospital transition approach. 

 

 
We partnered with Halton Healthcare in September 2015 to test and implement the Seamless Transitions approach at HHS-Georgetown Hospital.

 
As implementation and spread occurs at THP and Halton Healthcare​ hospital sites, Seamless Transitions is positioned to become the regional standard for hospital to home transitions.