Seamless Transitions: Hospital to Home Program Reduces Re-admissions & Enhances Patient Experience

Rationale / Objectives

There is a lack of shared understanding of patients’ needs to inform and execute a care plan that will give them confidence to leave the hospital. To help facilitate the patient’s critical transition from home to hospital, the systems in place must be easy for patients and caregivers to navigate. Seamless Transitions: Hospital to Home is a multi-year, formal partnership initiative, funded by the Mississauga Halton Local Health Integration Network (MH LHIN) in Ontario, Canada. The initiative is aimed at improving health care delivery through the development of a consistent, integrated, person-centered approach for hospital to home transitions. 

Project/Program Description & Major Achievements

To find a more patient-centred way to transition patients from hospital to home, the Mississauga Halton Community Access Centre (CCAC) and Trillium Health Partners (THP) (within the MH LHIN) worked together to implement this approach. The Seamless Transitions: Hospital to Home program is grounded in leading practices and insights from both patients and practitioners. The goal is to eliminate process duplications and reduce gaps in care and communication that put patients at risk. The program gathered input from staff, community care providers, leading practice reviews, patients and families. The Seamless Transitions Guidebook provides a summary of the partnership journey and design process. A care team member that meets with patients daily is a key part of the program. Acheivements include a 52% reduction in 30-day readmission rates and a 14% increase in the use of community-based supports.

Lessons Learned

The enhanced communication of the providers and patients in this approach allow patients to remain at home and out of hospital, helping to improve patient experience, hospital flow/capacity and relationships between hospital and community providers. Additionally, the approach did not begin with a solution in mind, but rather used collaboration to find the best possibilitlies for care providers, patients and their families. 

Further Description

The Seamless Transitions program was implemented at the Trillium Health Partners-Credit Valley Hospital (CVH) Medicine program from September 2014 to June 2015. The integrated, mobile care team provides care to patients and follows them from admission tthrough to discharge and recovery at home. It is an inter-professional team consisting of a transition care coordinator, occupational therapist, physiotherapist and a physician. Planning for transition starts during admission based on post-hospital care coordination needs, and the team work collaboratively to develop a post-acute plan of care. The Transition Coordinator role is the single point of contact for transition planning and the connection between patients, families, care team and community-based providers. Planning and care for discharge includes individualized, comprehensive written transition plans. 'My Story' is a customized resource binder of important information that patients use to track their care at home and is focused on patients’ personalized life goals. Additionally, the program includes daily discharge rounds, and post-discharge phone calls and/or visits with patients.

Major Achievements

In addition, to the metrics in the table below from the pilot phase of the program, patient experience also improved measurably as well, with many patients commenting they felt better prepared to leave the hospital. The program is also being piloted at Georgetown Hospital.

Metric Result
30-day Readmission Rates Decreased 52%*
Community Service Utilization Increased 14%*

*with Seamless Transitions Approach