Seamless Transitions: Hospital to Home


Effective transition from acute care to community care is an essential element of high quality patient care and is a core business of hospitals and Community Care Access Centres (CCACs). Transition planning is most effective when hospitals, community providers and primary care physicians work together to coordinate care for patients. This Guidebook outlines the steps taken by the Mississauga Halton CCAC and Trillium Health Partners (THP), in equal partnership, to better integrate care for patients being discharged from hospital to home/community. It is intended not only to document the partnership journey and design process, but to serve as a resource or blueprint for other hospital and community organizations to use to implement new models of transition planning, focused on better integrating care for patients. Seamless Transitions: Hospital to Home is a multi-year, formal partnership initiative, funded by the Mississauga Halton Local Health Integration Network (MH LHIN). The initiative is aimed at improving health care delivery through the development of a consistent, integrated, person-centered approach for hospital to home transitions. 


  • Section 1 Overview
  • Section 2 Design process
  • Section 3 Evaluation
  • Section 4 Implementing the Seamless approach
  • Section 5 Appendix 
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Seamless Transitions: Hospital to Home - Helping patients leave hospital sooner to recover at home

SeamlessTransitions: Hospital to Home