Health Quality Ontario (HQO), in partnership with the Ministry of Health & Long-Term Care, has published a guide that will facilitate improved transitions of care across the province. This guide, Adopting a Common Approach to Transitional Care Planning, outlines the principles and practices that will help health providers improve the consistency and efficacy of transitions as patients make their way through the health system.

“Improving transitions of care will not only improve outcomes for patients that are transitioning between levels of care, but will also ensure that patients and their families have a better grasp of their care after they leave the hospital,” said Dr. Joshua Tepper, President and CEO of HQO. “High quality care means that care extends beyond the walls of the hospital or practice and ensures that patients remain in good health after they are discharged. This guide will help providers improve these transitions and more effectively and collaboratively plan the patient discharge process.”

Recent data from Ontario shows that only 59% of hospital patients know what danger signs to watch out for after getting home from the hospital, while only 52% knew when to resume their usual activities. Studies have found that improvements in hospital discharge planning can dramatically improve outcomes for patients as they move to the next level of care, whether it be home or to a different health provider. Despite the beneficial impact transitional care planning can have on health outcomes, there is a surprising lack of consistency in both the process and quality of transitional care planning across the health care system.

“Reducing readmissions by improving transitional care planning is a critical lever to improving the quality of care in Ontario and ensuring that patients move smoothly from one part of our health system to another,” said Helen Angus, Deputy Minister of Health & Long-Term Care.

“This guide will assist Community Health Links and hospitals across Ontario adopt the principles and best practices that will help them reduce readmissions and improve patient satisfaction.”

Adopting a Common Approach to Transitional Care Planningis a tool that will promote patient engagement, enhanced communication, and the timely coordination of resources. The practices recommended within the guide are organized into three categories: pre-transition; transition planning; and assessing post-transition risk and activating post-transition follow-up. Many of the best practices related to these categories were identified in previous work undertaken by HQO, which built on research and knowledge about leading practices related to transitional care planning in Ontario and other jurisdictions.

To learn more about Health Link communities and to download a copy of Adopting a Common Approach to Transitional Care Planning, please visit the Ministry of Health & Long-Term Care’s website, or visit


HQO works in partnership with Ontario’s health care system to support a better experience of care, better outcomes for Ontarians and better value for money. HQO’s legislated mandate under the Excellent Care for All Act, 2010 is to: monitor and report to the people of Ontario on the quality of their health care system, support continuous quality improvement, and promote health care that is supporte d by the best available scientific evidence HQO is an arms-length agency of the Ontario government. Visit for more information.

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