Building blocks for successful transitions of care

A new guideline is now available that outlines the supports Albertans need to safely transition from their home to hospital and then back to their community. The Primary Health Care Integration Network, along with stakeholders from across the system including patients and families, developed the Home to Hospital to Home Transitions Guideline to identify best practices in facilitating effective transitions of care. 

The Alberta Medical Association, Accelerating Change Transformation Team (ACTT) and the Primary Health Care Integration Network are developing a support package of tools and resources to help primary care practices improve transitions of care while working with acute care, patients and the community. These transitions form a vital link between the Patient’s Medical Home and the hospital. Virtual training for primary care to support the implementation of the changes is coming in 2021.

In the meantime, a webinar to provide an overview on successfully implementing improved transitions was held in January. Entitled “Building blocks to successful transitions of care” this virtual event was held Thursday, Jan. 21. Webinar recording now available. During the webinar, family physicians, Dr. Joseph Ojedokun and Dr. Heather La Borde shared their experience and tips on how they:

  • Utilize technological enablers (CII/CPAR) to improve continuity and transitions of care
  • Implement practice changes to better identify patients being admitted and discharged from hospital and prevent patients from being re-admitted through effective risk screening and follow-up in primary care
  • Have improved the experience of transitions of care for patients, physicians and team members