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Alberta now has its first provincial guideline on how patients can best transition from their communities, to hospitals and then back home again. This process is called ‘Home to Hospital to Home Transitions’ and this guideline is for healthcare workers in acute, primary and community care settings to help ensure Albertans have the support they need to keep them healthy in their communities.
The guideline is for adult transitions from a patient’s community, to hospital and then back home again. Transitions for other services and demographics may be added to the guideline in the future.
Important notice!
With the engagement period on this project complete and the Home to Hospital to Home Transitions Guideline available, this page will be archived and will no long be updated. All information and updates regarding the guideline will be hosted on the Alberta Health Services website at ahs.ca/hhhguideline.
Engagement period has ended: What's next?
During the engagement period, from Sept. 2019 - Jan. 2020, more than 200 people completed a survey, asked a question and/or provided input to help determine how the guideline should best be implemented in Alberta. Thank you to all who provided feedback!
The guideline, which is being facilitated by the Primary Health Care Integration Network, is finalized and is available at ahs.ca/hhhguideline.
Background
Why are provincial guidelines needed?
Evidence shows that we can help reduce readmissions, length of hospital stays and emergency department encounters with transitions initiatives that coordinate across different points on a patient’s journey.
The new provincial Home to Hospital to Home Transitions Guideline will help guide patients and healthcare workers through this journey — from checking if patients have a family doctor when they come to a hospital and are admitted, through referral and access to community supports when they are discharged.
What can a standard approach to these transitions do?
A standard approach to transitions will:
Create a common understanding of processes from everyone involved in a transition
Improve patient outcomes, experience and satisfaction
Improve provider satisfaction
Enable a collaborative team approach to provide patient-centered care
Alberta now has its first provincial guideline on how patients can best transition from their communities, to hospitals and then back home again. This process is called ‘Home to Hospital to Home Transitions’ and this guideline is for healthcare workers in acute, primary and community care settings to help ensure Albertans have the support they need to keep them healthy in their communities.
The guideline is for adult transitions from a patient’s community, to hospital and then back home again. Transitions for other services and demographics may be added to the guideline in the future.
Important notice!
With the engagement period on this project complete and the Home to Hospital to Home Transitions Guideline available, this page will be archived and will no long be updated. All information and updates regarding the guideline will be hosted on the Alberta Health Services website at ahs.ca/hhhguideline.
Engagement period has ended: What's next?
During the engagement period, from Sept. 2019 - Jan. 2020, more than 200 people completed a survey, asked a question and/or provided input to help determine how the guideline should best be implemented in Alberta. Thank you to all who provided feedback!
The guideline, which is being facilitated by the Primary Health Care Integration Network, is finalized and is available at ahs.ca/hhhguideline.
Background
Why are provincial guidelines needed?
Evidence shows that we can help reduce readmissions, length of hospital stays and emergency department encounters with transitions initiatives that coordinate across different points on a patient’s journey.
The new provincial Home to Hospital to Home Transitions Guideline will help guide patients and healthcare workers through this journey — from checking if patients have a family doctor when they come to a hospital and are admitted, through referral and access to community supports when they are discharged.
What can a standard approach to these transitions do?
A standard approach to transitions will:
Create a common understanding of processes from everyone involved in a transition
Improve patient outcomes, experience and satisfaction
Improve provider satisfaction
Enable a collaborative team approach to provide patient-centered care
CLOSED: This discussion has concluded. Thanks to all who provided input.
We want to hear from you on the front line about your work to improve transitions. Please use the space below
to share stories of what transitions initiatives worked and didn’t work. Your
expertise will help inform the implementation approach and ultimately improve
transitions for everyone in Alberta.
Things to consider:
What
kind of transition was occurring for patients? (e.g. Patient was transitioning from Long Term Care to Acute Care)
What change or improvement was
made to enhance their transition? (e.g. Discharge summary was sent from Long Term Care to Acute Care)
What worked well and what challenges did you
come across? (e.g. There were no Electronic Medical Records that connect Long Term Care to Acute Care so the discharge summary had to be sent with the patient)
The online engagement period for this project has now ended.
Read a summary of who we heard from and what healthcare workers across the province said about how the new Home to Hospital to Home Transitions Guideline should be implemented.
Click here to play video
Patient’s Story: D’Arcy & Vicki
D’Arcy and Vicki share their experience in transitions in care from hospital to home with a four day visit to the hospital turning into a 71 days
Project Life Cycle
2018
Home to Hospital to Home Transitions in Alberta has finished this stage
Extensive literature review on transitions from hospital to home completed
March 2019
Home to Hospital to Home Transitions in Alberta has finished this stage
Over 80 person design team from across the
health system, including patient advisors, developed preliminary content for
the guideline
July 2019
Home to Hospital to Home Transitions in Alberta has finished this stage
Nearly 300 online consultations on the guideline received from primary care providers, AHS zone/clinical operations, Primary Care Networks and AHS Strategic Clinical Networks
August 2019
Home to Hospital to Home Transitions in Alberta has finished this stage
Extended consultations completed with primary
care providers in coordination with the Alberta Medical Association
September 2019
Home to Hospital to Home Transitions in Alberta has finished this stage
Online engagement launched to get input on implementation
October 2019
Home to Hospital to Home Transitions in Alberta has finished this stage
- “Modified Delphi process” held for sections of the
guideline where consensus had not yet been reached
- Patient consultations
held about leading operational practices identified in the guideline
- Patients and families met to work on
recommending patient resources to be made available with the guideline
Home to Hospital to Home Transitions in Alberta has finished this stage
Patients, families and healthcare workers gathered at six sites across Alberta to discuss how best to implement the new guideline. The six sites were joined together virtually to create a pan-Alberta discussion. Read more in this update.
January 2020
Home to Hospital to Home Transitions in Alberta has finished this stage
Online
engagement closed on Jan. 10. Read a summary of the online engagement.
July 2020
Home to Hospital to Home Transitions in Alberta has finished this stage
AHS Executive Leadership Team endorsed new Home to Hospital to Home Transitions Guideline
September 2020
Home to Hospital to Home Transitions in Alberta has finished this stage
Provincial PCN Committee endorsed new Home to Hospital to Home Transitions Guideline
Winter 2020-2021
Home to Hospital to Home Transitions in Alberta is currently at this stage
- Home to Hospital to Home Transitions Guideline launched for teams to start using
The Primary Health Care Integration Network, part of the Strategic Clinical Network™ family, assists health, social and community organizations across the province to become even more coordinated. Email us at PHC.IntegrationNetwork@ahs.ca
Subscribe to our PHC Newsletter to stay updated on this project.