Help improve Home to Hospital to Home Transitions in Alberta. Have your say!


Alberta will soon have a 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 will used by 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.

What you can do

Get involved by asking a question, sharing a bright idea and/or starting a discussion in the forum. Have your say on how these guidelines can be implemented in a way that works for your region and practice. We value your feedback as an implementation approach is crafted.

What is a Home to Hospital to Home Transition?

Home to Hospital to Home Transitions are when adult transitions from a patient’s community, to hospital and then back home again.

Here’s an example:

After visiting your family doctor, you still can’t shake what has been plaguing you. You go to your local Emergency Room and are admitted to a nursing unit. You see a lot of people – doctors, nurses, healthcare aides, lab workers.... There's a lot of chatter but none of it is making sense in your drowsy state.

You are sent home and told to follow up with your family doctor, who didn’t realize you had been hospitalized. You are trying your best to share what you were able to remember. You were told you may
have to see a dietitian but can’t remember why.

After all you’ve been through, you feel tired, confused and frustrated.

Our primary goals: coordination & information sharing

How do we, as the health system, ensure that our patients move along on their healthcare journey in a coordinated way, with important information following them?

Why are provincial guidelines needed?

A 2012 Canadian Institute for Health Information report found that 1 in 12 patients are readmitted within a month of leaving hospital which costs the Canadian healthcare system a reported $1.8 billion.

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 Transition 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

Get involved and help us create better transitions for patients

The guideline, which is being facilitated by the Primary Health Care Integration Network, is being finalized and will be available across the province in 2020 to support health care teams with their transition projects.

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.

Have questions? Ask them here and we will respond. Our goal is to connect with the thousands of healthcare workers these guidelines impact— digitally!


Alberta will soon have a 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 will used by 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.

What you can do

Get involved by asking a question, sharing a bright idea and/or starting a discussion in the forum. Have your say on how these guidelines can be implemented in a way that works for your region and practice. We value your feedback as an implementation approach is crafted.

What is a Home to Hospital to Home Transition?

Home to Hospital to Home Transitions are when adult transitions from a patient’s community, to hospital and then back home again.

Here’s an example:

After visiting your family doctor, you still can’t shake what has been plaguing you. You go to your local Emergency Room and are admitted to a nursing unit. You see a lot of people – doctors, nurses, healthcare aides, lab workers.... There's a lot of chatter but none of it is making sense in your drowsy state.

You are sent home and told to follow up with your family doctor, who didn’t realize you had been hospitalized. You are trying your best to share what you were able to remember. You were told you may
have to see a dietitian but can’t remember why.

After all you’ve been through, you feel tired, confused and frustrated.

Our primary goals: coordination & information sharing

How do we, as the health system, ensure that our patients move along on their healthcare journey in a coordinated way, with important information following them?

Why are provincial guidelines needed?

A 2012 Canadian Institute for Health Information report found that 1 in 12 patients are readmitted within a month of leaving hospital which costs the Canadian healthcare system a reported $1.8 billion.

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 Transition 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

Get involved and help us create better transitions for patients

The guideline, which is being facilitated by the Primary Health Care Integration Network, is being finalized and will be available across the province in 2020 to support health care teams with their transition projects.

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.

Have questions? Ask them here and we will respond. Our goal is to connect with the thousands of healthcare workers these guidelines impact— digitally!

Discussions: All (1) Open (1)
  • 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)


    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)


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