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!

As you think about your work and how transitions fit in to it, what questions and ideas come to mind?


What are your burning questions?

Ajax loader transparent
Didn't receive confirmation?
Seems like you are already registered, please provide the password. Forgot your password? Create a new one now.
  • I work as a Hospitalist. My discharge summaries are sent to family doctors by our health records department. For patients who do not have a family doctor the discharge summary is available on NetCare. If they go to a specific walk-in clinic I will choose a name of a Physician from that clinic to CC the discharge summary to. I am concerned that some General practitioners may not be accessing NetCare. Is there a way to check with Netcare to see what percentage of Family Doctors access Netcare in any given week. If the percentage is low then that should be addressed or at least we need to know how these doctors wish to be notified about patient admissions and discharges.

    Brian Inglis asked 6 months ago

    Hi Brian,

    Thank you so much for your very thoughtful question and your patience while we consulted teams for the answer.

    Currently there are over 51,000 health professionals who are registered to use Netcare. Netcare use is voluntary, and there’s no publicly available information on who is using Netcare, or how often it’s being accessed by certain groups (such as family physicians). However, the College of Physicians and Surgeons of Alberta endorses Netcare and set as an expectation in their 2016 Vision that every physician practicing in Alberta will “access and use relevant information” in Netcare in the near future.

    In order to help encourage Netcare use, the province has established e-Notifications (in the process of testing and staged rollout), which provide an electronic notification in a community physician/nurse practitioner’s EMR alerting them that their patient has visited an ED, hospital or acute care facility, or has been discharged from an AHS facility. These notifications are automatically generated so the health practitioner is alerted to read all details on the encounter in Netcare. There are other provincial initiatives in the works that will provide more information flow between Netcare and community EMRs, which we anticipate will encourage greater use of Netcare and more continuous information flows.

    If a patient does not have a relationship with a family physician/nurse practitioner, encourage a conversation with the patient to discuss which practitioners they would like to receive a discharge summaries. Although these conversations may not always be possible, particularly if a patient is in a vulnerable or ill state, patients can give permission for any Netcare-registered allied health practitioner with whom they have a relationship to receive a discharge summary.

    Additionally, to encourage patients to find a family doctor/nurse practitioner, a public website has been launched to let patients know which providers in their geographic area are accepting new patients: https://albertafindadoctor.ca/. Please let patients know about the website if they are seeking a primary care provider. Although this won’t help your team determine where to send a discharge summary in that moment, it could encourage a patient to find a provider, who they could then ask to review the discharge summary available in Netcare.

    We heard from an AMA rep who is working on CII/CPAR that Netcare activation among family physician clinics throughout the province is north of 80% (approaching 90%).

    With that said, we have no data on who is actually using Netcare. Some physicians are quite proficient and access Netcare directly, whereas many others delegate use to office staff. They benefit from the data that’s available on Netcare, but do not (and don’t know how to) directly utilize the service themselves.

    I hope that helped answer your question but if not, we are happy to continue the discussion. Again, our sincerest apologies for not getting back to you sooner :)