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December 2024 - Transitions in Care Talk: An Introduction to Home to Hospital to Home

The Home to Hospital to Home (H2H2H) Transitions Guideline is a unique, province-wide initiative that merges acute, primary and community care under one guideline. Learn more about potential practices that Primary Care teams can use to support better transitions in care.

Session Summary

Session Hosts: 

  • Sunday Welsh, AACM
  • Krishna Kasireddy, AMA-ACTT

Guest Presenters:

  • Shantel Farncombe, Director, Primary Health Care, Alberta Health Services
  • Sherri Sterling, Senior Consultant, Primary Health Care, Alberta Health Services
  • Emily Andreiuk, Educational Design Advisor, Primary Health Care, Alberta Health Services

Recommended Resources

 

 

Session Highlights & Themes

 

Overview: 

  • Home to Hospital to Home (H2H2H) Is a province-wide initiative that focuses on how patients move from home to hospital and then back home again.

 

H2H2H Guideline Elements

  1. Confirmation of the primary care provider
  2. Admit notification
  3. Transition planning
  4. Referral & access to community supports
  5. Transition care plan
  6. Follow-up to primary care

 

Potential Areas for Primary Care Provider Team Improvement

  • Join CII/CPAR
  • Ensure patients know their Primary Care Provider's name
  • Review admit notifications
  • View patients' discharge summaries
  • Provide follow up care

 

Supporting the Foundational Element: Confirmation of the Primary Care Provider

  • Display posters
  • Share business cards with the primary care provider's name
  • Encourage patients to add the primary care provider's name/contact info to contacts list in phone or digital wallet
  • Use advertising space in the clinic
  • Encourage patients to add a sticker on Alberta health care card
  • Validate the patient’s primary care provider every time they come into the clinic

 

Troubleshooting

Routing issues can be reported to:

  • [email protected] or
  • Alberta Health Provincial Service Desk: 1-877-311-4300
    • Select option 1 for Clinical Applications, then option 1 for Connect Care
    • Please have your location, contact information and Prac ID available when you call 
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