Glossary - Home to Hospital to Home Transitions

8P Screening Tool:  This tool identifies your patient’s risk for adverse events after discharge.  The 8Ps include:

• Problems with medications
• Psychological
• Principal diagnosis
• Physical limitations
• Poor health literacy
• Patient support
• Prior hospitalization
• Palliative care

AHS: Alberta Health Services.

Alberta Find a Doctor: A website designed to assist patients in finding family physicians that are accepting new patients to their panel.

AMA ACTT: Alberta Medical Association - Accelerating Change Transformation Team.

BRASS: The Blaylock Risk Assessment Screening Score index is an instrument used to identify patients requiring complex discharge planning. 

Care Plan: Is a plan to keep everyone on the “same page” as to what matters to the patient (goals, values and preferences).  It also helps keep track what  has been planned or being worked on to improve the patient’s health and wellbeing.

Change Package: A change package makes clinic team process improvement work easier. It is an evidence-informed collection of tools and resources that supports process improvement and behaviour change in a focus area by following the Sequence to Achieve Change.

CIHI: Canadian Institute for Health Information is an independent, not-for-profit organization that provides essential information on Canada’s health system and the health of Canadians.

CII/CPAR: Community Information Integration and Central Patient Attachment Registry. CII allows providers to send select patient information to Alberta Netcare including consult letters and information about patient visits to contribute to Community Encounter Digests (CEDs). CPAR identifies relationships between patients and their primary provider in Netcare and sends eNotifications to providers when their patients are seen in the emergency department, have a hospital admission or day surgery.

Continuity: Continuity of care is how a patient’s experiences of care over time are coherent and linked. This includes relational, informational and management continuity. Relational continuity is a therapeutic relationship between a patient and one or more providers that spans various healthcare events and results in accumulated knowledge of the patient and care consistent with the patient’s needs; the aim is that a patient sees their own primary care physician more than 80% of the time. Informational continuity is the use of information on past events and personal circumstances to make current care appropriate. Management continuity is the extent to which services delivered by different providers are timely and complementary such that care is experienced as connected and coherent.

CPSA: College of Physicians and Surgeons of Alberta regulates the practice of medicine.

Dyad (PC/PF): Physician Champion and Practice Facilitator Dyad. Based on a proven model in healthcare improvement, this duo of change agents is also known as the Health Transformation Workforce in Alberta and work with community care practices to positively impact the implementation of quality improvement interventions.

EMR: Electronic Medical Records; the computerized chart in the physician’s office.

Find A Doctor: A website designed to assist patients in finding family physicians.

H2H2H: Home to Hospital to Home

H2H2H Transitions Guideline: This guideline bridges the connections between hospitals, primary care and community services. Transitions in care require a coordinated approach as many factors may contribute to high quality care transitions. To assist providers and teams within Alberta, this guideline presents leading operational practices, change management, tools, resources, and additional information for six elements.

HQCA: Health Quality Council of Alberta is a provincial agency that brings an objective perspective to Alberta’s health system, pursuing opportunities to improve patient safety and health service quality for Albertans.

LACE: The Length of stay, Acuity of admission, Charlson comorbidity index, Emergency department visits in past six months (LACE) index was developed to predict hospital readmissions in Canada.

LOP: Leading Operational Practice. A defined set of activities that are standardized and evidence informed. They support health system change to drive improvements that lead to safer transitions in care, and improved patient, family and provider experiences.

Panel: A group of patients for whom a primary provider(s) and team is responsible for providing comprehensive and longitudinal care. Paneled patients have a confirmed relationship with their primary care provider.

Patient Representatives Guide: This resource is for patients, family members and/or caregivers who have been asked to engage and partner with primary care clinics or Primary Care Networks (PCNs) to be part of the Home to Hospital to Home (H2H2H) transitions.  It also helps the PCN when including a patient representative in planning new services or approaches.

PCN: Primary Care Network is a joint venture between a group of primary care physicians (who form a non-profit corporation) and Alberta Health Services to coordinate service delivery through a network of physicians and other primary health care providers.

PHCIN: Primary Health Care Integration Network was established to improve health outcomes and patient/provider experiences, while addressing challenges in Alberta to reduce spending in healthcare. It works closely with key partners to support integration priorities as they are identified by primary care within the zones.

PPCNC: The Provincial PCN Committee is responsible for determining high-level strategic direction for primary healthcare in the province. They set specific goals, objectives, and targets as well as endorsing large provincial initiatives for primary care and primary care networks.

TNA: Third next available. The most basic measure of access, where clinic scheduling staff is asked to count the number of days to the TNA appointment for all providers within a practice, one-time per week, and record this information for examination over time. The TNA delay measure provides feedback on the amount of time a patient has to wait to see a member of the health professional team and measures the success of backlog reduction.

Transition Planning: Historically referred to as Discharge Planning. Transition Planning is now the preferred term as it highlights that there is no termination of care. A Transition Care Plan is a document that serves as a permanent record of a patient’s visit to hospital and as a critical communication method to transfer information back to primary care. The AHS Connect Care system uses the term Discharge Summary to refer to the Transition Care Plan.