What is the purpose?
The purpose of the Home to Hospital to Home (H2H2H) Transitions Change Package is to assist primary care clinics in optimizing processes for paneled patients for effective transitions in care from home to hospital to home.
This change package facilitates behaviour changes that can be made within primary care to support the implementation of the H2H2H Transitions Guideline. Familiarizing yourself with this guideline will add context to the high-impact changes and potentially better practices outlined in this change package.
What is the aim statement?
By a specific date, the clinic will offer a follow-up appointment, as appropriate, to a specific number of patients within 14 days post-hospital discharge.
What is the outcome measure?
A percentage or number of high-risk patients with a visit within 14 days post-hospital discharge.
What constitutes the balancing measure?
The time to the third next available (TNA) appointment.
What will help with implementation?
CII/CPAR participation is strongly recommended. It is a technical enabler for implementing potentially better practices.
CII/CPARHigh Impact Changes
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Improve the patient experience
Potentially Better Practice
Establish a multidisciplinary improvement team and consider including a patient with lived experience.
Process Measures
Team meetings are scheduled regularly.Tools
Sequence to Achieve Change Patient Partner Guide Quality Improvement Project Team List
Potentially Better Practice
Invite patients to bring a caregiver or family member to a follow-up appointment when appropriate.
Process Measures
The clinic has a pre-visit script and processes to applyTools
Scripting Samples - H2H2H PDSA Worksheet -
Identify paneled patients
Potentially Better Practice
Upon receipt of admit notification, develop a process to provide hospital team with any relevant patient information.
Process Measures
The process is documented for notifying hospital team of relevant patient information.
Tools
Panel Processes Change Package Summary Process Mapping
Potentially Better Practice
Develop a process to identify patients discharged from the hospital (using CII/CPAR)
Process Measures
A process exists for identifying patients discharged.
Tools
CII/CPAR Team Toolkit for Primary Care
Potentially Better Practice
Partner with your PCN when you are accepting new patients to your panel.
Process Measures
A process exists for accepting new patients
Tools
AlbertaFindaDoctor.ca -
Optimize care processes
Potentially Better Practice
Develop a process to review patient discharge summary* from hospital
Note: The H2H2H Transitions Guideline uses ‘transition care plan’ to describe the discharge summary
Process Measures
A process is documented for reviewing the discharge summary.
Tools
Roles and Responsibilities - H2H2H Process Mapping
Potentially Better Practice
Develop a process to check each discharge summary for a risk of readmission score.
Process Measures
The process is documented for checking risk of readmission score.
Tools
LACE
Potentially Better Practice
If a risk of readmission score has not been provided by acute care, develop a process to determine who your high-risk patients are.
Process Measures
A process is documented for determining high-risk patients.
Tools
PDSA Worksheet
Potentially Better Practice
Develop a process to offer and manage follow-up care, as appropriate.
Process Measures
A process is documented for offering and managing follow up care.
Tools
Post Discharge Follow-up Process Virtual Care
Potentially Better Practice
Create a plan for the patient appointment (e.g., medication reconciliation, review care plan, results and outstanding test follow up)
Process Measures
A plan is documented.
Tools
My Next Steps: Getting Ready to Leave the Hospital -
Standardize documentation
Potentially Better Practice
Standardize entry of admit notifications, discharge notifications and discharge summaries.
Standardize entry of patient risk for hospital readmission in the patient record.
Process Measures
The number or percentage of discharged patients with risk assessment documented in the patient record.
Tools
EMR Guides - H2H2H -
Coordinate care in the medical home
Potentially Better Practice
Establish clear roles and responsibilities for supporting patients in transitions.
Process Measures
Documented roles and responsibilities of team members.
Roles and Responsibilities - H2H2H Team Huddles Guide -
Coordinate care in the health neighbourhood
Potentially Better Practice
Communicate as needed post-transition with care providers outside of the medical home. (e.g., primary care accessing specialist advice and liaising with homecare or other members of the extended healthcare team)
Process Measures
A process for contacting specialist advice programs, home care, and others must be in place.
Tools
Introductions with IntentionSpecialist Advice Programs
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