Updated on October 30, 2015


In Ontario, a key area of focus is reducing avoidable hospitalizations in order to provide the best quality and safety of health care for all Ontarians, and to optimize the use of health care resources.1 The current rate of 30-day readmission to any facility in Ontario is 15.1% (Table 1). This rate varies widely across the province, and is high in comparison with other leading health care systems.1

Table 1: 30-day readmission rate to any facility target setting, 2012/13 QIPs2

Best Achieved to Date in Ontario Theoretical Best Provincial Average Relative Improvement Targets by
Hospitals That Selected as Priority
Average Target  Lowest Target  Highest Target 
To Be Determined

(Q4 2010/11)

 18% 0% 35%

It is noteworthy that in Ontario up to 30% of patients who visit the Emergency Department have no follow-up within 30 days. In fact, 20% to 30% of patients who visit the emergency department with an acute exacerbation of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or diabetes have no follow-up with a family doctor or specialist within 30 days of their visit (Figure 1):

Figure 1: Percentage and type of follow up within 30 days of Emergency Department discharge, Ontario, 2005-2008; Source: Schull et al. Institute for Clinical Evaluative Sciences unpublished2

Providing safe and effective transitions in care is an important strategy for minimizing unnecessary hospitalizations and ED visits, and reducing avoidable readmissions of patients discharged from hospital to the community.1-7 A care transition describes the transfer of a patient between different settings and health care providers during the course of an acute or chronic illness.3 Some key transition points include preparing for discharge, discharge, primary care, community care, and self care follow-up. Many people are readmitted to hospitals during the first 30 days following discharge because of:3-6

  • Unclear or delayed discharge plan and instructions
  • Conflicting plans and instructions from different providers
  • Medication errors, including dangerous drug interactions and duplications

Transitional care involves multiple health professionals within and between disciplines and settings, all sharing the responsibility of care for one individual. However, this presents challenges to providing continuous care delivery, particularly for the elderly with complex conditions.1,3,5,6,7,8 Individuals with one or more conditions such as diabetes, congestive heart failure, coronary artery disease, stroke, and chronic obstructive pulmonary disease have complex care needs involving primary care, home care, hospitals, and specialists and can have even more complex transitions of care. Without coordinated continuous care from the hospital to the community, they are at risk for hospital readmissions.3-9 By bringing together providers and organizations from across the continuum of care, we will ensure complimentary and coordinated services, share information between providers with greater accuracy, and be better equipped to manage patients with chronic disease and multiple illnesses.6

Call to Action

In Ontario, reducing 30-day readmissions is important. This section focuses on the transition from hospital to the community and highlights the importance of continuity of care with the goal of reducing unnecessary hospital readmissions. It emphasizes careful discharge planning, reconciliation of medication, and clear communication – where the care will be managed by the primary care provider or community care access provider. The goal is to reduce 30-day hospital readmissions in order to improve the quality of care, enhance patient safety, optimize health resources, and improve patient and provider experience.

In Ontario, we can reduce the 30-day readmissions rate and attain our goal of best care, best health outcomes, and best value by effectively planning care and discharge from hospital to appropriate hand-offs, discharge summaries, medication reconciliation, and smooth transitions between these areas of care. This tool will provide you with information such as indicators, targets, measures, evidence informed best practices, and tools and resources to get started on your quality improvement plans.

  1. Baker GR et al. Enhancing the Continuum of Care: Report of the Avoidable Hospitalization Advisory Panel.

    Toronto: Ministry of Health and Long-Term Care; 2011 Nov.
    Available from: http://www.health.gov.on.ca/en/common/ministry/publications/reports/baker_2011/baker_2011.pdf

  2. Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement.

    Toronto: Health Quality Ontario. 2012 Nov [cited 2012 Nov 12]. p. 61.
    Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf

  3. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.

    J Am Geriatr Soc. 2003 Apr;51(4):549-55.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/12657078

  4. Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home.

    Cochrane Syst Rev. 2010 Jan;20(1).
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/20091507

  5. Phillips CO, Wright SM, Korn De, Singa R, Sheppard S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.

    JAMA. 2004 Mar 17; 291(11): 1358-67.
    Available: http://www.ncbi.nlm.nih.gov/pubmed/15026403

  6. Schnipper JL, Roumie CL, Cawthon C, Businger A, Dalal AK, Mugalla I, Eden S, Jacobson TA, Rask KJ, Vaccarino V, Gahdi TK, Bates DW, Johnson DC, Labonville S, Gregory D, Kripalani S; PILL-CVD Study Group. Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study.

    Circ Cardiovasc Qual Outcomes. 2010 Mar;3(2):212-19.
    Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021350/

  7. Dhalla IA, O’Brien T, Ko F, Laupacis A. Toward safer transitions: how can we reduce post-discharge adverse events?

    Healthc Q; 2012 Apr; 15 (Special No.):63-67.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/22874449

  8. Nasmith L, Ballem P, Baxter R, et al. Transforming Care for Canadians with Chronic Health Conditions: Put People First, Expect the Best; Manage for Results [Internet].

    Ottawa: Canadian Academy of Health Sciences; 2010.
    Available from: http://www.cahs-acss.ca/transforming-care-for-canadians-with-chronic-health-conditions-put-people-first-expect-the-best-manage-for-results-2/

  9. Naylor MD, Aiken LH, Kurtzman ET, Olds DM, & Hirschman KB. The care span: the importance of transitional care in achieving health reform.

    Health Aff. 2011 Apr;30(4):746-54.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/21471497

Best Practices

Updated on October 30, 2015

“By changing nothing, nothing changes.”
Tony Robbins

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.10 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.

To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach. 

Change ideas are specific and practical changes informed by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

  1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care.

    Lancet. 2003 Oct 11;362(9391):1225-30.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747


Updated on October 30, 2015

“Some is not a number, soon is not a time.”
Don Berwick, former CEO and President of IHI, December 2004, at launch of the 100,000 Lives Campaign

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Type of Indicator Indicator of Quality Improvement How to Calculate:


Targets/ Benchmarks How is This Indicator Used?
Outcome Percentage of home care patients with unplanned hospital readmissions within 30 days of referral from hospital to Community Care Access Centre after acute hospital discharge The number of unplanned hospitalizations by home care patients newly referred to home care services within 30 days of initial hospital discharge
The number of home care applications from patients referred from hospital who received a home care service visit
Targets: As low as possible (set by individual homes)

Provincial benchmarks:
Quality improvement

QIP indicator

Publicly reported by HQO

Run Charts

Collected measures can be presented graphically by plugging the monthly results into run chart.

Tools & Resources

Updated on October 30, 2015


Transitions Tools
Medication Reconciliation Tools
QI Tools

For a more comprehensive list of tools and resources, visit the following links on our HQO website:



Transitions Resources
White Papers
Position Papers on Medication Reconciliation
QI Resources