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Overview

Created on December 30, 2016

Issue

Creating smooth transitions between care providers is a key quality issue facing Ontario. Individuals with chronic conditions have complex care needs and require better coordination between the different levels of care. The primary quality indicator used to monitor care transitions from hospitals is the 30-day readmission rate. In 2014/15 the provincial hospital readmission rate for medical patients was 13.7 per 100 patient discharges while surgical patients was 7 per 100 patient discharges1. Patients treated for chronic obstructive pulmonary disease and heart failure had higher rates at 18.5 and 21.4 per 100 discharges respectively2. While readmissions are not always avoidable, they can indicate that the quality of care the patient received in the hospital or in the community after leaving the hospital was inadequate. Causes for a readmission within 30 days can occur due to3-6:

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

Addressing issues in transitional care will involve multiple health professionals in a number of health settings. Through it all, it is important that patients are kept educated about their condition and what they are responsible for.

Call to Action

The goal in Ontario is to reduce the number of unplanned hospital readmissions. This can be accomplished by developing personalized discharge plans, scheduling post-transition follow up appointments, facilitating patient education and self-management, and completing medication reconciliation. By implementing these practices, hospitals can improve the patient experience, enhance patient safety, and improve the overall quality of care provided. Establishing strong cross-sector collaborations will be important to implement and sustain these practices.

  1. Canadian Institute for Health Information. 2016. Your Health System: In Depth.

    Available from: http://yourhealthsystem.cihi.ca/hsp/indepth?lang=en#/theme/C5001/2/N4IgKgFgpgtlDCAXATgGxALlAYwPatQEMAHAZygBNNQAGGgFkxQFcoBfDoA

  2. Measuring Up. A Yearly report on how Ontario's health system is performing.

    Health Quality Ontario, 2016.
    Available from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2016-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

  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).

  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.

  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.

Best Practices

Created on December 30, 2016

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.8 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 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.

Measurement

Created on December 30, 2016

“Some is not a number, soon is not a time.”
Don Berwick, former President and CEO 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 respondents who responded positively to the following question: Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? See Indicator Library Targets: As high as possible (set by individual hospitals) QIP Priority Indicator
Outcome Risk-adjusted 30-day all-cause readmission rate for patients with chronic obstructive pulmonary disease See Indicator Library Targets: As low as possible (set by individual hospitals) QIP Priority Indicator
Outcome Risk-adjusted 30-day all-cause readmission rate for patients with congestive heart failure See Indicator Library QIP Priority Indicator
Outcome Risk-adjusted 30-day all-cause readmission rate for patients with stroke See Indicator Library QIP Priority Indicator
Outcome Readmission within 30 days for selected Health Based Allocation Model Inpatient Grouper (HIG) See Indicator Library QIP Additional Indicator
Process Total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital See Indicator Library Targets: As high as possible (set by individual hospitals) QIP Priority Indicator
Outcome Total number of discharged patients for whom a best possible medication discharge plan was created as a proportion of the total number of patients discharged See Indicator Library QIP Priority Indicator


Tools & Resources

Created on December 30, 2016

Tools

Individualized Discharge Planning
Post Transition Follow-up Tools
Promote Self-Management and Patient Education
Medication Reconciliation
QI Tools

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

QI Resources