Abstract
Introduction: Transitions between hospitals and primary care pose challenges, leading to increased mortality, morbidity, and high costs due to information loss. To improve patient safety during transitions, the World Health Organization emphasizes standardized discharge planning, better documentation, and enhanced Clinical Information Systems (CIS). Together, Alberta's newly implemented CIS “Connect Care” (CC) and the Primary Health Care Integration Network's (PHCIN) Home to Hospital to Home (H2H2H) Transitions Guideline and related metrics, aim to improve patient outcomes and system integration.
Who is it for: Adults ≥18 years transitioning from hospital to home within Alberta's healthcare system.
Engagement/Involvement: Engaged 750+ stakeholders in co-designing the Home to Hospital to Home (H2H2H) Transitions Guideline and related metrics, including patients, families, caregivers, and trans-disciplinary providers.
Methods: This study utilizes provincial data on H2H2H transitions measures within acute care hospitals using CC from April 1, 2022 to March 31, 2023. Provincial data sources encompass CC, discharge abstract database, practitioner claims, and the national ambulatory care reporting system. The integration measures aim to comprehensively assess H2H2H care transitions provincially and strengthen ongoing improvement initiatives. Serving as pivotal indicators, they assess various components of the patient journey during transitions, including confirming the primary care provider at hospital discharge, utilizing the LACE Readmission Risk Index, ensuring timely discharge summaries, monitoring primary care physician follow-up, and evaluating unplanned hospital readmissions post-discharge.
Key Findings: Results include discharges of Albertan adults from 47 sites that have implemented CC, totaling 98,108 discharges from hospitals to home/home with support. Nearly 80% of discharges listed a primary care provider. Less than 5% of discharge summaries included the LACE index. Approximately 90%, 91%, and 93% of discharge summaries were signed within 24, 48, and 72 hours, respectively. Around 58% of moderate-risk and 52% of high-risk discharges had follow-up care within set timeframes. Readmission rates within 7, 14, and 30 days were below 4%, around 7%, and approximately 11%, respectively.
Conclusion: The adoption of CC and H2H2H transition metrics enables provincial integrated care measurement in hospital-to-primary care transitions, emphasizing the need for enhancing risk index inclusion and high-risk discharge follow-up to further improve patient transitions. Ongoing initiatives are crucial for optimal patient outcomes and system integration in Alberta.
International Relevance: The indicators employed in this study are potentially applicable to other health systems aiming to monitor hospital-to-home transitions in care. As countries strive to enhance patient safety during transitions, these standardized measures and metrics may offer valuable insights into establishing effective discharge planning, improving documentation, and bolstering electronic CIS.
Next Steps: Continuing work involves devising additional integration metrics to enhance understanding and improve patient outcomes during hospital-to-home transitions.