Health Quality Ontario Releases New Quality Standard on Transitions from Hospital to Home

Health Quality Ontario has released a new quality standard that addresses care for people going home after a hospital admission.

Transitions between hospital and home are complex, multiple-step processes that require integrated communication and coordination among the patient, their caregivers, the hospital team, primary care, and home and community care providers. When not managed well, patients may suffer harm from errors and delays in care. 

This quality standard addresses care for people of all ages transitioning (moving) between hospital and home after a hospital admission. This includes people who have been admitted as inpatients to any type of hospital, including complex continuing care facilities and rehabilitation hospitals. “Home” is broadly defined as a person’s usual place of residence and may include personal residences, retirement residences, assisted-living facilities, long-term care facilities, hospices, and shelters. 

The scope of this quality standard includes all clinical populations, including groups that often face challenges with transitions, such as people with complex care, mental health, addictions, palliative, or end-of-life care needs. The scope also includes all health care providers. 
View the Quality Standard Transitions Between Hospital and Home.  Take note of the Quality Standards as well as the Patient Guide and the resources to support implementation of the Standards.

Implications for Occupational Therapists

Occupational therapists have much to offer the discharge planning and implementation process and will find the new Standard is attentive to the processes of an effective discharge and transition home.  OSOT asserts that occupational therapists are uniquely positioned to play key roles in discharge planning and may use these Standards to underline the importance of the roles and perspectives that they can bring to support effective transition from hospital to home.

Rogers et al (1) reported that they found that OT is the only service category where there is a statistically significant relationship between increased spending and lower readmission rates across the medical conditions they studied.  "OT focuses on a vital issue related to readmission rates - can the patient be discharged safely into her or his environment?"  They identify several OT interventions that could potentially lower readmission rates;

  • provide recommendations and training for caregivers that affect both safety and the ability of patients to meet basic needs after discharge
  • assessment of the level of supervision and care patients will require after discharge, including needs for personal support workers
  • assessment of needs and potential for further rehabilitative care especially amongst those patients with more serious impairments affecting function such as cognitive deficits, mobility issues
    ability to support and promote accommodation of existing disabilities by prescribing assistive devices
  • performance of home safety assessments as part of the inpatient rehabilitation discharge planning to address potential hazards, suggest safety modifications and ensure environment is set up to enable maximal function and safety
  • cognitive and physical training to promote function can support medication management, an effective component of readmission management
  • Work with physical therapists to increase the intensity of inpatient rehabilitation

    ​(1) Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016, September 2). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 1–19.