Quality Standard Details
Transitions Between Hospital and Home: Care for People of All Ages
- Publication Date
-
2025-February-01
- Status
- Published
- Topic Area
- Transitions in Care
-
Care transitions occur when patients transfer between different care settings (e.g., hospital, primary care, long-term care, home and community care) and between different health care providers during the course of an acute or chronic illness. Transitions are critical and vulnerable points in the provision of health care. Transitions between hospital and home are complex, multistep processes that require integrated communication and coordination among the patient, the patient’s family and care partners, the hospital team, the patient’s primary care clinician, and home and community care providers.
The transition process is further complicated by the complexities of the health system because care is delivered by multiple providers with various levels of accountability. As a result, there are many points at which communication and care processes can break down. When care transitions are poorly managed, patients may suffer harm from errors and delays in care. Some patients transitioning between hospital and home are particularly vulnerable and at increased risk of hospital readmission, such as people with complex care needs (including children and older people with multiple comorbidities or cognitive impairment).
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. The transition from hospital to home is commonly referred to as a “hospital discharge.”
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, as well as people experiencing homelessness. The scope also includes all clinicians, hospital teams, and home and community care providers involved in the care of people transitioning from hospital to home.
Quality Standard in Brief
-
Quality Statement 1: Information-Sharing on Admission
When a person is admitted to hospital, the hospital shares information about the admission with their primary care clinician, home and community care providers, and any relevant specialist clinicians soon after admission via real-time electronic notification. Community-based providers then share all relevant information with the admitting team in a timely manner.
Quality Statement 2: Comprehensive Assessment
People receive a comprehensive assessment of their current and evolving health care and social support needs. This assessment is started early upon admission, and updated regularly throughout the hospital stay, to inform the transition plan and optimize the transition process.
Quality Statement 3: Patient, Family, and Care Partner Involvement in Transition Planning
People transitioning from hospital to home are involved in transition planning and developing a written transition plan. If people consent to include them in their circle of care, family members and care partners are also involved.
Quality Statement 4: Education, Training, and Support for Patients, Families, and Care Partners
People transitioning from hospital to home, and their families and care partners, have the information and support they need to manage their health care needs after the hospital stay. Before transitioning from hospital to home, they are offered education and training to manage their health care needs at home, including guidance on community-based resources, medications, and medical equipment.
Quality Statement 5: Transition Plans
People transitioning from hospital to home are given a written transition plan, developed by and agreed upon in partnership with the person, any involved care partners, the hospital team, the primary care clinician, and home and community care providers before leaving hospital. Transition plans are shared with the person’s primary care clinician, home and community care providers, and relevant specialist clinicians within 48 hours of discharge.
Quality Statement 6: Coordinated Transitions
People admitted to hospital have a named clinician who is responsible for timely transition planning, coordination, and communication. Before people leave hospital, this person ensures an effective transfer of transition plans and information related to people’s care.
Quality Statement 7: Medication Review and Support
People transitioning from hospital to home have structured medication reviews on admission, before returning home, and once they are home. These reviews include information regarding medication reconciliation, adherence, and optimization, as well as how to use their medications and how to access their medications in the community. People’s ability to afford out-of-pocket medication costs is considered, and options are provided for those unable to afford these costs.
Quality Statement 8: Coordinated Follow-Up Medical Care
People transitioning from hospital to home have follow-up medical care with their primary care clinician and/or a specialist clinician coordinated and booked before leaving hospital. People with no primary care clinician are provided with assistance to find one.
Quality Statement 9: Appropriate and Timely Support for Home and Community Care
People transitioning from hospital to home are assessed for the type, amount, and appropriate timing of home care and community support services they and their care partners need. When these services are needed, they are arranged before people leave hospital and are in place when they return home.
Quality Statement 10: Out-of-Pocket Costs and Limits of Funded Services
People transitioning from hospital to home have their ability to pay for any out-of-pocket health care costs considered by the health care team, and information and alternatives for unaffordable costs are included in transition plans. The health care team explains to people what publicly funded services are available to them and what services they will need to pay for.
Supporting Documents
-
Patient guide for this quality standard
Know what to ask for in your care
Placemats for this quality standard
Quick-reference resources for clinicians that summarize the quality standard and include links to helpful resources and tools:
- For transitions between hospitals and home
- For transitions between hospitals and long-term care homes
- For transitions between hospital and home for alternative-level-of-care patients with a dual diagnosis
Quality improvement tools and resources for health care professionals, including an action plan template
Supplementary information to support the data collection and measurement process
Additional Resources
If you would like to receive these resources, please send us a message using our contact form:
- Case for improvement (slide deck)
Share why this standard was created and the data behind it, to get the support you need to put it into practice - Technical specifications
See the technical specifications for the indicators within the quality standard - Summary of the public feedback we received
Last Updated: February 24, 2026
