Operational Direction for Acute Hospitals on the Repatriation Process Within Ontario

Ensuring timely access to the appropriate level of care for Ontarians requires all hospitals to balance their capacity, access and flow. The coordination of repatriation and inter-facility transfers (IFT) is an essential component of health system performance and is intended to support care closer to home.

Repatriation and IFT refer to the process of transferring a person from one acute hospital bed to another following a critical phase of illness or episode of care, where hospitalization for acute medical needs is still required. There are various scenarios that can result in the need for a repatriation or IFT.

This operational direction is intended for acute care hospitals to support access and flow and overall system efficiency, with a focus on access to the appropriate level of care, at the right time, closer to home. This operational direction has been developed to strengthen system coordination by setting out standard processes for acute care hospitals, prioritization criteria and their responsibilities for repatriations and IFTs. This Operational Direction reinforces the long-standing expectation of sending hospital accountability. An accountability framework is provided.

The standards aim to 1) safeguard the functional integrity of specialty regional programs and 2) support delivery of the appropriate level of care closer to home when specific treatments are completed. The standards will mitigate and balance risk across the system. This operational direction aligns with and supports Ontario’s Life or Limb Policy (2025).

A key enabler to this operational direction is the Repatriation Tool within CritiCall,Ontario’s Provincial Hospital Resource System (PHRS). As such, the accountabilities for the use of this tool are described. Detailed educational materials, including how to access and use the Repatriation Tool, are available through CritiCall Ontario.

Repatriation and IFT Guiding Principles

1. People in Ontario can expect to receive the right level of care closest to home.
2. Person transfers will support flow from tertiary/quaternary hospitals and hospitals1 that support specialized care, ensuring a balanced approach to access to care.
3. Sending hospitals are expected to take the person back once their tertiary/quaternary specialized care is complete, except in clearly defined and documented exceptional circumstances.
4. Health service providers across the province have a shared accountability in providing timely, high quality, safe, and accessible care, and all hospitals are committed to expedient transfers. Through health service provider collaboration, all Ontarians have access to one system of health care.
5. Transfers will support culturally safe and inclusive care wherever possible (e.g., for First Nations, Inuit, Métis and urban Indigenous populations, Black communities, Francophone populations, people living with disabilities, communities with geographic disparities in access to care, newcomers, 2SLGBTQIA+ communities).

¹Large/medium size hospitals receiving persons from small/rural hospitals requiring specialized services.

Scope

This operational direction applies to all hospitals with acute care beds within Ontario. It includes the repatriation or IFT of all admitted medically stable adult populations in acute care beds except for the following:

• Mental health (Note: This would not apply for someone with a known or new onset mental health diagnosis which resulted in the need for a higher level of care. After the critical phase of illness, when specific treatments and a psychiatric consult have been completed, if a mental health bed would be required for ongoing care needs, this operational direction must then be followed.
• Pediatric and neonatal.
• Clinical conditions with existing Memorandum of Understanding (MOUs) (Note: Not all clinical conditions or hospitals within the province have affiliated MOUs; this operational direction would be followed where MOUs do not exist).
• Out-of-province repatriations (Note: Existing agreements in place between regions and Manitoba and Quebec will maintain status quo)
• Out of country repatriations.
• For persons brought for assessment to the Emergency Department (ED) through field trauma triage guidelines or bypass protocols, after Paramedic transfer of care (TOC) has occurred, if an assessment (clinical assessment and diagnostic testing as appropriate) determines that admission to that hospital for speciality-specific care is not required, but person cannot be discharged home, prompt repatriation, to the closest to home hospital, should be initiated. All hospitals (sending and receiving) are required to have procedures/protocols in place to support this. The closest to home hospital must be notified in advance of transfer to provide opportunity to secure a bed and discuss logistics of transportation.

Special Considerations for Northern Populations

To promote equity and person-centred care, it is important that repatriation decisions do not unintentionally disadvantage northern populations due to geography, access barriers, or infrastructure limitations. The following special considerations will be addressed when managing repatriation/IFT requests within northern regions.

1. Person and Family Support – Ensure access to accommodations, culturally appropriate services, and travel assistance when repatriating persons from northern communities.
2. Primary Care Access – Consider the location and availability of the person’s primary care provider when determining appropriate repatriation destinations.
3. Geographic Burden & Transportation – Factor in physical distances and available transportation options to avoid unnecessary hardship for families in remote areas.
4. Repatriation Pathways – Maintain care at local northern hospitals where clinically appropriate and avoid unnecessary transfers to higher-level centres unless care needs demand it.

Operational Direction to Hospitals

1. Standard Processes

Hospitals must follow the standard process outlined in this section.

1. Hospitals will use CritiCall Ontario’s PHRS online Repatriation Tool (‘the tool’) to document all repatriation and IFT requests to completion. This operational direction and use of the Repatriation Tool in PHRS does not eliminate the need for communication between sending and receiving hospitals, directly between physicians, and with hospital administration.
2. The status of requests in the tool must be kept updated seven days per week.
3. All accepted repatriation requests are completed within a best effort window of no more than 48 hours from request transfer date entered (or redirect date) in the tool. IFT requests must have a decision and a plan within 48 hours of request transfer date entered in the tool. Physical transfer must be completed within seven days of transfer request.
4. Sending hospital deems person no longer requires services unique to their current hospital and the person does not have an estimated date of discharge within the next three days.
   • Person is deemed medically stable and suitable for transfer, with no outstanding subspecialty diagnostics /consultations, and/or procedures (specific to sending hospital) required.
   • Person cannot be discharged home or transferred to post-acute care.
     • Home First principles will be leveraged for all persons.
     • Sending hospitals will continue to support active discharge planning for all persons listed as active in the PHRS system awaiting transfer.
5. The hospital that originally referred the person must accept the person back except in the following limited circumstances:
   • it is not one of three closest-to-home hospitals identified through CritiCall Ontario’s PHRS Hospital Search Tool,
   • it cannot provide the services required for the person’s care,
   • the person requests a hospital where they have an established and relevant care history, or
   • the decision-support criteria are not met.
6. Sending hospital uses CritiCall Ontario’s PHRS Hospital Search Tool to identify up to three closest-to-home most appropriate hospitals.
   • Prior to initiating transfer request, ensure that the current care needs, including language and culturally safe care of the person can be achieved at the target destination. For persons with no fixed address, the hospital closest to home will be based on the address associated with their OHIP card. Sending hospitals will ensure that all standardized decision support criteria are reviewed and considered (see Section 2).
7. Person and/or caregiver1 have participated in a discussion and are aware of transfer to up to three identified hospitals.
8. Sending hospital creates a new transfer request, identifying Active status in the tool and ensures all required documentation is up to date and available as needed.
9. Receiving hospital must Acknowledge or Decline all requests for transfer in the tool within 12 hours, seven days/week.
   • The response of ‘Acknowledged’ is not an acceptance but rather an acknowledgment the request has been viewed.
   • The response of ‘Decline’ is to be used only in extenuating circumstances that prevent the receiving hospital from even discussing the request. (e.g., code grey).
10. Receiving hospital reviews incoming transfer requests and follows internal policies/processes to engage the requested service and identify a most responsible provider (MRP).
11. If request is acknowledged, the receiving hospital Accepts or Not Accepts the request in the tool within 24 hours of transfer request date for repatriations and within 48 hours for inter-facility transfers.
    • The response of ‘Acceptance’ is not limited by bed availability.
    • A request cannot be “not accepted” without all outstanding questions being addressed between sending and receiving site and existing internal surge/bed access and management policies/protocols, as well as engagement with hospital leadership (which may include Chiefs of Staff as needed) having occurred at receiving hospital.
    • If a request is “Not Accepted,” the sending hospital will redirect this request to the second receiving hospital option identified in step five. Status in the tool will be changed to Redirect to the new receiving hospital. Receiving hospital(s) with a redirected request follow step eight onward.
12. Sending hospital to arrange and only use the most appropriate type of transportation as soon as acceptance is received. Bed must be confirmed and receiving hospital is expected to have bed ready for transfer upon arrival.
13. Any delays must be documented in the PHRS tool.
14. Prior to transfer the sending hospital will ensure:
    • The receiving MRP is identified in the tool.
    • Direct provider-to-provider clinical handover is completed.
    • The transfer is arranged by the sending hospital (including most appropriate type of transport, and appropriate accompanying personnel).
    • The receiving hospital has been notified of anticipated transfer time and/or the expected arrival time at their hospital once the person has left the sending hospital
15. Sending hospital completes the Transport and Repatriate status in the tool for all accepted transfers.
16. Sending hospital will cancel the request if the transfer is no longer required (e.g., person’s medical needs change or the person is discharged).
    • A cancellation can only be entered by the sending hospital.
    • Cancelled requests remain available to reissue for seven days.
    • The sending hospital will call any engaged hospitals and booked transportation providers to inform them of the cancelled request.

¹Caregiver may include but not be limited to family or substitute decision maker (SDM).

2. Decision Support and Prioritization Criteria

Decision Support for Sending Hospitals

Sending hospitals must follow standardized criteria (outlined below) prior to initiating a request in the PHRS Repatriation Tool. These criteria are intended to help balance risk across the system.

Criteria

All criteria must be reviewed and considered before a request is initiated.

1. Person is stable and/or suitable for transfer.
2. Expected date of discharge (EDD) to post-acute care (e.g., community, rehab, CCC, etc.) is greater than three days from date transfer request is to be initiated.
3. Up to three closest to home most-appropriate hospitals have been identified.
4. Person/caregiver have participated in a discussion and are aware of transfer to the identified hospitals.
5. Hospital’s overall adult occupancy rate is ≤ 120% as of current data refresh day/time (Review CritiCall Ontario’s PHRS Total Hospital Occupancy Board). Hospital’s volume of active repatriation requests is green (≥ 0 and ≤ 4 requests) as of current data refresh day/time (Review CritiCall Ontario’s Daily Repatriation Dashboard).

Prioritization Criteria for Receiving Hospitals

Ontario Health recognizes that the volume of outgoing and incoming transfer requests will fluctuate and that these requests may occur at times of high occupancy pressures and/or may be competing for limited resources (i.e., beds) and that a system to prioritize requests may be necessary. Prioritization processes will support system-wide risk management. The priority level (1-3) of the transfer request, as well as additional criteria for consideration, will support decision making for receiving hospitals.

When multiple referrals are received, receiving hospitals should prioritize transfers based on the following level of priority:

1. Priority 1: Life or Limb

• After the critical phase of the illness and when specific treatments have been completed, if required, the person is transferred on a priority and no-refusal basis to the closest-to-home most appropriate hospital.
• To support readiness for the next Life or Limb case, repatriate person(s) in intensive care unit (ICU) and regional specialty program beds.
• Hospitals have a shared accountability to expediate transfers of person(s) identified as priority 1. While timelines are provided, the time to acknowledge, accept, and repatriate this group should be below the established timelines.

2. Priority 2: All other repatriations

3. Priority 3: IFTs

If multiple requests fall within the same priority level, additional prioritization criteria for consideration include:

• Date and time request was received (i.e., oldest request should be prioritized)
• Risk of service cancellation at sending hospital
• Overall adult occupancy of sending hospital (i.e., sending hospital with highest occupancy pressure should be prioritized)

Note:

Any IFT on the transfer list that has exceeded seven days since transfer request date will be prioritized for the next available bed at the receiving hospital.

Prioritization criteria are meant to guide decision making. Risk to service cancellation must always be factored into a decision.

Reference Guide: Categorization of Transfer for Persons and Applicable Timelines

Expanded Definitions

1. Repatriation: The process of transferring the person to the acute care hospital that is the closest to home most-appropriate hospital once the person is deemed to be medically stable* and/or suitable for transfer.

Notes:

• The closest to home most-appropriate hospital is determined based on geography (closest to person’s home address) and the ability for the person to receive the required services for the phase of illness at the time of transfer. The receiving hospital may or may not have been the referring hospital.
• Lack of history with a hospital is not a reason to decline a repatriation request, however, if deemed appropriate, and the person has a pre-existing relationship with a specific hospital for ongoing clinical services, treatment or care, this hospital may be considered as the first choice receiving hospital, based on person’s preference, should the distance not be closest to the person’s home address
• Medical stability does not imply that all medical issues are resolved, only that transportation can be safely performed, and the receiving hospital/service can manage these issues, including with support from the sending hospital service.

Applicable Scenarios

• Emergency Bypass: The person was initially transferred to a hospital outside their geographic area due to emergency protocols, such as bypass, field trauma triage, or air ambulance utilization standards.
• Specialized Care Referral: The person received specialized care at a hospital other than their home hospital because the services are not available at their home hospital.
• Unplanned Care: An unplanned medical event outside their geographic area (closest to home hospital) required the person to receive treatment outside the geography of their home hospital. Unplanned medical events may include but not be limited to:
  • Events that occur while travelling within Ontario
  • Events that occur while at work, where person works outside their geographic area

Timeline Expectations: All repatriation requests must be completed within a best effort window of no more than 48 hours of request entered or redirected in the tool.

2. Inter-facility Transfer: The process of transferring a person between hospitals that may only be initiated by the person/family without meeting the Repatriation Definition/Applicable Scenarios.

Notes:

• Person Preference: The person chooses to receive care at a hospital that is not their closest to home most-appropriate hospital. Reasons may include, but not be limited to: prior experience, familiarity with providers or services, perceived shorter wait times.

Timeline Expectations: All IFT requests must have a decision and a plan within 48 hours of request entered. Physical transfer must be completed in seven days.

Components for Implementation

1. Sector Responsibilities

Ontario Health

• Oversee and support operational direction implementation (e.g., education, tools, quality improvement).
• Monitor indicators through CritiCall’s Ontario reports.
• When appropriate, manage performance based on identified hospital, regional and provincial trends impacting capacity, access, and flow (e.g., percentage of repatriations and IFTs exceeding established timelines, percentage of system cancellations, etc.).
• Support escalations.

CritiCall Ontario

• Provide access, education, training and technical support to hospitals on the PHRS Repatriation Tool and applicable data and reports, including occupancy data in the Total Hospital Occupancy Board.
• Ensure tools are reflective of and support the needs of hospitals in facilitating timely repatriations.
• Collect data and produce or provide access to reports to support provincial, regional, and heath service provider performance monitoring, management and quality improvement.

All Hospitals

• Monitor and manage flow
  • Ensure policies/processes (including moderate surge) are in place and align with the Operational Direction for Acute Hospitals on the Repatriation Process Within Ontario (2025) to facilitate repatriation within no more than 48 hours.
  • Identify a senior executive leader responsible for flow and the regular review of repatriation performance, and compliance with this operational direction.
  • Ensure hospital has staff assigned to access and use the Repatriation Tool.
  • Ensure hospital has staff assigned to monitor and update the hospital’s Total Hospital Occupancy Board (THOB) in PHRS to support accurate occupancy information.
  • Ensure hospital has staff assigned to monitor hospital’s repatriation data including the Daily Repatriation Dashboard and dashboard reports in CORD BI.
  • Ensure data accuracy in all PHRS reporting and repatriation tools.
  • Establish processes to identify most appropriate service and MRP.
  • Establish a process to prioritize cases that have not been transferred within the timelines.
  • Participate in the escalation pathways for issues if there is deviation from this operational direction which may lead to a delay in transfer.
• Facilitate direct provider-to-provider conversation.
• Address barriers to transfer including any issues related to MRP, pharmaceutical or care supply issues, or perceived lack of skills/expertise to meet persons’ care needs.
• Participate in finding solutions with Ontario Health Regional Leadership and regional partners, when escalation has occurred.

2. Accountability Framework

As this operational direction applies to hospitals in Ontario with acute care beds, monitoring, compliance, and escalation outlined within the accountability framework is the responsibility of hospitals and Ontario Health. While other health system partners operating outside of this operational direction may monitor their own identified indicators relevant to repatriations, Ontario Health’s focus is on monitoring those metrics identified for hospitals.

Monitoring

It is the responsibility of hospitals to consistently monitor CritiCall Ontario’s PHRS Repatriation Tool for incoming and outgoing requests to ensure timely communication and updates on transfer status. Hospitals are responsible for supporting the use and monitoring of CritiCall Ontario’s PHRS Repatriation Tool, seven days per week.

Hospitals are also responsible for regular review and monitoring of CritiCall Ontario’s Daily Repatriation Dashboard to track repatriation activity, identify delays, support timely transfers, and close out any active repatriation request that have been completed, redirected or need to be cancelled.

Repatriation and IFT data is available in CritiCall Ontario Reports and Data portal with business intelligence (CORD BI). All acute hospitals are accountable to review this information monthly to identify trends and areas of opportunity.

Hospitals’ monthly review and monitoring to include, but not limited to:

• Organizational alignment with operational direction
• Percentage of completed repatriations to receiving hospital exceeding 2 days
• Identified barriers and reasons for delay
• Percentage of system cancellations and other reason for cancellation
• Identification of mitigation strategies if not meeting targets

Ontario Health’s regional teams’ monthly review and monitoring will be shared with appropriate sub-regional Access and Flow Tables and Hospital Operations Table (HOT) and will include, but not be limited to:

• Trends
• System barriers (e.g., internal and external to hospitals)
• Areas of opportunity

Findings will be incorporated into hospital performance management approaches, as needed.

Compliance

Access to high quality, safe, and accessible care is a shared accountability. A person entering one hospital in Ontario is entering a provincial system of care, whereby all parties under the operational direction are expected to participate. The expected compliance rate of the operational direction is 100%.

If there is deviation from the operational direction in which access to treatment and/or person safety may be compromised, escalation pathways will be invoked.

Escalation

Transfer requests that exceed timelines set out in the operational direction compromise the functional integrity of quaternary/tertiary/specialized programs and pose a safety risk to persons requiring these services. Transfer requests exceeding established timelines will follow established escalation pathways. Up to date information and communication (in PHRS Repatriation Tool and between sending and receiving hospitals) is integral to safe, efficient and timely transfers. This operational direction and any escalation pathway within does not eliminate the need for communication between sending and receiving hospitals, directly between physicians and with hospital administration.

Escalation Processes to Ontario Health

Escalation meetings/processes with Ontario Health are intended to facilitate discussion on transfer plans and timelines. They are not intended to be a forum to discuss outstanding questions related to a specific transfer request. All questions/answers are expected to be addressed prior to escalation to Ontario Health.

The following criteria must be met before the sending hospital can initiate an escalation:

1. Transfer request(s) has/have exceeded timelines established in the Operational Direction for Acute Hospitals on the Repatriation Process Within Ontario (2025) (i.e., no more than 48 hours, seven days).
2. Communication between sending/receiving site has occurred and all questions and answers are addressed:
   • current PHRS repatriation tool status known
   • repatriation or IFT confirmed
   • clinical suitability/stability/special needs confirmed
   • all notes/documentation provided
   • accepting most responsible physician identified (MRP)
   • all identified barriers have been addressed
3. Bed has not been secured, and/or plan/timeline provided.
4. Confirmation from receiving hospital that internal bed access and management policies/surge protocols have been activated, as well as escalation to hospital leadership which may include but not be limited to a Vice President/Clinical and/or Chief Nursing Executive (which may also include Medical Chiefs of Staff) as needed.
5. Receiving hospital has been made aware that timeline for transfer request has been exceeded, no bed secured, or plan identified and escalation to Ontario Health will be the next step.

When all criteria have been met, the sending hospital will escalate to the Ontario Health team responsible for repatriations/escalations in your region. Out of region (cross-regional) escalations will follow the Inter-regional Escalation Pathway.

Regional Escalation

Each Ontario Health region will establish and follow their own repatriation/IFT escalation pathway allowing for consideration of local context. To ensure a standard approach and adequate communication prior to escalation to Ontario Health at a regional level, the escalation requirements described above will be used.

Inter-Regional Escalation

Repatriations and IFTs escalations, where the closest to home most-appropriate hospital is located outside the sending hospital’s designated Ontario Health region will be brought forward to the Ontario Health Regional Clinical and/or Capacity, Access, and Flow (CAF) team responsible for repatriations in that Ontario Health region through regional pathways. Ontario Health regional teams will collaborate and follow the established Inter-regional Escalation Pathway (Appendix 5).

3. Operational Review Cycle

This operational direction is the result of engaged consultation with providers and partners across Ontario and will be reviewed six months post implementation and annually thereafter.

Appendices

Appendix 1 – Definitions

Home Hospital (also known as ‘hospital closest to home’) – The target destination that is the closest to home and most appropriate hospital for repatriation following the critical phase of the illness episode. When the person no longer requires the bundle of services unique to the sending hospital, repatriation to the referring hospital or to the closest to home hospital that has the appropriate services is considered. The hospital that is geographically closest to the person’s identified address.

Initial Hospital – The hospital to which the person first presented.

Inter-facility Transfer – The process of transferring a person between hospitals that may only be initiated by the person/family without meeting the Repatriation Definition/Applicable Scenarios.

Life or Limb is defined as an episode of treatable time-sensitive critical illness. This is an episode of illness that has all three attributes, i.e., treatable and time sensitive and critical, where:

1. Treatable – clinical intervention(s) within standard of care is available.
2. Time-sensitive – critical threats are mitigated with treatment received within 4 hours.
3. Critical – a clinical condition that poses a threat to a person’s life and/or a threat to the minimally essential function of an organ or body system (e.g., vision, limb function). This includes threats related to pregnant persons and/or in-utero transfers when newborns are anticipated to need a higher level of care.

Memorandum of Understanding (MOU) – An agreement between hospitals to identify their agreement, establish accountability and determine timelines in the provision of person care.

Most Responsible Provider (MRP) – The physician, or other regulated health care professional, who has overall responsibility for directing and coordinating the care and management of a person at a specific point in time.

Out of Country (OOC) – Refers to a person who resides outside of Canada, and the request to transfer to their home country.

Out of Province (OOP) – Refers to a person who reside outside of Ontario, and the request to transfer to their home province.

Provincial Hospital Resource System (PHRS) – The PHRS, built and managed by CritiCall Ontario, provides a single source of information on the availability of acute care and psychiatric beds and resources in Ontario hospitals. It also hosts the Repatriation Tool and Total Hospital Occupancy Board (THOB).

Receiving Hospital – The hospital to which the person is being transferred.

Repatriation – The process of transferring the person to the acute care hospital that is the closest to home most-appropriate hospital once the person is deemed to be medically stable and/or suitable for transfer.

Sending Hospital – The hospital where the person is currently receiving services.

Substitute Decision-Maker – A substitute decision-maker is a designated person authorized to make decisions on behalf of a person who is unable to make important decisions about their own personal care.

System Cancellation – Repatriation requests will automatically cancel after a 30-day period of no activity in the PHRS system. If requests are left to System Cancel, the request activity is not included in system data. All effort must be made to complete documentation to prevent system cancellation.

Appendix 2 – References

1. Champlain LHIN (2023). Patient Repatriation Policy & Procedure.
2. Critical Care Services Ontario (2014). Repatriation Guide.
3. Critical Care Services Ontario (2019). Repatriation Guide: Addendum.
4. CritiCall Ontario (2014). Repatriation Tool.
5. Ministry of Health and Long-Term Care (2013/2025). Life or Limb Policy.
6. North East Ontario Hospital (2021). Repatriation Shared Understandings/Agreement.
7. Ontario Health (West) Region. (2022). Adult Repatriation and Inter-facility Transfer Agreement.
8. Ontario’s Life or Limb Policy (2025)
9. South Eat LHIN (2013). Region Wide PATIENT FLOW Policy and Procedure

Appendix 3 – Care Continuum Pathway

ISSUED TO: Hospitals with Acute Care Beds

ISSUED FROM: Matthew Anderson, Chief Executive Officer

CC: Christine Nuernberger, Chief Regional Officer (interim), Central Region Nicole Robinson, Chief Regional Officer (interim), West Region Scott Ovenden, Chief Regional Officer, Toronto and East Regions Brian Ktytor, Chief Regional Officer, North West and North East Regions

RELEASE DATE: December 19, 2025