Optimize hospital capacity and patient flow

• Use a risk assessment tool to identify patients at risk for complex discharge
  Blaylock Discharge Planning Risk Assessment Screen

Follow best-practice rehabilitation care pathways

• Implement evidence-based care pathways for rehabilitation
  Quality-Based Procedures Clinical Handbooks by the Ministry of Health and Long-term Care

Apply behavioural support and preventative deconditioning strategies to patients designated as alternate level of care to optimize health status

• Minimize risk of longer-than-expected lengths of stay by embedding evidence-based practices that actively mitigate the risk of avoidable deconditioning, falls, delirium, etc.
  Behavioural Supports Ontario
  ALC Leading Practices Guide: Preventing Hospitalization and Extended Stays for Older Adults (2021 V1); and Self Assessment Tool

Transition patients requiring palliative support back to the community

• Use evidence-based tools to identify individuals who would benefit from palliative care
  The Ontario Palliative Care Network’s Tools t3o Support Earlier Identification for Palliative Care outlines recommended tools that can integrated into various settings of care
• Implement an evidence-based model of care for providing palliative care in community settings
  The Ontario Palliative Care Network's Palliative Care Health Services Delivery Framework outlines recommendations to guide organization and delivery of palliative care includes a patient pathway
• Foster collaboration and communication internally and across care settings to support discharge to home or to other dedicated end-of-life settings
  Explore virtual platforms for connecting with specialists or with patients, especially in remote areas (e.g., Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs
  Reach out to your Regional Palliative Care Network to get information on supports and partners in your local area
  Share resources (staff, technology, or training opportunities) among partners in your region (e.g., sharing and co-funding a nurse practitioner among partners within a region, holding regional educational events)