Effective transition from acute care to community care is an essential element of high quality patient care and is a core business of hospitals and Community Care Access Centres (CCACs). Transition planning is most effective when hospitals, community providers and primary care physicians work together to coordinate care for patients.

Seamless Transitions: Hospital​​​ to Home was a Mississauga Halton LHIN-funded, partnership initiative between the Mississauga Halton CCAC and Trillium Health Partners (THP) to improve patient and carer experiences through the development of a consistent, integrated, person-centered approach for hospital to home transitions. The nine-month Seamless Transitions test period yielded remarkable results, reducing readmissions by 52% and dramatically improving patient experiences.

This Guidebook and complementary toolkit outline the steps taken by the Mississauga Halton CCAC and Trillium Health Partners (THP), in equal partnership, to better integrate care for patients being discharged from hospital to home/ community. It is intended not only to document the partnership journey and design process, but to serve as a resource or blueprint for other hospital and community organizations to use  to implement new models of transition planning, focused on better integrating care for patients.

Seamless Transitions: Hospital to Home recently earned the Ontario Association of CCAC’s 2016 Sector Innovation Award, which recognizes the efforts of a team that has demonstrated outstanding, innovative leadership in developing and implementing initiatives driven by sector-shared priorities.