Health programs are largely funded and managed independently of one another.¹ Yet, healthcare consumers are dependent on these organizations to work together seamlessly across all organizations and levels of care in the healthcare system. With the introduction of Local Health Integration Networks (LHINs) in Ontario, it is essential to support and encourage healthcare providers to communicate with each other across complex organizational boundaries (Glouberman 2002). From the patient/client perspective, the LHINs will be successful when integration occurs at the point of care.

Changing demographics and patterns of healthcare use by healthcare consumers is creating a quiet revolution in the way care delivery is designed and in the way transition planning is managed across the continuum. In this article, the key quality processes of routine one-way discharge planning from acute care to primary and community care are expanded to examine the need for a new function within the healthcare system called, by the Ontario Home and Community Care Council (OHCCC),² "transition planning."

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