Catch 22: Going to Long-Term Care After Being Hospitalized

By listening to elderly patients and caregivers, our Having Their Say & Choosing Their Way project highlighted needed changes to improve the transition from hospital to long-term care. This report summarizes findings from the two Ontario regions where hospitals and community care access centres (CCACs) worked together to address poor communication and inadequate information systems, faulty design and processes, and confusion about who is responsible for what.

A collaboration of The Change Foundation and the Ontario Association of Community Care Access Centres (OACCAC), the project mapped out and improved the myriad interactions and decisions that patients and their caregivers must make during the transition from hospital to “home.” The project demonstrated that low-cost (and no-cost) changes in processes have potential to improve patient experience, decrease unnecessary hospital stays, reduce adverse events in community care, and eliminate confusion about provider roles and responsibilities. 

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