Purpose and scope
The purpose of this best practice guideline (BPG) is to provide evidence-based recommendations for nurses and members of the interprofessional team, organizations and the health system. These recommendations support safe and effective transitions in care for pediatric and adult persons and their support network.
This BPG is to be used by nurses and members of the interprofessional team across the continuum of care (e.g., primary care, home and community care, mental health and substance use health settings, acute care, rehabilitation, long-term care, correctional facilities and shelters), in all domains of practice (e.g., clinical care, administration, education, policy and research) supporting persons and their support network during transitions in care. It is also to be used by organizations that employ nurses and members of the interprofessional team, including health and social service organizations and academic institutions.
Registered Nurses’ Association of Ontario (RNAO). Transitions in care and services. 2nd ed. Toronto (ON): RNAO; 2023.
Recommendations
Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Download and share the full best practice guideline (BPG), Transitions in Care and Services.
See below for a snapshot of the recommendations from this BPG. We strongly suggest you review the full BPG before implementing the recommendations and good practice statements. The BPG also includes further resources to support implementation and evaluation.
Good practice statement 1.0: It is good practice that health and social service providers collaborate with persons and their support network before, during and after a transition in care in order to ensure a safe and effective transition.
This good practice statement is an overarching statement that is foundational to implementing all other recommendations and good practice statements.
Good practice statement 2.0: It is good practice that health and social service providers assess with persons and their support network their care needs and readiness for a transition.
Good practice statement 3.0: It is good practice that members of the interprofessional team collaborate to develop a transition plan that supports the unique needs of persons and their support network.
Recommendation 3.1: The expert panel suggests that health and social service organizations collaborate to implement a formal interprofessional cross-sectoral approach to support persons encountering transitions in care.
Good practice statement 4.0: In order to ensure medication safety, it is good practice for health providers to conduct the following in collaboration with the person encountering a transition and their support network:
• obtain a best possible medication history; and
• perform medication reconciliation at all transition points.
Good practice statement 5.0: It is good practice for health and social service providers to provide persons and their support network with information and support to manage their needs during and after transitions in care.
Recommendation 5.1: The expert panel suggests that navigation support be provided by health or social service providers for persons with complex care needs encountering a transition in care. This support includes regular follow-up by the provider(s) to assess and respond to the person’s current and evolving health and social care needs.
Recommendation 5.2: The expert panel suggests that peer workers with lived experience offer support to persons with mental health needs who are encountering a transition in care.
Disclaimer: These guidelines are not binding for nurses, other health providers or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
