Transitions in Care and Services

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.