Transitions in care and services

5 Questions to Ask about Your Medications is a guide to help persons and their support network start conversations with health providers about their medications (168). Ensuring persons are active partners in their care, and ensuring they receive important information about their medications helps promote medication safety. It may be particularly helpful for persons to ask the following five questions about their medications when attending appointments with their primary care providers, communicating with their community pharmacist, and when preparing for a transition from hospital to home. The 5 Questions to Ask About Your Medications resource is available in 30 languages. Source: Reprinted with permission from: Institute for Safe Medication Practices (ISMP) Canada, The Canadian Patient Safety Institute (CPSI), Patients for Patient Safety Canada (PFPSC), et al. 5 questions to ask about your medications [Internet]. Toronto (ON): ISMP Canada; 2016. Co-published with CPSI and CFPSC. Registered Nurses' Association of Ontario. (2023). Appendix K of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp. 128 . 

This interview guide from Alberta Health Services provides a list of questions health providers can ask when conducting a best possible medication history. Source: Reprinted with permission from: Alberta Health Services (AHS). Best possible medication history (BPMH) interview guide [Internet]. Edmonton (AB): AHS; 2014. This material is protected by Canadian copyright law. Except as otherwise provided for under Canadian copyright law, this material may not be copied, published, or distributed without the prior written permission of the copyright owner. This material was originally published by Alberta Health Services and has been reprinted with permission. Registered Nurses' Association of Ontario. (2023). Appendix I of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp. 125.

My Transitional Care Plan© summarizes information to facilitate successful transitions in care for older adults presenting with, or at risk of, responsive behaviours or complex mental health, substance use or neurological conditions (166). It provides a synopsis of essential information that should be communicated to members of the interprofessional team to prepare and facilitate a transition in care. The tool is written in first person to promote person-centred care, and health and social service providers should collaborate with persons and their support network when completing the form. My Transitional Care Plan© can be built within an electronic health record. The form is also available in French (166). Registered Nurses' Association of Ontario. (2023). Appendix H of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp 123-124 Source: Reprinted with permission from: Behavioural Supports Ontario (BSO). 

The Patient Oriented Discharge Summary (PODS) is an easy-to-use discharge summary designed for persons transitioning from hospital to home (164). Most traditional discharge summaries are dense documents with technical terms and are designed to communicate information to primary care providers, rather than persons receiving care. PODS was co-created with persons and their support network, including individuals with limited health literacy and language barriers, to help persons understand important information when leaving a hospital. The resource uses plain language, large fonts, space for persons to take notes and is available in 15 languages. Registered Nurses' Association of Ontario. (2023). Appendix G of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp. 121-122.

The Patient, Family and Caregiver Declaration of Values was drafted by the Minister’s Patient and Family Advisory Council in consultation with Ontarians to communicate patient, family and caregiver expectations of Ontario’s health-care system (163). The Declaration can serve as a compass for persons and organizations involved in health care and reflects a summary of important person, family and caregiver values. The Patient, Family and Caregiver Declaration of Values for Ontario is also available in French. Registered Nurses' Association of Ontario. (2023). Appendix F of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 120. Source: Reprinted with permission from: Government of Ontario. Patient family and caregiver declaration of values for Ontario [Internet]. Toronto (ON): Government of Ontario; 2021.  © Queen’s Printer for Ontario, 2021.  

This resource lists topics and other Registered Nurses’ Association of Ontario (RNAO) guidelines, and resources from other organizations that align with the Transitions in Care and Services best practice guideline (BPG). Registered Nurses' Association of Ontario. (2023). Appendix B of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp. 93-94.     

The Ontario Primary Care Medication Reconciliation Guide provides quality improvement strategies for implementing, sustaining and measuring medication reconciliation in primary care settings in Ontario (167). A sample medication reconciliation form can be found on pages 43 and 44 of the guide. The Ontario Primary Care Medication Reconciliation Guide is also available in French. Registered Nurses' Association of Ontario. (2023). Appendix J of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author.  pp. 126-127. Source: Reprinted with permission from: Institute for Safe Medication Practices (ISMP) Canada, Health Quality Ontario (HQO). Ontario primary care medication reconciliation guide [Internet]. Toronto (ON): ISMP Canada; 2015. Co-published with HQO.   

 A tool to assist with comparing your organization’s current practice with evidence-based RNAO best practice recommendations. Registered Nurses Association of Ontario (2023). Opportunity Analysis-Transitions in Care and Service, 2nd edition. Toronto, ON.