Identifying Risks and Supports for Seniors After Discharge from Hospital

Transitions in Care Pilot – Early Identification and Support for Transitions in Care for Complex Older Adult Populations



Coordinated hospital discharge practices linked to community services can ease pressures on older adults trying to navigate the complexity of the health care system. This pilot is designed to develop an intervention for early identification of patients at risk for readmission and promote patient-centered, targeted discharge planning with intentional connections to community supports.


Lead: Lisa Jensen, Corporate Director, Integrated Access, Covenant Health in collaboration with Alberta Health Services, Primary Care Networks (PCNs) and community service organizations for seniors


The goal of this project is to design and develop an effective tool to identify risk or complexity for readmission and develop a post discharge follow up methodology that includes provider identification and community connections. The project will also aim to identify high-risk populations, system gaps and risk factors for patients.

The objective is to improve patient transitions which connect the patient journey from home, to hospital, to home again, with potential reduction in both length of stay and readmission rates.

Emerging impact

Through initial collaborative work, primary care providers are now notified when their older adult patients are admitted to or discharged from hospital. Home Care system case managers are able to ensure seamless transitions through established connections, such as SAGE, Aids to Daily Living, and Caregivers Alberta. The risk assessment tool and post-discharge follow up methodology will be available to be adapted by other PCNs and health providers.