Transitions in Care: Improving Supports for Seniors After Discharge from Hospital

Project Leads

Lisa Jensen, Corporate Director of Integrated Access, Covenant Health

Dr. Lesley Charles, Covenant Health.

This project was conducted in collaboration with Alberta Health Services, Primary Care Networks (PCNs) and community service organizations for seniors.


Coordinated hospital discharge practices linked to community services is the goal.  When these are in place, pressures on older adults are eased, as they try 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.

Project Summary

Acute visit to the hospital

The innovation’s objective is to improve patient transitions across care sectors to create seamless care transitions connecting the patient journey from home to hospital to home. The development of an effective tool for identification of complexity and risk for readmission to hospital, and the development and implementation of post discharge follow up are part of the process of reaching the objective. Ultimately, we hoped to prevent hospital readmissions by supporting these complex patients safely and as independent as possible in the community.


A sustainable and effective intervention for complex, high-risk discharges, at-risk for readmission. The intervention implementation at the Grey Nuns Community Hospital included 1) use of the LACE tool for screening of high-risk patients at admission; 2) implementation of the post discharge phone call; and 3) notification of primary care providers and follow up appointment booking prior to discharge.

Impact and Ultimate Success

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.

The project resulted in an effective intervention for complex, high risk discharges to prevent their readmission to hospital. Evaluation demonstrates that this intervention has been successful in decreasing acute care utilization, which may also be correlated to seniors being better supported in the community.

Seamlessly returning home

  1. Having LACE on chart highlights complexity of patients to interdisciplinary team and has decreased length of stay by an average of 4 days. Discharge planning should start on day 1 of admission helping teams identify that more planning may be required on a multi sector basis to support the complex older adult to successfully transition into community.
  2. Despite the decrease length of stay, short term ED revisits and readmissions were not increased.
  3. In the short term the phone call did not seem to have an impact on readmission, but in the long term the phone call may have. Connection with supports from community (during the phone call) may have created more sustainable and effective partnerships with community providers and primary care on a longer term basis leading to enhanced health maintenance.
  4. The phone call identified that there is a problem with patients picking up equipment that wouldn’t have been identified otherwise. This is a bigger systems issue within EDM Zone and was clearly highlighted in the results (phone call).