Transitions in Continuing Care Report and Recommendations for Improvement. Prepared by: Transitions in Continuing Care Working Group

Transcription

1 Transitions in Continuing Care Report and Recommendations for Improvement Prepared by: Transitions in Continuing Care Working Group May 28, 2014

2 Transitions in Continuing Care - 2 Table of Contents Transitions in Continuing Care Project Context... 3 Project Overview and Objectives... 3 What We Did... 4 What We Heard... 4 Issue #1 Unresolved Legal and Financial Status... 5 Issue #2 Inadequate Communication/Collaboration/Information Sharing Processes... 7 Issue #3 Difficulty in Providing Services to Individuals with Mental Health Issues and Responsive Behaviours Summary...11 Appendices...12 References Glossary... 20

3 Transitions in Continuing Care - 3 Transitions in Continuing Care Project Context A care transition is defined in the Alberta Health Services (AHS) Transitions in Continuing Care: Literature Review and Best Practices document as the act of leaving one care setting; i.e. a hospital, emergency department, assisted living site, long term care site, home care, specialist care or primary physician care, and moving to another care setting (AHS 2012). Poorly managed transitions can result in physical and emotional costs for patients and their families and can be prone to miscommunication, medication errors and other lapses in patient care and safety. The responsibility for coordinating a transition free of adverse outcomes rests with everyone involved, both senders and receivers. Developing comprehensive strategies to manage transitions across health care settings are a critical area for improvement (AHS, 2012). In fiscal year , AHS admitted 7,694 people to a designated living option. Of those admitted, 5,522 came from acute or sub-acute care and 2,172 from community (Appendix A). Countless more were discharged from acute care back to lodges, senior apartments and other seniors living options. In the same year, approximately 322 people transitioned from one continuing care designated living level to another. This does not include those individuals who were placed in a temporary living option and then moved to their first choice. The Transitions in Continuing Care Quality Improvement project was undertaken at the request of the Minister of Health and addresses an expressed concern from the September 25, 2013, Continuing Care Quality Forum to examine the transitions between acute care and continuing care and between continuing care settings for inefficiencies. This request builds upon work already initiated by to develop a Provincial Framework for Transition Management in Continuing Care based on the Coordinated Access to Publicly Funded Continuing Care Health Services Directional and Operational Policy element for transition management. The framework will include protocols and guidelines to be followed by practitioners in managing transitions within continuing care, across the health care system and into seniors housing options. Directional Policy: F1 Transitions are minimized and actively managed to ensure that care is coordinated and seamless (AHW/AHS, 2010). Project Overview and Objectives The Transitions in Continuing Care Working Group was struck and met five times via teleconference over a four-month period from December 2013 to April 2014 to complete the transitions review. Working Group members included a broad representation of stakeholders from Alberta Health (AH), AHS Provincial and Zone transition leaders, the Alberta Senior Citizens Housing Association (ASCHA), the Alberta Continuing Care Association (ACCA), and AHS owned and operated designated living sites (Appendix B). Linkages were made with the AHS CoACT 1 initiative and AHS experts in Quality Improvement and Business Process Mapping. Final project deliverables were approved by the Working Group and submitted for final approval to David O Brien, Senior Program Officer for Community, Seniors, Addictions and Mental Health and Dr. James Silvius, Provincial Medical Director for Seniors Health. 1 CoACT is a provincially funded AHS project integrating three major legacy projects in acute care Path to Home, Care Transformation and Workforce Model Transformation - into one cohesive model.

4 Transitions in Continuing Care - 4 The objective of the initiative was to take an in-depth look at the continuing care transitions from acute care to continuing care; continuing care to acute care and between the continuing care services of home care, supportive living and long term care to determine significant issues and any inefficiencies, and to recommend improvements upon the current practice. The deliverable is a series of care transition flow maps identifying gaps and system issues in the transition process and recommendations for improvement that include both short term and long-term actions and deliverables. What We Did A series of 13 focus groups were held the last two weeks of January 2014, with 97 people across all stakeholder groups participating. The format was designed and facilitated by AHS evaluation expert Leslie Podruzny. Each focus group was approximately 1.5 hours in duration and held by teleconference. Focus group objectives were: To document stakeholder perceptions of the processes for transitioning patients from acute care to continuing care; continuing care to acute care and between continuing care living options. To identify strengths, weaknesses and gaps in the transition processes from the perspective of acute care, transition services, supportive living, long term care and home care providers in congregate living settings. A series of questions were sent out ahead of time to the participants, focusing on four specific client transition scenarios: 1. Clients being moved from acute care into designated continuing care living option (placement); 2. Clients returning to a seniors living option site from acute care i.e. lodge, seniors apartment; 3. Continuing care clients that are transferred to another facility (hospital or hospice) for acute or palliative care services; 4. Continuing care clients that have been transferred to another continuing care living option or home care. The focus group participants came prepared and shared freely with the facilitator and the other group members. The information from the focus groups was consolidated by the facilitator according to type of transition and validated with participants. The information was then analyzed and grouped on process maps according to the larger issues and gaps (Appendix C). From the maps, the Transitions Working Group identified the top three issues that appeared most frequently and developed the recommendations for improvement that are included in this report. What We Heard There are many transitions that occur every day, and the vast majority of them are handled efficiently and without delays. Among all of the transitions being reviewed, the most problematic transitions are from acute care going back to continuing care, particularly to seniors housing sites where health care resources are off site. The least problematic are the transitions from one continuing care setting to another. The three major areas that manifested themselves most often in the focus groups and in every transition type, accounting for the majority of transition delays are: 1. Unresolved Legal and/or Financial Status; 2. Inadequate Communication/Collaboration/Information Sharing processes; 3. Difficulty in providing services to individuals with mental health or behavioral issues.

5 Transitions in Continuing Care - 5 These areas are the focus of the recommendations and opportunities for improvement in the remainder of this report. Additional issues that were identified in the focus groups are charted in Appendix D. The major assumption behind the recommendations is the importance of maintaining people in the best state of health and well being as possible for as long as possible. This is of particular importance during transitions, when individuals and families are most vulnerable to adverse experiences. Implementation of the recommendations would put more emphasis on the social determinants of health that impact well being during transitions, as well as enhance all of the quality dimensions of the Health Quality Council of Alberta s Quality Matrix for Health: acceptability, accessibility, appropriateness, effectiveness, efficiency and safety (HQCA 2005). To address these recommendations, it is proposed that three separate working groups are established with an identified lead to further define the context for the specific issues, to determine solutions and to implement them, engaging the identified key stakeholders including individuals and their families in the process and developing outcomes from the perspective of the individual and family. Issue #1 Unresolved Legal and Financial Status Recommendation # 1 Establish a joint Governmental Cross-Ministry and Alberta Health Services working group to identify strategies for improving access to personal and financial competency assessments, identifying options when there are capacity or financial challenges and for expediting orders for Guardianship and Trusteeship when required. This includes identifying when other mechanisms for alternate decision-making may be used such as Personal Directives and Enduring Power of Attorney and solutions where there is no alternate decision maker available. It also includes identifying alternatives to the Public Trustee when an individual has too few assets, as well as options for operators when the individual has limited or no capacity to pay or becomes incapacitated while a resident. This is a large issue that impacts acute care; addictions and mental health and all of continuing care including home care, AHS owned and operated living option sites, contracted providers and seniors housing operators. The problem contributes significantly to delays in placement to a continuing care living option and complicates every step of a transition when not resolved. The current problem is multi-faceted and includes delays in identifying the need for a capacity assessment (either personal or financial) and subsequent delays in accessing and completing those assessments. It also includes situations where there is no alternate decision maker and/or not enough assets to warrant a Public Trustee, leaving the individual, the health system, contracted care providers and housing operators in limbo. If a transition occurs and an individual moves into a community seniors living option or is placed into a designated living option without financial matters resolved, it often causes financial hardship for the individual, delays in payment to the site and a loss of momentum when another organization assumes responsibility for shepherding the process. If a resident becomes incapacitated while living at the site it can leave the site with no access to assets especially if there is no one else to manage the individual s financial affairs and in a conflict of interest if the site becomes informal trustee. If Guardianship is required, it often must be obtained before the placement

6 Transitions in Continuing Care - 6 into a designated living option can occur, and/or can take many months to obtain once transferred. When both Guardianship and Public Trusteeship are required, significant delays are experienced as they are separate processes. If financial resources are limited and an application for charges reduction is warranted, this limits living option choices to the individual. Outstanding financial issues may prohibit transfer to another site. In addition, there is no recourse for an operator when an Enduring Power of Attorney is in effect and the appointed attorney is not acting in the best interest of the resident. Participants on the working group would include but not be limited to representatives of the Office of the Public Guardian, Office of the Public Trustee, Social Services, Alberta Health, Alberta Health Services and contracted partners. Opportunities for Improvement - Legal and Financial Status Long term Opportunities Actions Responsible/ Accountable/ Consulted/Informed Expedited Guardianship and/or Trusteeship process Shorter term Opportunities Improved Access to Personal and/or Financial Capacity Assessments and processes Establish joint Governmental Cross Ministry/AHS working group -Due to urgency of this work an initial meeting with AH and AHS has been held -Mapping of the specific issues/key screening points for competency and financial assessments underway Actions Identify resources to complete capacity assessments R-AH and AHS Seniors Health A- other ministries, Acute care, Continuing Care, Addictions and Mental Health C- Contracted Providers, Seniors Housing Operators, individuals and families Responsible/ Accountable/ Consulted/Informed R- A- Acute care, Continuing Care, Addictions and Mental Health C- Contracted Providers, Seniors Housing Operators, individuals and families System Integration Required with other initiatives/groups Persons with Developmental Disabilities (PDD) Cross-Ministry initiative as potential model for this work. System Integration Required with other initiatives/groups Social Work Provincial Professional Practice Council and Health Professions- Interprofessional Practice work on Social Work Role in the Decision- Making Capacity Process with Adults

7 Transitions in Continuing Care - 7 Increased options for contracted providers and seniors housing operators when encountering capacity challenges with current residents Identify clear, ethical processes for AHS, contracted partners, seniors housing operators and families in resolving capacity issues that may arise with residents Identify resources to support the site and resident/family Explore options for an office of the government to handle bad debt issues on behalf of operators R- A Contracted providers, Seniors Housing Operators, Addictions and Mental Health C Individuals and families Health Professions Practice and Strategy Lead for Social Work Issue #2 Inadequate Communication/Collaboration/Information Sharing Processes Recommendation #2 Build upon initiatives already in place to enhance communication; collaboration and information sharing among care providers, contracted providers, seniors living operators, individuals and their families. This includes developing standardized protocols for transitioning between acute care and the continuing care and within the continuing care system which details the minimum amount and type of information to be shared, identifies the required steps in the collaborative process, identifies resources at the sites and provides a clearer understanding of roles and responsibilities of professional caregivers, contracted care providers, seniors housing operators, individuals and their families. It also includes providing timely, accurate information to individuals and their families. Many of the issues identified in the focus groups related to communication, inter professional and inter organizational collaboration and information sharing. There are no standard processes for ensuring that someone transitioning between acute care and the continuing care system will receive the care that is required. Transition issues include; lack of coordination between acute care or emergency and the seniors living site, contracted provider, AHS case manager, individual or family when the individual is transitioning back and forth; there is no transition care plan to support pre-planning and ensuring that previous care and/or additional care needs are set up; there is a lack of understanding about resources available at the housing site or ability of the site to provide the care required; and there is a lack of clarity around roles and expectations for all of the stakeholders. Timing is critical to the success of the transition. For placement into a designated living option, the information shared with partner sites is not standardized or consistent and the attempt to obtain additional information can delay the placement process. Patients and their families may not receive the right information about living options, which can cause confusion and emotional distress.

8 Transitions in Continuing Care - 8 Opportunities for Improvement - Communication/Collaboration/Information Sharing Short term Opportunities Actions: Responsible/ Accountable/ Consulted/Informed System Integration Required with other initiatives/groups Improved transitions between the continuing care system, housing providers and acute care Develop communication protocols that support the sharing of information between housing and health, including role expectations for all stakeholders involved in transitions between acute care and the continuing care system Develop an integrated plan of care based on the agreed minimum amount of information required for transition success R- A- Acute Care, Continuing Care, Contracted providers, Seniors Housing operators, EMS, physicians C- individuals and families Health Information Act and AHS Information and Privacy team/resources Collaborative Practice model for Case Managers and DSL developed at request of Forum. Edmonton Zone Seniors Health Transitions Project in acute care. Previous Calgary Health Region Patient Flow Collaborative transition communication work Develop a decision support tool to guide the key transition steps AHS CoACT project in acute care to support integrated plan of care and shared information Improved Placement decisions Improved information sharing with clients and families Develop education plan for key stakeholders on all of the above when completed Provincially standardized client information profile for partner providers at time of acceptance and time of placement Provincially standardized clinical charting by AHS for decision points in placement process Develop information packages and transition support that allows for maximum understanding of placement process, costs and expectations for clients and their families. R- A- Contracted providers, Continuing Care R- A- Acute Care, Continuing Care, Contracted providers, Seniors Housing Operators, EMS, physicians C Individuals and Families ASCHA s revitalized Housing Directory on line AHS 24/7 RN on call initiative The client information profile is in progress and ready for stakeholder input Standardizing clinical charting for decision points in placement process is underway in continuing care Build on Zone work in this area, much has been developed This is also a recommendation in the HQCA FAALO Review Final Report and should be integrated with that work

9 Transitions in Continuing Care - 9 Issue #3 Difficulty in Providing Services to Individuals with Mental Health Issues and Responsive Behaviors Recommendation #3 Enhance the work being done in Addictions and Mental Health by forging a stronger collaboration between Continuing Care and Addictions and Mental Health to address the needs of those individuals with mental health and responsive behavioural issues. The need to address complex care particularly with individuals who have mental health and responsive behaviour needs is ongoing. People with mental health issues or responsive behaviours often remain in their current living option while waiting for appropriate placement which places a burden on the site and puts the individual and other residents at risk. The ability of AHS to support contracted providers, seniors housing sites, the individual and the family to meet these types of needs is currently lacking and securing a living option that meets those care needs is much delayed. Opportunities for Improvement Services to Individuals with Mental Health or Behavioural Issues Long Term Opportunities Actions Responsible/ Accountable/ Consulted/Informed System Integration Required Improved support to individuals with mental health or behavioural issues -Develop stronger collaborative practice expectations among Home Care Case Managers, Addiction and Mental Health Clinical Staff, Contracted providers and Seniors Housing Operators -Collaborate on the development of a Comprehensive Mental Health Behavioral Assessment for Continuing Care based on the InterRAI Mental Health Assessment tool. -Expand Appropriate Use of Antipsychotics (AUA) principles and lessons learned on managing responsive behaviours to all long term care centers. Explore expansion into Supportive Living environments and home care, including Seniors Living settings. R- AHS-Addiction Mental Health and Seniors Health Provincial Teams A-Addiction and Mental Health, Acute Care, Continuing Care, Contracted Providers and Seniors Housing Operators, Seniors Health Strategic Clinical Network C- Individuals and families Addiction and Mental Health Complex client initiatives, including Persons with Developmental Disabilities (PDD), and 150 Project AHS Capacity Planning and Funding models for care Rosehaven outreach team, zone outreach teams Seniors Health Strategic Clinical Network (SCN) AUA project SH SCN Dementia Care Pathway development initiatives related to addressing Violence in the Workplace

10 Transitions in Continuing Care - 10 Summary There are a number of issues that have been identified that directly impact transitions between acute care and the continuing care system. Each is owned to a greater or lesser degree by the stakeholders involved in this work, but with implications for each of the other stakeholders. The majority relate to transfers from acute care with three being particularly singled out as major issues. Given their significance, they will be addressed as the priority from amongst all of the identified issues. The solutions will need to be collaboratively developed through joint efforts of the stakeholders and including other parties who have a significant interest in the solution. It is also important to identify a timeframe in which the work will be targeted for completion. The lead will be charged with the accountability for ensuring that the work is completed in an appropriate time frame. Given the nature of the work historically undertaken by the area, Seniors Health, Community, Seniors, Addictions and Mental Health is the most appropriate component of AHS to take the lead on this work. If this proposal is accepted, work will be planned to commence shortly.

11 Appendix A Continuing Care Living Option Data Transitions in Continuing Care - 11

12 Transitions in Continuing Care - 12 Appendix B Transitions in Continuing Care ad hoc Working Group Members Name Representing Position Signe Swanson, Co-Chair James Silvius Co-Chair Carleen Brenneis Deb Trumbley Pansy Angevine AHS Edmonton Zone Transition Services, SH AHS Calgary Zone Transition Services, SH AHS Central Zone Transition Services, SH Director Coordinated Access, Community and Seniors Health, AHS Provincial Medical Director Seniors Health, Community, Seniors, Addictions and Mental Health, AHS Director, Transition Services Edmonton Zone. AHS Director (Acting) Transition Services Calgary Zone, AHS Manager Transitions, Specialty Programs and New Initiatives, Central Zone. AHS Dennis Cleaver Seniors Health SCN Executive Director, Seniors Health SCN, AHS Niki Sibera Alberta Health Manager, Home Care Policy & Implementation Irene Martin (Jeannette Leafloor, ASCHA Executive Director, Alberta Seniors Citizens Housing Association alternate) Tammy Leach (Bruce West, alternate) ACCA Executive Director, Alberta Continuing Care Association Ian Woodcock ACCA long term care VP and COO Intercare Corporate Group and specialty populations Brant Poirier AHS owned and operated Area Director, Central Zone, AHS Housing Jay Woodmass AHS QIPE Senior Program Manager, Quality, Information, Projects, Evaluation (QIPE), AHS Sherry Silver Administrative Assistant, Seniors Health, AHS Corrine Truman Director Case Management, Seniors Health, AHS Special thanks to: Lesley Podruzny Focus Group Facilitator Lead, Seniors Health Research and Evaluation, QIPE, AHS Anurag Pandey Process Improvement Executive Director, Process Improvement, AHS Consultant to project Bob Graham and Business Process QIPE, AHS Sharon Leontowitz Mapping experts Dr. Anne Colbourne CoACT project, AHS Senior Medical Director Quality and Transformation CoACT Project, AHS

13 Transitions in Continuing Care - 13 Appendix C Larger Issues and Gaps Identified Continuing Care to Acute Care Transition Review/ Establish Criteria for calling EMS Communication/ Information sharing review Continuing Care Acute Episode EMS Called Emergency Acute Assessment Treatment and sent home Admission to hospital Issue Themes at EMS callout: - Health issue could be addressed by primary care or home care - EMS disagrees with lodge and refuses to take client to EMR - Family is apprised, and refuse to transfer client to acute care more efforts should be made to address the acute issue in LTC Issue Themes at EMR assessment -No information is prepared to accompany client to hospital -Incomplete or inaccurate information is provided -Goals of care/acp documentation does not exist Issue Themes at Treatment and sent home - Site not notified that client is returning. - If client requires enhanced care (equipment, medication, home care, etc.) may not be in place or not available. - Documentation sent with client to the hospital is not returned. - Acute staff not aware of the level of care available at the site. Site may be unable to provide level of care required, may result in client being refused and sent back to EMR. Issue Themes at Admission - Site is not informed that client has been admitted. - Family is not informed

14 Transitions in Continuing Care - 14 Acute to Continuing Care Transition Financial, Trustee and Guardianship processes. Communication/ Information sharing review Approved Waitlisted Discharged from Acute Acute Care ( No Longer Acute) Continuing Care Assessment / Reassessment Service Needs Determination and Selection Transition To Living option Post Transition Issue Themes at assessment: - Too early to assess no opportunity to rehab -not all acute care sites have staff dedicated to transitions -mental health and behaviour issues not always captured in RAI-HC -inaccurate info given to patient/ family by acute care staff resulting in unrealistic expectations - need for competency assessment -need for legal status - need for financial status review - PDD and other social service agency referrals difficult Issue Themes at Service Needs Decision -Not enough information sent to housing operators for decision -People with mental health/behaviour issues are difficult to place and not accepted by housing providers -limited capacity for these types of clients - Disparity in costs and services between SL and LTC (medications, equipment, access to physician) -inconsistent application of FAALO policy delays placement out of acute care -a declined offer by either the site or patient delays placement -sites may decline due to loss of funding if client is lighter care -People who smoke have limited options causing delays Issue Themes at time of Transfer - Selected living option not a fit anymore - Not enough information on actual care needs - Not enough time to set up services, site not expecting return - Mismatch between expectations service and what is actually available at site - Case manager not aware of hospital admission and/or discharge Issue Themes immediately post transfer - mismatch results in individual being sent back to emergency - missed care including medications - Case manager not readily available to respond -Resident does not have furniture required for DSL -If transitioned temporarily to a LTC site, family creates unrealistic expectations -lack of understanding of how long it will take to transition to first choice

15 Transitions in Continuing Care - 15 Continuing Care to Continuing Care Transition Communication/ Information sharing review Continuing Care New living option required Assessment / service needs determination Waitlisted for new living option Living option becomes available Transition to new living option Issue Themes at assessment / service needs determination - Can take a long time (3-5 weeks) to have a reassessment done. Issue Themes at waitlist for new living option - Current site may not be aware that client is on waitlist for a different site/ level of care. - Site receives one potential client name at a time. If that client is not a suitable match, process starts over and bed remains empty Issue Themes at living option becomes available - -Some sites receive message from Pathways notifying them that client has a bed. Not all sites are notified consistently. - Clients/families unwilling to transition from LTC to DSL and assume more out of pocket costs for care - Difficult for client/family and site staff when client is offered their first choice living option within a short period of time from being moved into a temporary space (FAALO). Issue Themes at Transition to new living option - Process varies from zone to zone: no formalized or standardized processes. Can result in important information not being transferred with the client. - Client finances may not be available for costs of new site -is often difficult to access the guardian or public trustee

16 Transitions in Continuing Care - 16 Appendix D - Additional Transition Delays Identified in Focus Groups that are not being addressed in recommendations ISSUE RESPONSIBLE LINKAGES TO CURRENT INITIATIVES Assessments for placement done too soon in acute care Need for restorative care beds in community rather than in acute care to support assessing for a living option when health and function is restored to optimal. Alberta Health Provincial Team This concept has been Incorporated into the development of AH Continuing Care Strategy Framework. Currently there are zones with community transition beds that are used for restorative care to seniors. Edmonton is piloting the use community restorative care at a long-term care site. Need for consistent client transfer process across zones for placement Provincial Team Moving to one provincial living option waitlist and supporting placement transitions across zones is embedded in the Continuing Care Waitlist Prioritization Policy. An AHS Information Technology Proposal is being developed proposing that all zones move to a single provincial Strata Pathways implementation. This is a software solution for waitlist management currently in use in Edmonton and Calgary in two different installations. More palliative care services in LTC/DSL to eliminate transfer to acute care Provincial Team Incorporate into the End of Life and Palliative Care Strategies for Continuing Care Clients who smoke are difficult to place when DSL/LTC are becoming smoke free Provincial Team Initiate collaboration between AHS Zones and Tobacco Reduction Resources as part of Tobacco and Smoke Free Environments Policy review Accessing home care for individuals on PDD funding problematic Provincial Team Home Care Redesign Address in Home Care Redesign efforts in collaboration with PDD program Lack of additional funding to LTC sites with high turnover (increased # of assessments, lost days of funding) Alberta Health Continuing Care Collaborative Review Funding models Declined placement by site due to loss of funding if care is lighter Disparity in costs and services between DSL and LTC, clients unwilling to transition from LTC to DSL and assume more out of pocket costs for care.

17 Transitions in Continuing Care - 17 Delayed placements due to declined offer of match by both client and family site/family receive one potential client name at a time, if unsuitable, process starts over and the bed remains empty Delayed placements when no suitable matches can be found on waitlist by site. Provincial Team Edmonton and Calgary Transition Services Initiate QI process with Edmonton and Calgary Zones regarding Strata Health Pathways and improving system response when matches are declined. Develop information package for couples and families at a younger stage to help them plan earlier for financial scenarios later in life Inconsistent application of First Available Appropriate Living Option Policy Difficulty for client/family and site staff when client is offered their first choice living option within a short time of being moved into a temporary (FAALO) space Process for when Client/Family refuses transfer Public Awareness and Education Working Group Provincial Team Coordinated Access working group Provincial Team Coordinated Access Working Group Connect Linda Cornwall at the Alberta Health Continuing Care Branch who is leading the public awareness and education working group A provincial First Available Appropriate Living Option Policy has never been approved. Zones are operating under former regional policies while the provincial policy has been on hold. With the recent release of the HQCA FAALO review report and recommendations, work in this area can resume. Incorporate into policy and protocol development

18 Transitions in Continuing Care - 18 References Alberta Health Services (2012). Seniors Health Transitions in Continuing Care: Literature Review and Best Practices. Coleman, E.A. & Boult, C. (2007). Improving the quality of transitional care for persons with complex care needs: American Geriatrics Society (AGS) position statement Assisted Living Consult, March/April: Coleman, E.A. & Fox, P. (2004). One patient, many places: Managing health care transitions, Part1: introduction, accountability, information for patients in transition. Annals of Long-Term Care, 12(9): Health Quality Council of Alberta (June 2005). Alberta Quality Matrix for Health User Guide. National Transitions of Care Coalition (May 2008). Improving transitions of care: The vision of the National Transitions of Care Coalition.

19 Transitions in Continuing Care - 19 Glossary Continuing Care An integrated range of services supports the health and wellbeing of individuals living in their own home, seniors housing or in a designated supportive living or long-term care setting. Continuing care clients are not defined by age, diagnosis or the length of time they may require service, but by their need for care. Source: Coordinated Access to Publicly Funded Continuing Care Health Services: Directional and Operational Policy (2010). Transition a passage from one state, stage, subject, or place to another; or a movement, development, or evolution from one form, stage or style to another, and/or a period of time during which something changes from one state or stage to another. Source: Merriam-Webster Dictionary (2012). Transitions in Care - the act of leaving one care setting; i.e. a hospital, emergency department, assisted living site, long term care site, home care, specialist care or primary physician care and moving to another care setting. Source: National Transitions in Care Coalition (2010). For frail elderly every transition is accompanied by a period of instability. Source: Coleman and Boult (2007) Transitions in Health Status a change in functional status, or a new condition or event that affects self-care ability. While a health care transition may be planned, typically health status transitions are unplanned and neither the patients nor their families know what to expect, nor do they always realize the extent to which the person is vulnerable. Source: Coleman and Fox (2004)