This study examined the discharge process from hospitals to home care services to identify barriers and inefficiencies that impede the transfer to home care. It used a series of interviews and focus groups with hospital and home care providers in seven jurisdictions, as well as an expert panel to detail key problems to effective transfers. Six main types of systems barriers were found: barriers to working together, family/patient barriers, geographic barriers, system management and control barriers, system change barriers, and resource barriers. The report identifies three overarching principles of best-practices to bridge the gap: establishing formal systems that include common information systems and the flexible use of resources; building relationships and informal networks between hospitals and home care with boundary-spanning positions and the development of working relationships; and building system capacity with adequate budgets, resources, and programs to underpin the system.
This project was supported by the Health Transition Fund, which was created in 1997 to provide support for evidence-based decision-making in health care reform by supporting pilot and evaluation projects which test innovative approaches to health care delivery. The views expressed herein do no necessarily represent the official policy of federal, provincial, or territorial governments.