culture / Knowledge-powered tools

Transitions of Care: Our Biggest Problem in Healthcare

August 23, 2017

By: Kelvin Yam
Clinical Research and Development Pharmacy Intern
Third-year PharmD Student

This is the story of Chi

Chi is an active 70-year-old man whose wife passed away 10 years ago. He has no children and no friends in the same city. A bit groggy after waking up one day, he suffers a fall on the stairs and has to be taken to the hospital. He is treated for his injuries, but the fall leaves him with persistent mobility issues, and he is unable to take care of himself. Chi has no caregivers and his community is unable to provide enough nursing and personal care support. He does not have the resources to pay for private home care, so he remains in the hospital waiting for a bed to free up in a long-term care home. It can take up to 4 years before a bed becomes available, Chi is bounced around different hospitals, resulting in a series of unfortunate consequences. With each transfer, pieces of his personal health information are lost, medications are changed in error, and lab tests are repeated unnecessarily. A year later, Chi has significantly deteriorated and has acquired a multidrug-resistant infection; he is found bedridden and delirious with pressure ulcers on his lower back.

What contributed to Chi’s rapid decline? Did transitions of care play a significant role?  Was it the lack of socioeconomic support? Or was it the lack of communication between care providers? Was this human error, or was this a system issue? Why was he left in the hospital for a year? What could have been done differently?

It could be argued that all of the factors mentioned contributed to his deterioration. Gaps in medication management, poorly coordinated communication between care providers, and inadequate support in the community are cited as common reasons patients like Chi suffer from poor transitions of care. There are certainly actions that could be taken by individual clinicians to prevent this from happening; however, as with most issues in health care, narratives like Chi’s shed light on how our healthcare system fails to provide the best care.

What are we aiming for?

Based on the bestPATH document developed by Health Quality Ontario in 2012, three main goals in care transitions were outlined: these were care, health, and value (Health Quality Ontario 2012). Smooth transitions of care are based on principles of safety, effective coordination, and clear communication. Care must be continuous, and the patient and their care providers must be engaged at all times (Health Quality Ontario 2012). This is important to prevent the patient from falling through the cracks of the healthcare system. Smooth transitions also ensure better health outcomes through the use of evidence-based practices, patient focused care, and disease prevention (Health Quality Ontario 2012). With well-coordinated care transitions, care will take place in the appropriate setting (Health Quality Ontario 2012). This reduces the need for unnecessary hospitalizations and allows resources to be used more optimally (Health Quality Ontario 2012).

What can we do about it?

Transitions of care impact the health of the entire population. Despite many initiatives to bridge gaps, we still live in a very siloed healthcare system. Communication among clinicians, healthcare institutions and patients are neither standardized nor coordinated. It’s common for patients to be transferred from one setting to another or be switched from one provider to another without the necessary infrastructure in place to ensure that these transitions are safe. The enormity of this problem has led to many quality improvement projects across Ontario.

Although we tend to brand our products at Think Research as clinical decision support tools, all of our products impact transitions of care. Order Sets facilitate best practices throughout different phases of care and include instructions for discharge planning. MedRec ensures medication information is properly communicated across the patient’s stay in hospital and transitioned back into their community safely. Progress Notes ensures healthcare documentation and communication is organized, centralized, and easily accessible to healthcare providers. eReferrals bridges the gap in communication between primary care providers and specialists.

What we did

Recognizing the enormous impact of this problem and the amount of work that needs to be done to address this, the Clinical Research and Development interns at Think Research were inspired to host the company’s first Thinkathon. The concept can be described best as an ideathon, meets hackathon, mixed with a designathon. In interdisciplinary teams of 3-4 people, we provided an opportunity for brilliant minds to collaborate outside of work towards the purpose of innovating a healthcare solution. Curious to know what came out of this Thinkathon? Check out this follow-up article.

Parting Thoughts

How would you describe the state of our healthcare system based on your knowledge and experiences? What do you wish was done differently to ensure smoother transitions of care? We’d love to know what you think.

“If you want something you’ve never had, you must be willing to do something you’ve never done.” — Unknown




Health Quality Ontario. (2012, November).  bestPATH: Transitions of Care. Retrieved from