True Co-Design for Patient Guide

“I just assumed my family doctor was aware.”

This is a common assumption amongst Albertans who have needed care outside of that received from their primary care physician. Unfortunately, this is often not the case due to a lack of continuity of information flow between hospitals and primary care providers.

The good news is that a dynamic team of patients, the Patient Transitions Resources team, are working hard alongside the Primary Health Care Integration Network to effect meaningful change on the system by improving the experience and outcome for all Albertans. The team is made up of patient and family advisors as well as staff members from Alberta Health Services, who are partnering together to co-design patient transition resources, with part one focusing on home to hospital to home transitions.Alberta’s Home to Hospital to Home Transitions Guideline facilitates safe, smooth transitions between acute, primary and community care. Transitions in care are consistently identified as a critical issue by Albertans: they expect a seamless healthcare journey as they are admitted, then moved within a hospital, and discharged back home. The guideline will help healthcare providers in acute, primary and community care work as a cohesive team, with patient information transferred smoothly between them.

“With input from over 750 stakeholders, including more than 15 patient and family advisors, this Home to Hospital to Home Transitions Guideline initiative is a critical resource to enable system integration. Providers from acute, primary and community care united alongside patients and researchers to design Alberta’s first provincial guideline on how to support patients as they transition from their community, into hospital and back home again. The input of so many stakeholders helped ensure the guideline reflects leading evidence, best practice and the real needs of Albertans.” – Rob Skrypnek, Provincial Director, Primary Health Care Integration Network Alberta Health Services

In addition to the guideline, the Patient Transitions Resources team has developed six recommendations for Alberta’s health system leaders to use when implementing the guideline.

  1. Commit to facilitating learning and development opportunities for healthcare providers to improve their skills in effective person-centered communication.
  2. Develop tools for patients to guide their conversations with providers and empower active engagement during the transition process.
  3. Provide patients with the QuRE (Quality Referral Evolution) Patient & Caregiver Journal when a specialist referral is made.
  4. Provide patients with an updated transition care plan and other relevant resources and documents, with their choice of electronic or print format.
  5. Support a social movement using various platforms to raise awareness of safe home to hospital to home transitions for patients, their families and community partners.
  6. Develop with patients a transition care plan which reflects their individual input and circumstances.

And to support patients during the pandemic, the Patient Transitions Resources team developed a patient tool for those hospitalized with COVID-19 as they prepare for discharge. In a few short weeks the team launched the COVID-19: My Discharge Checklist, as part of the Safe Discharge Home package for acute care teams.

As the team continues to build resources, they are focused on actions that will implement their recommendations, namely developing tools to guide patient conversations in transition engagement and supporting a social movement.

A new patient-centred hospital to home transition tool for all adult patients is in development and expected to launch in summer 2021.

As our health system continues to change and evolve, the patient voice is growing louder with help from individuals and teams like the Patient Transitions Resources team. Stay tuned for future resources and exciting events!

If you would like to learn about the AHS Primary Health Care Virtual Patient Engagement Network (VPEN) and stay informed about opportunities to partner with Primary Health Care, email phc.integrationnetwork@ahs.ca or visit Primary Health Care Integration Network – Patient Engagement.