Speakers
Description
Background: Transitions in care are critical points in the patient journey and can significantly impact safety, continuity, and overall patient experience. Individuals receiving care at home may experience uncertainty, repeated assessments, fragmented communication, and difficulty navigating services. S.R.T. MedStaff is a home healthcare organization that implemented the RNAO BPG Transitions in Care and Services creating an opportunity to focus on improving the patient experience during transitions.
Aim: To highlight improved patient experience during transitions in care in our organization by strengthening people-centred communication, coordination, education, and access to information.
Method: Guided by the RNAO Leading Change Toolkit, an interprofessional working group conducted a gap analysis to evaluate current transition practices against best practice recommendations. Findings informed quality improvement initiatives focused on revising care planning tools, enhancing shared decision-making processes, updating patient education materials, improving visibility of key information within the electronic health record, developing standardized transfer tools, and strengthening navigation and mental health supports. Implementation was supported through leadership engagement, frontline staff education, patient and family input, and continuous quality review processes.
Results: Pre- and post-implementation patient surveys demonstrated sustained high performance in overall patient experience (Top Two Box up to 100%) and improved patient involvement in care planning (84.2% to 98.8%), with minimal variation and no deterioration over time. These findings show strong patient experience and improved care planning collaboration. Additional outcomes included revised transition-of-care policies, updated patient resources, enhanced welcome call scripts, and organizational access to Connecting Ontario, supporting improved communication, continuity, and information access.
Lessons learned: Improving patient experience during transitions in home care requires clear policies, practical tools, meaningful engagement of patients, families, and staff, and digital supports that enhance coordination, accessibility, and people-centred care. Ongoing collaboration and evaluation remain essential to sustaining safe and seamless care transitions.
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What RNAO BPG or tool/toolkit is your abstract related to?
Registered Nurses’ Association of Ontario (RNAO). Transitions in care and services. 2nd ed. Toronto (ON): RNAO; 2023.
RNAO Leading Change Toolkit
Author(s) Credentials and Title
Naidy Vazquez Leon, RN, BScN, NSWOC, WOCC © Education Specialist (speaker)
Jamie Arthur, PT, M.Sc., QIPS Senior Director Quality, Risk, Safety and Performance
Leanne Nash, RN, BScN Supervisor, Nursing Program (speaker)
Carolyn Acton, RN, BScN, MEd. VP Patient Services and Operations
| Organization Name | S.R.T. MedStaff |
|---|
