Sharing Best Practices: Transition Management in Ontario Home First Implementation Guide & Toolkit

Home First is an evidence-based, person-centred, transition management philosophy focused on keeping patients – specifically high needs seniors - safe in their homes for as long as possible with community supports. If/when acute hospital care is required, Home First aims to support patients to return home on discharge prior to assessment for and/or admission to a Long Term Care (LTC) home or other appropriate care setting. Under Home First, transferring patients from hospital to a LTC home is considered only after all other community options are considered.

Home First was first introduced in Ontario by the Mississauga Halton (MH) Local Health Integration Network in 2008 to address significant patient flow issues within hospitals that were resulting in increased numbers of individuals designated as ALC (alternate level of care).

Because of the variation of practices across the province and the early stages of implementation that many of the LHINs are at, the benefit of developing this Implementation Guide & Toolkit (herein referred to as the guide) as a “how-to” manual for LHINs was identified.

The purpose and focus of this guide is on the transition management of patients from institutional care to the home setting. It is meant to act as a manual for the LHINs in implementing Home First and reflects the diversity of approaches across all LHINs. Given the unique local circumstances within each LHIN, this guide does not endorse or recommend one specific model or approach to Home First; rather, LHINs have the ability to adopt the tools described in this guide at their discretion. Specifically, the purpose of this guide is to:

• Promote a provincial philosophy of Home First
• Be a resource guide for LHINs to implement Home First
• Outline common risks and challenges associated with Home First and strategies to address them
• Provide a set of provincial performance metrics to be used across all LHINs to measure the progress and success of Home First
• Provide a set of tools and templates for LHINs to use in rolling out Home First

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