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Transitions in Care Collaborative Quality Improvement Plan (cQIP)
The Transitions in Care Collaborative Quality Improvement Plan (cQIP) is a system-wide initiative focused on improving how older adults transition between hospital care, primary care, and home and community services.
This work strengthens integrated, team-based care by supporting earlier identification of patients at risk of requiring Alternate Level of Care (ALC) and improving communication and coordination during transitions from hospital to home.
Alternate Level of Care (ALC) refers to situations where a patient remains in a hospital bed even though they no longer require the level of care provided in that setting. These patients are medically stable but are waiting for the next appropriate place of care, such as home with supports, rehabilitation, or long-term care.
By improving coordination across partners, this initiative aims to reduce unnecessary hospital stays and ensure individuals receive the right care in the most appropriate setting.
Older adults with complex health needs often require care from multiple providers and services. When transitions between these services are not well coordinated, patients may remain in hospital longer than necessary, contributing to increased ALC days and reduced access to hospital beds for others who need acute care.
This initiative addresses these challenges by strengthening collaboration across health and social care partners to improve care planning, coordination, and navigation across the care journey.
This work is supported through two complementary working groups that focus on improving transitions across the care system.
Community and Primary Care Coordination
Hospital to Home Transitions
Measure of Success
The initiative tracks the percentage of inpatient hospital days occupied by patients who have completed the acute phase of treatment but remain in hospital while awaiting their next care setting.
Current Performance: 17.8%
Target: Reduce to 17.0%, representing an approximate 5% improvement across the system.
Intended Impact: Improved transitions between care settings, reduced hospital stays when acute care is no longer required, and stronger coordination across the health system.
This initiative is supported through collaboration across health and community partners working together to improve care transitions for older adults.
Partners & Collaborators include:
This initiative supports the KW4 Ontario Health Team’s strategic priorities by:
It also advances KW4 OHT goals by:
Currently in development.
The Mental Health and Addictions Hospital to Home Program strengthens the transition from hospital to home or community-based care for adults requiring mental health and addictions support.
This initiative focuses on improving discharge planning, enhancing post-discharge supports, and connecting individuals to coordinated community-based services. By ensuring patients receive the right care after leaving hospital, the program improves patient flow, reduces unnecessary emergency department visits, and decreases alternate level of care (ALC) days.
The goal is simple: safer transitions, stronger community supports, and better outcomes.
The transition from hospital to home is a critical moment in the care journey for individuals living with mental health and addiction-related conditions. Without coordinated discharge planning and timely community follow-up, patients are at higher risk of readmission, prolonged hospital stays, and gaps in care.
This initiative addresses those challenges by strengthening partnerships across hospital and community providers to ensure individuals receive appropriate, ongoing support once they leave hospital.
This program focuses on:
Intended Impact: Improved continuity of care, stronger community supports, reduced hospital utilization, and better patient outcomes.
Lead Organization:
Waterloo Regional Health Network (WRHN)
Partners & Collaborators:
This program reflects a shared commitment across hospital and community partners to provide integrated, person-centered care.
This initiative supports the KW4 Ontario Health Team’s strategic priorities by:
It also advances KW4 OHT goals by:
Currently in development.
Seamless Care Optimizing Patient Experience (SCOPE): Black Health Initiative
The SCOPE Black Health Initiative is a multi-year collaboration focused on improving access to coordinated, culturally responsive care for Black communities across KW4 (Kitchener, Waterloo, Wilmot, Wellesley, and Woolwich).
Through this initiative, primary care providers are better supported to navigate local health and social services and connect patients to appropriate specialist care. At the same time, care pathways are being co-designed with Black community members to ensure services reflect lived experience, local needs, and identified gaps.
This work aims to strengthen equity, improve navigation, and build a more inclusive health system.
Black communities continue to experience barriers to timely, coordinated, and culturally responsive healthcare. These barriers may include challenges in system navigation, limited culturally relevant services, and gaps in care continuity.
This initiative addresses these inequities by improving access to local health, social, and specialist services while ensuring community voices directly shape solutions.
This initiative focuses on:
Intended Impact: More equitable access to care and a health system that reflects, respects, and responds to the needs of Black communities in KW4.
Lead Organization:
Waterloo Regional Health Network (WRHN) – SCOPE Team
Partners & Collaborators:
This initiative is grounded in community partnership and shared decision-making.
This initiative supports the KW4 Ontario Health Team’s strategic priorities by:
The Health Services Delivery Framework is comprised of three Models of Care (MOCs) and serves as a guide for transformational change to improve palliative care in Ontario. The Model of Care approach rethinks the organization, integration, and delivery of health services for a patient population as they progress along a care pathway.
The first Palliative Model of Care focuses on community settings and applies to individuals in their usual place of residence, including: Adults living in the community; Residents of long-term care homes (LTCHs); and Indigenous communities.
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Community HealthCaring-KW (CHC-KW) received Ontario Health funding to expand mental health supports for Black children and youth in KW4. This initiative builds on existing services by increasing focus on Black populations and community organizations, while ensuring access to the mental health and addictions expertise required to support these patients in a culturally responsive and sensitive way.
Through partnerships with local hospitals, mental health and addictions providers, and community organizations, CHC-KW is working to strengthen care pathways and reduce barriers to timely, appropriate support for Black children and youth and their families.
