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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.
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.
This initiative strengthens collaboration across health and social care partners to improve care planning, coordination, and navigation across the care journey.
Community and Primary Care Coordination
Hospital to Home Transitions
Measure of Success
Percentage of inpatient hospital days occupied by patients who have completed the acute phase of treatment but remain in hospital awaiting their next care setting.
Current Performance: 17.8%
Target: 17.0% (approx. 5% improvement)
Intended Impact: Reduced unnecessary hospital stays and improved coordination across the health system.
Currently in development.
For more information about this initiative:
info@kw4oht.com
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