Managing Transitions — A Guidance Document (2nd ed.)Managing Transitions - A Guidance Document (PDF, 716 KB)

Across Ontario, transitioning patients from hospitals to home, community, and long-term care remains a key challenge for hospitals. A symptom of larger capacity issues within the health care system, it is a critical area of focus for the Ontario Hospital Association (OHA) and its members. Addressing these capacity issues involves developing and implementing solutions that enable patients to receive the care they need, while ensuring that health service providers and caregivers have the support they require to transition patients through the health care system.

With this in mind, the OHA has developed the second edition of the Managing Transitions guidance document. This newly updated resource aims to promote a standard approach to care transitions and a consistent understanding of the information necessary to support and manage this process. It synthesizes the various laws and regulations governing transitions in care and presents them in a way that is easy to understand and follow. It acts as a single source of information for the entire care transitions process, assisting health care providers and others in transitioning patients from the hospital to home care, community care, and long-term care. It also outlines the important role played by health care providers, patients, families, and caregivers in ensuring patient flow through the continuum of care.

The guide reflects legislative changes within Ontario's health care landscape, including the Patients First Act, 2016 amendments to the Local Health System Integration Act and the Home Care and Community Services Act, 1994, which expanded the mandate and role of Ontario's Local Health Integration Networks (LHINs). It also reflects the LHINs' responsibility for the management and delivery of home and community care (directly or through contracts with service providers), including the placement of patients into long-term care homes.

Written by legal counsel who regularly assists health care providers with difficult discharge issues, the guide focuses on:

  • The legislative framework for discharge planning;
  • The different roles and responsibilities of those involved; and
  • Information to effectively manage transitions in care.


Katharine Byrick


Health Law