Healthcare Areas

This measure tells us what percentage of designated supportive living and long term care residents were readmitted to acute care within seven days of discharge.

Higher percentages of residents that return to the hospital within a week after being discharged from the hospital may indicate that poor transitions are occurring between acute care and the resident’s site or that a site lacks the resources (e.g., staff with necessary skills, equipment, etc.) required to care for and support the resident.

One reason transitions can be challenging is because of information continuity. Information between acute care, emergency medical services, continuing care operators, and the resident and their loved ones is not easily shared, which can make it difficult to support residents as they move between areas of the healthcare system. For example, a resident may return to a site with incomplete information about how to continue and follow up with care, and if the resident and their loved ones were not involved in the discharge plan, information gaps can be difficult to address.

It is important for discharge plans to contain complete information about the resident’s hospital visit, including diagnosis and treatments done. In addition, sometimes discharge plans include elements that cannot be delivered at the resident’s long term care or designated supportive living site. This can result in gaps in care and support or confusion that might result in readmission to acute care.

When thinking about readmissions to acute care from continuing care, providers and leaders can consider a number of things to better understand and improve these results. Some questions they could ask before taking action include:

• What are some of the reasons why residents might be readmitted to hospital shortly after discharge? Which of these reasons are avoidable and within a site’s control?
• How might continuing care providers collaborate with acute care and/or emergency medical services to address reduce avoidable reasons for readmission?
• How can the quality of transitions between acute care and continuing care sites improve to deliver better and safer care experiences?

The Health Quality Council of Alberta uses the Alberta Quality Matrix for Health as a way of organizing information and thinking around the complexity of the healthcare system. This measure can be used as input to assess supported living’s performance in these dimensions of quality: Accessibility, Appropriateness, Effectiveness, Efficiency, and Safety.

LEARN MORE