SIIReN - System Integration & Innovation Research Network



“Transitions in Care” has been defined as the movement of patients from one care setting to another as their conditions and care needs change (Coleman, 2003).  Transitions occur at many different levels: within a given health system setting (transitioning from ICU to a hospital ward); between settings (primary care provider and hospital, or hospital to home) and across health states or trajectories of care (curative care to palliative care).

Ineffective care transitions lead to poor patient outcomes including: sub-optimal treatment, delays in diagnosis, severe adverse events, patient complaints, increased health care costs and system utilization due to increased lengths of stay in acute care settings.

Current areas of study include:

  • The transitions during initial investigation and treatment of cancer
  • Post treatment transitions between specialists and primary care providers
  • Transitions between acute (hospital) and community care and studies of the transitions at the end of life.

Recent Works include:

  • Family Physician Integration with the Cancer System:    A comprehensive study of integration between family physicians and the regional cancer programs across Ontario. Over 2000 primary care providers responded to a rigorously designed survey that gave critical insights, by LHIN region, into the variation in processes of care undertaken in relationship to the regional cancer programs. The project has illuminated the gaps and opportunities in care integration between primary and cancer care.

  • Hospice Evaluation Study: The Transitions program has also initiated a unique applied research project to study the potential impact of hospice care at the end of life. This is the first project of its kind in Ontario and will generate important information to support decision-making around the role of hospice care for end of life transitions in Ontario.