Transitions in Care: Overview

Introduction

Transitions in care are when transfer of responsibility and accountability for some or all aspects of patient care occurs among providers, institutions, and/or sectors (e.g., federal and provincial jurisdictions, or education, judicial and other environments). Our Canadian health systems are organized in a way that requires individuals to receive health services from a number of care providers, in a number of locations, leading to multiple transitions in care over time. This is especially true for individuals experiencing changes to their health status, as they grow older, experience a change in care need and/or have a change in their location of care.

This initiative is a multi-Institute, multi-pillar and trans-disciplinary initiative that integrates CIHR's commitment to the health and wellness of Indigenous Peoples, Sex and Gender Based Analysis, Training and Early Career Development, and Data Use and Management across three primary focus areas.

Primary Focus Areas

  1. Across life's trajectories: Transitioning through life's trajectories (e.g., infant to child, child to youth, youth to adult or adult to older adult and beyond) necessitates changes in the source and nature of the services provided that are challenging to navigate, creating uncertainty and exposure to known care gaps that can lead to poor yet avoidable outcomes.
  2. Changing health status or care: Individuals facing changes in their health status or living with chronic or complex health conditions may visit their primary care physician, be referred to specialists, be assessed in an emergency department, be admitted to hospital, require surgery, move to a rehabilitation facility, and/or become disabled and not be capable of returning to their previous place of residence. These individuals experience change over between health providers, care settings, institutions, and/or hospital units and/or have a change in their location of care (e.g. hospital vs home; tertiary care vs community care).
  3. Key populations to optimize transition outcomes: Populations at increased risk of adverse transition outcomes include: First Nations, Inuit and Métis Peoples; individuals from rural and remote communities, transgender individuals; individuals with an intersex condition, older adults, new aging populations (i.e. survivors of diseases/conditions that previously led to early death); new immigrants to Canada and those who experience systemic, cultural and/or language barriers.

Objectives

  • To inform actionable health system changes within the TiC focus areas through systematically identifying transition in care knowledge gaps and/or identifying effective evidence-based interventions and/or policies;
  • To address transition in care gaps and/or determine effectiveness of implemented activities through evaluation of existing evidence, policy and/or best and wise practices;
  • To address identified transition in care gaps at a local, regional and/or national level through identification, adoption, spread and scale, and iterative evaluation of evidence-based practices and/or solutions;
  • To improve quality of life, and support efficiencies and sustainability of health care delivery with a potential to stimulate economic growth and competitiveness through development, adoption, scaling and iterative evaluation of innovative policies and/or best and wise practices for transitions in care; and,
  • To achieve measurable and sustainable impacts in the health system, and for patients, through effective partnerships among researchers, health providers, patients, family, care-givers, agencies, government, industry and other relevant stakeholders.

Commitment to Equity

Recognizing that equity is an integral part of a sustainable health research ecosystem, TiC is committed to supporting and promoting CIHR's Strategic Action Plan on Equity. The TiC initiative commitment to equity allows for diversity, which is expected to lead to more creative, innovative and meaningful outcomes. This commitment to equity specifically includes incorporating the CIHR Action Plan: Building a healthier future for First Nations, Inuit and Métis peoples and the CIHR Gender Equity Framework into TiC funding opportunities.

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