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Excellent Care for All

Guide to Clinical Initiatives - Transitions in Care


South West LHIN Transitions in Care Initiative

Extensive evidence suggests a great many avoidable hospital readmissions occur because patients do not understand how to manage their conditions at home. To support the province's commitment to quality in every part of the health care system, the South West Local Health Integration Network (LHIN) Transitions in Care initiative is intended to help improve the transitions of care between hospital and home, thereby better preparing patients and caregivers for what occurs after a hospital stay.

Who's Involved

This initiative was developed as a collaboration between researchers, The Change Foundation, the South-West LHIN, the Ontario Ministry of Health and Long-Term Care (MOHLTC) and local stakeholders.

Target Population

This initiative's target population is patients who are admitted to general medical wards in community hospitals with complex medical conditions, because they are most likely to require home health services and therefore risk readmission.

Benefits to the System

The goal is to design and pilot an intervention that will minimize this risk, by improving care transitions from acute to home, enhancing patient outcomes and reducing adverse events.  The South West LHIN Transitions in Care Initiative:

This initiative will create knowledge not only of what works but also how and why, thereby extending its usefulness to other jurisdictions and providers.

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Virtual Ward

The Virtual Ward is an innovative service model that delivers high quality co-ordinated care to patients in the community, after they have been discharged from hospital. It combines the best aspects of hospital care and management, outside the walls of the hospital. It is designed to provide for safe and seamless transition of patients between acute and primary care.

Who's Involved

Target Population

Virtual wards are an appropriate form of post-discharge care for patients who are considered to be at high risk of readmission, according to the LACE index.

Benefits to the System

Virtual Ward at St. Michael's Hospital


Virtual Ward at Toronto East General and South East Toronto Family Health Team


The SETFHT Virtual Ward uses remote monitoring technology provided by Ontario Telemedicine Network (OTN). They are helping lay the groundwork for a new model of primary care in Ontario, one that ensures both quality and value and results in the best possible outcomes for patients.

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For More Information

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