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Home to Hospital to Home Transitions

Information for healthcare providers to help ensure patients move through their healthcare journey in a coordinated way.

About the guideline

Alberta’s first provincewide Home to Hospital to Home (H2H2H) Transitions Guideline for adult patients will help healthcare providers and teams in acute, primary and community care operate as a singular entity with patients and their loved ones as equal partners — where people and communities, not diseases, are at the centre of the system. Join us on the journey.

What the guideline includes

To assist providers and teams within Alberta, this guideline presents leading operational practices, change management tips, tools and resources and additional information for the following:

  • Confirmation of the primary care provider
  • Admit notification
  • Transition planning
  • Referral & access to community supports
  • Transition care plan
  • Follow-up to primary care

Implementing the guideline

  • When planning transition initiatives, use the guideline to understand what processes and partnerships need to be in place to create safe, reliable and effective transitions.
  • Committees in each area are developing implementation plans. More information will be shared in the coming months.
  • Review the H2H2H Transitions Guideline one-pager for an overview of the initiative.

How to monitor and assess transition

H2H2H Transitions Monitoring Measures are a set of recommended measures, both system and strategic, developed at the same time as the H2H2H guideline.

For more information refer to the H2H2H Transitions in Care Data Infographic.

Guideline in Action: ADAPT Project

ADAPT stands for A DiseAse-Inclusive Pathway for Transitions in Care.

The ADAPT project helps bring the Home to Hospital to Home (H2H2H) Transitions Guideline into everyday practice. ADAPT is a grant-funded implementation initiative focused on the follow-up to primary care element of the H2H2H Guideline. The goal of ADAPT is to improve patient care by supporting primary care clinics across Alberta to develop or build upon their follow-up processes to support adult patients with heart failure, chronic obstructive pulmonary disease, cirrhosis, and chronic kidney disease as they return to community after a recent hospital stay.

ADAPT is a Partnership for Research and Innovation in the Health System grant funded by Alberta Innovates and concluded in Jan. 2026. A change package/toolkit will be released soon.

Using the guideline

H2H2H Transitions Guideline

Helping healthcare providers and teams in acute, primary and community care operate as a singular entity with patients and their loved ones as equal partners.

Monitoring measures

Recommended monitoring measures, both system and strategic, for home to hospital to home transitions in care within the Alberta healthcare system.

Patient partnership: Lessons learned through co-design

Insights on creating meaningful, trusting relationships that support patient engagement and collaborative team culture.

Recommendations to support patients & families

Recommendations for making H2H2H care transitions safer, more patient-centered and better coordinated across the health system.

Guideline overview

High-level summary of key steps for safe, coordinated patient transitions.

Story: WestView transitions in care (video)

See how WestView Health Centre and WestView Primary Care Network teams improved their process for timely follow-up care.

Discharge tools and readmission

When to use which discharge summary template

Understanding when to use basic or advanced discharge summary templates.

Discharge summary templates: A physician’s view (video)

Dr. Peter Ao explains why the basic and advanced discharge summary templates improve informational continuity between acute care and primary care teams.

Preparing your discharge summary

Quick guidance for acute care prescribers on how to prepare and send discharge summaries using templates accurately and promptly.

LACE Index overview

Designed by Canadian physicians and evidence-based, the LACE index stratifies patients into those who are at low, moderate or high risk for readmission to hospital within 30 days after discharge.

LACE Index podcast

A quick overview of how the LACE index helps care teams identify patients at higher risk of readmission.

Connect Care and technology

Connect Care & community provider work processes

If you work in primary care, Connect Care may have changed some of your work processes. Find responses to frequently asked questions to help you understand those changes.

Connect Care overview: How Connect Care improves transitions in care

To ensure patients are safe and well during transitions in care, the guideline relies on technology systems like Connect Care.

IT enabler fact sheet and FAQs

Get the facts on the IT systems that enable H2H2H, along with answers to common questions about the impact of these systems on transitions in care.

Evolving Health Record FAQ

A guide to understand changes to Alberta’s health information systems.

Understanding the patient guide (My Next Steps)

Watch this short provider video to gain a better understanding of the features and benefits of the patient guide (My Next Steps: Getting ready to leave the hospital).

Frequently asked questions

Frequently asked questions

Background information one-pager

Background information one-pager

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