Transitions in Care

Transitions in care between healthcare settings and services represent a critical and vulnerable juncture for clients, caregivers, and families. Indigenous People, in particular, face heightened risks during these transitions due to colonialist policies, a lack of culturally safe healthcare environments, and disproportionate levels of poverty, complex trauma, and isolation.

The Mamow Ahyamowen Mortality Report, updated in 2020, revealed that 1 in 3 deaths in Northern Ontario could have been prevented with effective and timely healthcare or public health interventions.

The Transitions in Care Project objectives include:

1. Solidifying the Indigenous System Navigation Service pathways between acute care hospitals and community health services.
2. Facilitate seamless communication and information exchange between healthcare providers, patients, and families to ensure continuity of care and support patient-centred decision-making.

The goals of this work are to enhance:

1. Integration, connection, and collaboration among care teams and resources.
2. Coordination and consistency in hospital discharge planning.
3. Self-identification processes required to connect patients to Indigenous healthcare services.
4. Cultural safety training and education among healthcare providers and agencies.

• Hosted tailored engagement sessions with participants from across the continuum of care, including hospital staff, First Nation community staff and leadership, regional healthcare organizations, and individuals with lived experience. These sessions mapped the current experiences and the ideal future state of a patient’s transition in care.
• Facilitated regular collaborative, interdisciplinary working groups with hospital and community representation.
• Informed the design and integration of a culturally safe process for collecting Indigenous self-identification information within our partner hospitals Electronic Medical Records.
• Enhanced accessibility and awareness of Indigenous System Navigation support.
• Developed resources to support staff training and public awareness about Indigenous self-identification and the availability of Indigenous health services.