Improving Transitions in Care Through Multi-Partner Collaboration: Reflections from KW4 OHT’s cQIP Initiative

By: Jessica Lemon, Digital Health Co-Lead/Project Manager, KW4 OHT and Integrated Care Manager, Amplify Care

Through Amplify Care’s Integrated Care Management service, we have the privilege of supporting healthcare organizations and Ontario Health Teams (OHTs) as they advance integrated care initiatives across their communities. In this series, we are highlighting examples of collaborative work that is helping improve care experiences and outcomes across the region.

Breaking Down Silos to Improve Care Transitions

One of the most meaningful aspects of my role as the Kitchener, Waterloo, Wellesley, Wilmot, Woolwich (KW4) Ontario Health Team (OHT) Digital Health Co-Lead/Project Manager in recent years has been the opportunity to work alongside healthcare and community partners committed to improving the patient care experience across the region. A major focus of that work was supporting the Transitions in Care Collaborative Quality Improvement Plan (cQIP) in 2025-2026, which is a system-wide initiative aimed at improving how older adults with complex care needs transition between primary care, community care services, and acute care.

For many patients, especially older adults navigating multiple health conditions and care teams, transitions between these settings can be among the most vulnerable points in their healthcare journey. When communication and coordination between care teams in these disparate settings is fragmented, patients can remain in the hospital longer than necessary while waiting for the next appropriate level of care. This is referred to as “Alternate Level of Care (ALC)”: when a patient is medically stable and no longer requires acute care but remains in the hospital awaiting transition to another care setting.

Through the cQIP initiative, partners across KW4 OHT worked together to strengthen care coordination and improve transitions by:

• Improved communication and information sharing between care teams
• Supported smoother hospital-to-home transitions
• Strengthening referral pathways across organizations and services
• Improving navigation support for patients and family caregivers
• Identifying patients at risk of ALC earlier in their care journey
• Enhancing continuity of care across settings

One of the most important insights to emerge from this work is that improving transitions in care does not necessarily require creating entirely new programs or models of care. In many cases, the opportunity lies in better connecting and optimizing the services that already exist. To do that effectively, partners first needed a better understanding of the programs, pathways, and supports already available across the region. While many organizations were doing exceptional work to support patients and caregivers, there were opportunities to increase awareness of those services and identify where stronger connections between them could improve the patient experience.

With that goal in mind, care teams from across the KW4 came together as part of a working group to share knowledge, explore existing resources, and identify opportunities to strengthen team-based care coordination. In this way, the cQIP initiative demonstrated the power of collaboration itself. Through ongoing discussions and knowledge sharing, partners gained a deeper understanding of one another’s services, programs, and areas of expertise. Organizations that may have historically operated in silos identified new opportunities to coordinate care, strengthen referral pathways, and better support patients across care settings.

Connecting Supports across the Care Spectrum

As an example, we learned more about several existing initiatives already helping advance cQIP goals. Programs such as the Community Navigation Team, Let’s Go Home (LEGHO), Dementia, Resource, Education, Advocacy, and Mentorship (DREAM), Hospital to Home, the Specialized Geriatric Services Integrated Care Team, and community-based seniors’ programs all play an important role in supporting patients before, during, and after transitions in care. Together, these initiatives demonstrate the value of coordinated, community-based supports that help individuals remain connected to the right services at the right time.

While these initiatives are making a meaningful impact individually, partners recognized that greater value can be achieved when services are better connected, and information flows more seamlessly across organizations:

• Together, the cQIP working group came together to develop simple, patient-centred tools such as the “Your Home Service Providers” document, which helped centralize information for patients, families, and all care teams. The group also highlighted the importance of increasing awareness of existing referral pathways and community resources.
• Rather than creating additional referral processes, partners focused on helping care professionals better understand the services already available and how patients could be connected to them. This included raising awareness of programs accessible through Ocean eReferral and exploring opportunities to strengthen connections between primary care clinicians and community-based supports.

While relatively simple in nature, tools like these demonstrate that improving care transitions often requires both practical solutions and technological innovations that support continuity of care.

Lessons for Integrated Care

The work happening across KW4 OHT reflects a broader commitment to prevention, early intervention, integrated care, and innovative home and community care models. It also demonstrates how healthcare organizations can build on existing strengths, programs, and partnerships to improve care delivery without necessarily creating entirely new models of care.

Through initiatives like the Transitions in Care cQIP, KW4 OHT demonstrated how cross-sector collaboration can strengthen care transitions, improve awareness of available services, and create a more connected experience for patients and caregivers. These are the same principles that underpin integrated care efforts across Ontario. As healthcare organizations continue to advance OHT priorities, there is growing recognition that dedicated coordination, relationship-building, and system navigation are essential to translating strategy into meaningful improvements for patients.

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