This initiative is designed to streamline a 24–48-hour service access pathway that addresses critical gaps in hospital discharge and follow-up care for older adults. By proactively identifying high-risk patients at the point of discharge, the project will pilot rapid-transition pathways aimed at reducing emergency department (ED) returns and improving continuity of care.
Developed in collaboration with The Ottawa Hospital, the Community Support Services Sector, and Ontario Health at Home, this initiative is grounded in a shared commitment to improve hospital-to-community integrated, patient-centred care. The pathway design will be guided by Ministry expectations for Alternate Level of Care (ALC) prevention and management, ensuring alignment with provincial priorities.

Goals

• Prevent avoidable hospital readmissions and return ED visits 
• Expedite safe discharge of ALC-designated patients via coordinated service tables and complex case rounds  
• Embed a standardized frailty screening tool in ED triage to identify and target high-risk older adults  
• Leverage the CSS Advisor role and integrate GEM teams for seamless referral, follow-up, and home-first planning  
• Align internal hospital processes and external community services under the Ottawa OHT ALC Action Plan

Working Group

Older Adults Living with Frailty

For More Information

Shaina Smith, System Transformation Lead, [email protected]