Priority 9 from the Seniors' Health (Alberta, Canada) PSP

UNCERTAINTY: What is the most effective strategy to ensure an optimal transition between care settings for older adults? (JLA PSP Priority 9)
Overall ranking 9
JLA question ID 0083/9
Explanatory note

Older people are often transferred between healthcare settings if they become unwell. Such transfers are often unsettling and open up opportunities for error or poor outcomes.  People wanted to know the most effective and safe manner in which to minimize the chances of these occurring


1. Akbari, A., Mayhew, A., Al-Alawi, M., Grimshaw, J., Winkens, R., Glidewell, E., . . . Fraser, C. (2005). Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd005471

2. Intermediate care including reablement. (2017, September). Retrieved from

3. Transition between inpatient mental health settings and community or care home settings. (2016, August). Retrieved from

4.Transition between inpatient hospital settings and community or care home settings for adults with social care needs. (2015, December). Retrieved from

Health Research Classification System category Generic health relevance
Extra information provided by this PSP
Original uncertainty examples Lack of continuity of care ~ Multiple moves through the system: home, hospital, lodge, assisted living, long term care. ~ having smooth transitions amongst all services and filling in the gaps.  ~ Lack of continuity of care – too many transitions from one level of care to the next as well as too many different caregivers who change from one day to the next b/c their pay is low (especially in homecare but also in LTC, SL).  What can we do to increase continuity?
Submitted by Health/Social care provider  6,  Caregiver  5, Older Adult  3
PSP information
PSP unique ID 0083
PSP name Seniors' Health (Alberta, Canada)
Total number of uncertainties identified by this PSP. 97  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 13 August 2018