Table 3.

Results of integrated care items from chart review.

ITEM	% PATIENTS WHO MET ITEM
Coordinating Care between Hospital and Community
1. There is a community care coordinator actively involved in the client’s care as measured by recent community assessment available.	57.8
2. The client has a primary care physician (PCP) that is recorded upon hospital admission.	70.6
3. While the person is in hospital, there is communication between community agencies involved in the persons’ care and the hospital (excluding home care).	27.1
4. Discharge summary was cc’ed to the PCP or receiving institution.	56.6
5a. Prior to, or within 48 hours of hospital discharge, the person’s discharge summary is available for receiving institution/care provider.	29.0
5b. Prior to, or within 48 hours of hospital discharge, the person’s discharge prescription is faxed directly to pharmacy.	70.1
6. Follow-up appointments with primary care provider are in place at time of discharge for those going home.	32.2
7. Cross-boundary person-specific education or training between hospital and community health care providers is provided for discharge care.	0.05
8. All post-hospital recommended home care in place upon hospital discharge.	76.2
Interdisciplinary Individualized Care
9. Preadmission, the client received care from a community-based or boundary-crossing multidisciplinary team.	22.0
10. The person’s risk is assessed to determine the level of care transition support needed during hospitalization (using hospital discharge screening tool).	77.5
11. The client receives a multi-domain assessment of discharge needs in hospital (multidisciplinary team working with client includes both social and health care professionals).	80.8
Within-Hospital Coordination
12. Disposition planning of multidisciplinary follows a care pathway or guideline (as developed with discharge risk tool).	36.0
13. The person’s health and social care needs for discharge is discussed at regular multidisciplinary meetings.	76.6
Patient Involvement in Care Planning
14. The discharge plan is discussed with the family.	69.7
15. Client provided with written discharge information form.	81.6
16. The discharge instructions are free of jargon.	46.1