What We Heard: Advancing Transitions in Care
Introduction
Transitions within the health care system, such as adolescents moving from pediatric to adult care services, or older Canadians moving from hospital to community-based services, often present significant challenges for patients, their families and caregivers. Researchers funded through CIHR’s Transitions in Care (TiC) initiative are investigating such challenges and proposing interventions that enable equitable and sustainable transitions across diverse care settings.
On May 6-7, 2025, the CIHR Institute of Circulatory and Respiratory Health, in collaboration with the Institute of Health Services and Policy Research, the Institute of Human Development, Child and Youth Health, the Institute of Indigenous Peoples’ Health, the Institute of Aging, the Institute of Cancer Research, the Institute of Gender and Health, the Institute of Musculoskeletal Health and Arthritis and the Institute of Neurosciences, Mental Health and Addiction, as well as the Azrieli Foundation, hosted a national workshop for TiC-funded teams on collaboration and policy impact. Researchers presented their work, discussed barriers and enablers to effective care transitions, and proposed strategies to translate research into practice and measure its impact.
Research Overview
Across Canada, researchers are testing new models to support smoother transitions for patients and families, while improving system efficiency. Workshop presentations featured a range of innovative projects, including about transition clinics for youth with chronic conditions and community-based follow-up programs for ICU survivors, as well as tailored support pathways for people facing mental health challenges. These initiatives supported transitions in care for diverse populations, such as people with disabilities, older adults and cancer survivors, and emphasized co-design with patients and caregivers to reflect lived experiences.
Learn more about the TiC Phase 1 research teams.
Learn more about the TiC Phase 2 research teams.
Barriers to Successful Transitions in Care
Teams identified barriers at both system and individual project levels:
- System level: Disconnected health services, poor coordination among health care providers, complex data sharing and limited cross-sector collaboration, such as with social and education services.
- Project level: Short-term funding, challenges in engaging equity-deserving communities and policymakers, as well as complex administrative barriers and rigorous ethics approval processes.
Enablers to Successful Transitions in Care
The research teams identified several factors that support effective transitions in care, including the following:
- Clear guidelines, measurable benchmarks, and well-defined team roles to strengthen coordination, enhance accountability, and support more seamless care delivery;
- A holistic care approach supported by partnerships across social services, education, policy, and community organizations to address social determinants of health and bridge service gaps;
- Patient, caregiver and stakeholder engagement to foster inclusive care, ensure services meet real needs and build lasting support;
- Training of health care providers in integrated care models and bringing on certified navigators to improve communication and coordination with patients and their caregivers;
- Digital tools to expand access to care, strengthen collaboration among providers, and give patients more control over their health.
Recommendations to Translate Research into Real-World Impact
Some health care organizations and provinces are starting to put research into action, shaping policies and improving everyday care. TiC researchers shared insights into how to take successful pilot projects and scale them up. Here are some of their top recommendations:
- Adapt projects to reflect local cultures and community needs, including those of Indigenous Peoples, in ways that are culturally appropriate, to ensure relevance and respect;
- Work across different parts of the health system to strengthen, maintain and share what works best in care delivery;
- Engage patients, families, health care teams, and decision-makers from the very beginning to build trust and create lasting, meaningful change together;
- Share real-life success stories to inspire others and help leaders champion smoother, more supportive care transitions;
- Build on already existing infrastructure and digital tools to efficiently scale up;
- Develop centralized resources to guide implementation across diverse settings.
Measuring Impact
Determining when and under what conditions care transition interventions are effective is critical to informing policy and driving improvements across the health care system. TiC-funded researchers recommended measuring the impact of such interventions through holistic indicators (e.g., patient satisfaction, reduced caregiver burden, return on investment beyond financial costs) and mixed-method approaches that combine quantitative with qualitative data.
Conclusion
Insights from TiC-funded teams offer a path forward to shape more integrated, equitable and effective transitions in care across the health care system.
For additional information, please contact TiC-TS@cihr-irsc.gc.ca.
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