Care transitions pose safety risks especially for hospitalized seniors with complex medical and mental health conditions. A partnership project improved acceptance and supported successful transitions by redesigning at the following three levels: (1) organization—program to facility agreement outlining accountabilities; (2) unit—adjusting the environment, education, and team processes; and (3) individual care—a transition checklist, a person-centred care plan, and customized transition supports to assist clients, family, and receiving staff.
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