A system-wide innovation in transition services: transforming the home care liaison role

This article describes how a provincial health authority in Canada improved patient care and staff satisfaction by transforming the role of home care (HC) liaison. The transformation focused on clearly defining the role, function and reporting structure, and identifying which healthcare providers could fill the liaison role. The transformation included adoption of transition best practices, leveraging an electronic referral system, creation of an interprofessional team, standardization of tools/orientation, and strong evaluation metrics, centralizing decision making, and developing a process for streaming referrals. The authors identify key success factors that made the transformation possible, as well as challenges and work that remains to sustain the change.