Discharge Stabilization Service Pilot Project

The Discharge Stabilization Pilot Project is a Shared Care proposal aimed at strengthening transitions from hospital to community care for unattached patients with medical complexity. The initiative is exploring the development of a coordinated discharge stabilization service that would provide short-term follow-up and structured support for patients who are medically ready for discharge but do not yet have longitudinal primary care. The goal is to improve continuity during this period to reduce avoidable hospital readmissions, and support pathways to community attachment.  

This work is being shaped through ongoing physician and stakeholder engagement to ensure the model reflects regional needs and sustainability. Modelled in part after the successful Pain and Symptom Management Clinic, the concept is also informed by engagement and knowledge sharing with similar provincial services, helping to guide best practices and thoughtful design.