Across Canada, 16% of patients are stuck in a hospital bed after their care is complete because the next point of care they need (e.g. care at home, care in a nursing home) is not available. These patients are referred to as Alternate Level of Care (or ‘ALC’). ALC numbers have climbed over the past decade despite efforts to address the issue and costs the Ontario’s health care system an estimated 2.5M each day. Led by Dr. Kerry Kuluski (Dr. Mathias Gysler Research Chair in Patient and Family Centred Care and IBH Scientist) and an interprofessional team of scientists, patients, clinicians and community partners, the project team is committed to co-designing and evaluating solutions that will support the advancement of patient-centred outcomes and address equity challenges in underrepresented populations to improve experiences, outcomes and the integration of health services. The project team is currently examining a leading practices toolkit which has been created by health care providers to help hospital providers and their partners in community settings transition patients out of hospitals. The Tool-kit has been implemented in many hospitals across Ontario but has never been evaluated. The project team will evaluate the uptake and use of ALC Leading Practices in Ontario hospitals in both urban and rural areas and compare hospital readmissions and utilization to hospitals that have not implemented ALC leading practices. This project has been awarded 200K from a Canadian Institutes of Health Research (CIHR) Operating Grant (Evaluation Grant), Transition in Care Strategic Initiative.