Concurrent Sessions

A4-a Team-Based Transition Management- A Hospital Discharge Follow-up Process

Theme 4. The “How to” stream

  • Date: Wednesday, October 24, 2018
  • Concurrent Session E
  • Time: 2:30-3:15pm
  • Room: Harbour B
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff,

Learning Objectives

“How To”:

  • Implement a patient-centered approach to manage transitions from hospital to home in a primary care setting
  • Capture/identify discharged patients using your EMR
  • Follow-up with ALL in-patient discharges within 7 days (no triaging, no eligibilities) Efficiently perform a medication reconciliation on discharged patients
  • Integrate timely screening tools and internal/external referrals (Health Links, LHIN Home/Community Care, Malnutrition, Diabetes)
  • Utilize the interdisciplinary team to increase capacity in the hospital discharge follow-up process
  • Incorporate different modules of the process depending on available resources


Literature and research state and prove that post hospital discharge follow-ups within 7 days reduce 30-day readmissions and improve patient-centered care.  This presentation focuses on “how to” implement an effective hospital discharge follow-up process with existing resources in primary care. Following-up with ALL discharged patients was the team’s goal, therefore, scalability was cemented as a core foundation during the design phase.  This led to the development of a modular process that can be implemented by teams of all sizes and varying resources. The core module is the Hospital Discharge Follow-up process which can be combined with additional independent modules: Medication Reconciliation, Screening, and Program Navigation.

Tilbury District Family Health Team implemented this 7-day hospital discharge follow-up   process that uses a holistic and team-based approach to accomplish the following: contact patient, assess patient condition, perform a medication reconciliation, screen for malnutrition/readmission risk and provide individualized post hospital discharge support.

The team leverages queries/searches and forms within the EMR to seamlessly identify and assemble pertinent information on every in-patient discharge from all surrounding hospitals. These tools streamline communication and collaboration within the team and allow PCPs/IHPs to have timely and more meaningful hospital discharge follow-ups with patients. Patients are very appreciative of this process and have expressed feelings of security, relief and trust that their Family Health Team will provide them with support during times of transition.

This modular process was designed to be actionable, scalable, and shareable in a primary care setting, and the AFHTO conference is the best forum to share.


  • Diana Nichol, RN, BScN, Tilbury District Family Health Team
  • Andrew Atkins, QIDSS, Windsor Family Health Team