Concurrent Sessions

A5 Helping Patients Transition from Hospital to Primary Care: An Interprofessional Approach

Theme 5. Coordinating care to create better transitions

Presentation Details

  • Date: 10/17/2016
  • Concurrent Session A
  • Time: 2:30pm – 3:15pm
  • Room: Pier 5
  • 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

  1. How to improve timely post-hospital discharge follow-up by identifying and overcoming barriers
  2. How to integrate allied health professionals during transitions of care with a focus on medication reconciliation
  3. How to integrate different FHT programs together to aid patients during transitions of care


Patients seen within 7 days increased from 12.5% to 66%  Elicited reasons why patients are not seen in clinic after hospital discharge EMR Rx list inaccuracy is 98% following discharge  Avg # of Rx discrepancies per chart is 5.5.


  • Yali Gao, Clinical Pharmacist, Health for All FHT

Authors & Contributors

Yali Gao, Clinical Pharmacist, Health for All FHT