Concurrent Sessions

C4-a The Markham FHT Transitions Program: Breaking Down Silos and Building Partnerships to Improve Post Hospital Discharge Follow Up

Theme 4. Strengthening partnerships

Presentation Details

  • Date: Thursday, October 26, 2017
  • Concurrent Session C
  • Time: 8:30am-9:15am
  • Room:
  • 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, Representatives of stakeholder/partner organizations

Learning Objectives

  1. Learn how Markham FHT is improving care transitions through hospital discharge follow up
  2. Understand the shared vision between acute care and primary care settings in treating the community’s most complex patients
  3. Determine key players that would enable your FHT to launch a program that suits your post discharge follow up patient care needs


The Markham FHT Transitions Program was honoured to be accepted for concurrent presentation at the 2016 AFHTO Conference, and feedback was highly favourable. This year, the Transitions Program will elaborate further on data collection in the year since, and how this shaped performance targets for the coming year. The program does not stand alone, and relies on the strong partnership between Markham FHT, Markham Stouffville Hospital and CCAC. The session will reassure attendees that it is possible to break down the silos of health care through personal and digital communication across health care organizations. The existence of the Transitions Program has led our community partners to the same table, with productive discussions on how to improve patient care at the forefront. Session attendees will also see how small initiatives, using FHT resources wisely, can produce a positive patient care experience beyond the “top 1%” cohort of patients. Presenters will highlight the importance of eHealth solutions such as HRM as a “digital partner” in the provision of excellent patient care.


  • Lisa Ruddy, RN Clinical Program Manager, Markham FHT
  • Dr. Allan Grill, MD, Lead Physician Markham FHT, Markham FHT
  • Rebecca Robinson, Transitions Program Administrator, Markham FHT

Authors & Contributors

  • Dr. Stephen McLaren
  • Danielle Meades, RN
  • Melissa Loney, RN