AFHTO Events

Focus on Follow-Up – Slides and Resources

November 27, 2018 Steelworkers Union Hall Conference Centre 66 Brady Street, Sudbury Ontario  

On November 27, over 50 people from primary care teams across the North East came together in Sudbury for Focus on Follow-Up. They came because they want their patients to get better follow-up after getting out of hospital. They also came because they know doing this is not easy.

Through this full-day workshop, we learned and shared about several aspects of follow-up. We heard about how to get and use discharge data, how to start doing follow-up and tracking it in the EMR; and how to include follow-up in the 2019 Quality Improvement Plan. External partners from OntarioMD, the North East LHIN, Health Quality Ontario, and the North East Ontario Network of Hospitals (NEON) also joined us. They shared information and heard from the primary-care teams about what is working and what isn’t.

Thank you to the presenters, sponsors, and attendees who braved the snow to join us, ask questions, and share stories. Everyone’s contributions helped us get closer to doing effective, timely follow-up care for patients when they come out of hospital.

Check out the slides other resources from our day,  linked below. There is plenty in here that can help your teams get better at timely follow-up, even if you didn’t attend the workshop, and even if you’re not in the North East!


Getting Access to Hospital Data

Getting and managing hospital data with POI and HRM – Brandon Fox (Health Sciences North), Jenna Serafini (Health Sciences North), and Rahim Rafiq (OntarioMD)

Using Patient-Oriented Discharge Summaries (PODS) – Shoshana Hahn-Goldberg, PODS Project, OpenLab

Getting hospitalization data about your patients: Please DO try this at home – Carol Mulder (AFHTO), Lori Oswald (Manitoulin Central FHT), and Anna Gibson-Olajos (Powassan & Area FHT)

Tracking follow-up in your EMR – Carol Mulder (AFHTO)

Resource Estimator – Carol Mulder (AFHTO)

Interprofessional strategies for better follow-up

A team-based approach: Multi-disciplinary approaches for care planning and follow-up – Mandy Weeden and Julie Moody (Kirkland & District FHT)

Pharmacist-led approaches to follow-up through medication reconciliation – Nancy Tripodi and Vickie Luckham (Mediwell); Sammu Dhaliwall (North West Telepharmacy Solutions)

Aligned QIPS 2019-20 – Meghan Peters (City of Lakes FHT), Jenn Osesky (North East LHIN), and Joanna DeGraaf-Dunlop (Health Quality Ontario)

Confidence-building and commitment to action

Our notes

Whenever the folks in the north get together, great ideas emerge from the conversations as well as from the presentations. Here are our notes about things what we learned from attendees.