Concurrent Sessions

D5 Transitions: The Program That Kept Judith from Re-Admission

Theme 5. Coordinating care to create better transitions

Presentation Details

  • Date: 10/18/2016
  • Concurrent Session D
  • Time: 9:30am – 10:15am
  • 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, Representatives of stakeholder/partner organizations

Learning Objectives

  1. Learn how to improve patient safety as well as improve their health care journey while transitioning from hospital to home and home to hospital
  2. Examine ways to prevent hospital re-admissions for both chronic and acutely ill patients
  3. Examine the care needs that can be addressed within a patients’ home post-hospital discharge


By October of 2016 we hope to have used our tracking codes and nearly full year of running the Transitions program to determine the following outcomes:

  • The number of patients followed up by Transitions who still required readmission to hospital within 30 days of discharge
  • Which medical diagnoses required the most follow-up and referrals, and to which disciplines
  • How many home visits were done
  • How many Primary Care Provider (PCP) visits were booked through Transitions and how many of these were within 7 days of hospital discharge ; if > than 7 days then why?
  • The number of times a patient or family member called in to their Transitions program point person with questions or concerns
  • How many hospital visits were completed through the Transitions program
  • Qualitative data about the patient/family experience using surveys
  • We hope to see that readmission rates within 30 days decrease over time. In keeping with our Schedule A and QIP targets, we hope to see > 80 home visits completed and 100 PCP appointments booked with >50% of PCP visits done within 7 days of hospital discharge.  Finally, we hope to see >400 pts at the bedside to initiate the transition from hospital to home.


  • Danielle Duns, Lead RN, Transitions Program, Markham FHT
  • Lisa Ruddy, RN, Clinical Program Manager, Markham FHT
  • Rebecca Robinson, Administrative Assistant, Markham FHT