AFHTO members have identified follow-up after hospitalization as a key area of focus for better patient outcomes. Delivering timely, team-based follow-up is also an important way to demonstrate the value of primary care teams to Ontario's health system. It's been an indicator in D2D since the second iteration. Now, transitions in care have surfaced as a province-wide improvement priority for the 2019-20 Quality Improvement Plans (QIPS). Looking for inspiration? Your peers have it! We know that providing timely follow-up is challenging. But we also know that our teams are up to the challenge! Some of your peers in AFHTO have shared their innovations in this area at the last few AFHTO conferences as well as at Focus on Follow-Up, a recent workshop by and for teams in the North East LHIN region. Check out what your peers have done here:
- Now that teams can choose to “unmask” themselves in D2D, you can see who is performing well on this indicator and reach out to them. Or find a peer whose team structure is similar to yours, and ask them how they are doing.
- HQO’s QIP Navigator allows teams to query submitted QIPs. This tool is can help you find peers who have focused on similar areas for improvement.
- Learn how the Woodbine FHT and Tilbury District FHT improved their 7-day post hospital discharge follow-up rates using the Model for Improvement.
- Check out the Markham FHT’s Transitions Program, which helps to reduce hospital-based care while affording the patient a better health care experience.
- Learn about the Algonquin FHT's Discharge Patient Program which supports transition back into primary care.
- Read about how Health for All FHT's interprofessional approach has helped them provide follow-up care to more patients.
AFHTO teams are already making great strides in improving transitions and follow-up. View the slide deck here.