Welcome to my Artefacts 632

See below for videos and presentations related to MHST 632! All artefacts created by Alex MacKinnon

Logic Model February 26th, 2026

Stakeholder Identification February 23, 2026

Health Promotion issue/opportunity: Older adults with polypharmacy face elevated risk of medication-related harm after hospital discharge due to limited health literacy, complex regimens, and fragmented transition processes. Strengthening health literacy–sensitive discharge practices represents an opportunity to empower patients and caregivers, enhance medication self-management capacity, and reduce preventable strains.

Questions I would pose.. Who do you think is the Most Responsible Person (MRP) when it comes to patient education during the discharge transition phase for acute care?

When in the transition would it be best to embed education interventions to patients? Pre or post discharge? Why?

What stakeholder have I not mentioned that may be overlooked? I know some hospital may designate positions differently than others

Expertise in the health problem OR its causes

Who has content knowledge relative to the health problem or its causes?

Hospitalists, pharmacists, Discharge lead nurses, Patient, safety, quality and risk specialists, health literacy specialists and home care clinicians

What disciplines can be most helpful in describing problems from an ecological perspective?

Social work, occupation therapy, speech language (communication), community pharmacy, and follow up supports

Who knows about similar problems?

Discharge call teams, hospitalists who are contacted for resolution post discharge, patient flow coordinators, and geriatric outreach programs

Who is well respected for knowledge of this health problem or others like it?

Pharmacy leadership, professional practice, risk department, nurse educators and discharge leads, unit managers, patient and family advocacy and physicians

Diverse perspectives and community participation

Who has needs and perspectives related to the problem?

Older adults with polypharmacy, family caregivers, patients with limited health literacy, language barriers and decreased ease of access to tech, culturally diverse communities, and rural patients who may not have as in-depth health surveillance

When programs are developed related to the needs and problems, who are the potential clients, participants, or beneficiaries?

Older adults being discharged home, Caregivers supporting the patients, patients at high risk (polypharmacy, high health care use, communication barriers)

Who already works with potential beneficiaries?

Frontline nursing, pharmacists, social workers, primary care teams, community care,

Who can help the planning group clarify values related to the needs assessment and intervention development?

PFAC, patient advisory committees, patient flow metrics,

Who are the potential critics of the program or initiative?

Inpatient units with limited time for discharge teaching, change management/ staff skepticism/, community provider buy-in

Responsibility and authority

Who will manage the needs assessment and program development?

Acute Care Hospital Patient Transitions department

Who is the funder?

Associated University partnership alongside hospital

Who can become a partner in the assessment and program development?

PFAC, Pharmacy services, Nursing/Professional practice,

Who can bring resources to the endeavor?

Leaders (program managers, directors), educators, decision support teams for metrics,

Influence

Who has served as a resource to community members for this problem or related ones?

Community pharmacists, community care coordinators, community agencies, family physicians and chronic disease programs

What policy makers have worked on this type of problem?

Hospital based related to quality and safety, involving client flow and medication reconciliation. Perhaps also community care?

Who are opinion leaders who might have an interest in this type of problem?

Physician groups, middle administrative leadership and pharmacists

Who can help the planning team access expertise and other resources of the community?

Who can garner support and buy-in to the project?

Executive leadership, unit managers, physician and pharmacy leads

Commitment to the issue

Who will manage the needs assessment and program development?

Acute Care Hospital Patient Transitions department

Who is the funder?

Associated University partnership alongside hospital

Who can become a partner in the assessment and program development?

PFAC, Pharmacy services, Nursing/Professional practice,

Who can bring resources to the endeavor?

Leaders (program managers, directors), educators, decision support teams for metrics,

Systematic Reviews

Powerpoint presentation for MHST 632- February 8th, 2026

This presentation introduces the purpose and value of systematic literature reviews and explains when they should be used in research. It outlines the key methodological steps, including developing a research question, conducting a structured search, screening studies using PRISMA, and appraising study quality. Finally, it describes how findings are synthesized through narrative, quantitative, or qualitative approaches to produce a transparent and reliable evidence summary.

06 Situational Awareness
January 27th, 2026

What impact does the current situation have on health outcomes, quality of life and other societal costs, such as noise, air pollution or increased healthcare spending?

Many older adults leave hospital with complex discharge instructions and medication regimens that are difficult to understand and manage. When health literacy is low and discharge communication is rushed or unclear, older adults are at increased risk of medication errors, missed follow-up care, worsening symptoms, and delayed recognition of red flags.

What is the situation? Improving health literacy and medication safety among adults aged 65+ following hospital discharge to reduce avoidable ED visits and 30-day readmissions.

This issue affects:

Health outcomes: adverse drug events, falls, complications, deterioration, re-hospitalization
Quality of life: anxiety, loss of confidence, reduced independence, caregiver stress and burden

Societal & system costs: increased ED volumes, hospital bed pressures, increased healthcare spending, and inefficient resource use related to avoidable return visits.

Which groups of people are at higher risk of health problems and poorer quality of life?

Older adults (65+) experiencing polypharmacy, multimorbidity, and complex regimens
Individuals with low health literacy
Patients with cognitive impairment, memory challenges, frailty, or sensory limitations (vision/hearing)
People with limited English proficiency or communication barriers
Individuals with low socioeconomic status
Those who are socially isolated or without reliable caregivers/family support
People who lack consistent access to primary care or follow-up services
Patients discharged after acute illness, surgery, or rapid discharges during periods of high system pressure

Which settings or situations are high risk, or pose a unique opportunity for intervention?

The immediate hospital discharge period, approx. 48-72 hours post discharge, especially when discharge occurs quickly or unexpectedly
High-turnover environments where communication must happen rapidly (busy inpatient units, short-stay areas)
Patients discharged with multiple medication changes or new high-risk medications (e.g., anticoagulants, insulin, opioids)

Opportunities:

Discharge planning moments where teaching + confirmation of understanding can occur
Medication reconciliation and pharmacist involvement at discharge
Use of standardized patient-friendly discharge summaries, plain language med lists, and teach-back
Caregiver engagement at discharge and early follow-up

Linking patients to community supports

How do local stakeholders perceive the situation? What is their capacity to act? What are their interests, mandates, current activities?

Discharge is a vulnerable transition point
Readmissions and ED visits are frustrating and sometimes preventable
Patient understanding is frequently overestimated
Workflows make it difficult to spend enough time on education

Stakeholder groups and typical mandates/capacity:

Hospital teams (nurses, physicians, unit leaders): responsible for safe discharge, but are limited by time pressures, staffing, bed flow demands, and competing priorities.
Pharmacists: strong interest and capacity to support medication reconciliation, teaching, and medication lists, but may be limited by resourcing or inconsistent integration at discharge.
Primary care providers: want continuity and accurate medication lists but often receive incomplete information and have limited ability to see patients quickly post-discharge.
Home care/community agencies: can support adherence and safety but depend on timely referrals and capacity.
Patients and caregivers: may feel overwhelmed, tired, or unsure what questions to ask.

What are the needs, perceptions and supported directions of key influential community members, and the community-at-large?

Clear, respectful, plain-language discharge instructions
Med lists that are accurate and easy to follow
Consistent follow-up and reassurance after discharge
Greater caregiver involvement when appropriate
Better communication between hospital and community providers
Increased system accountability so the burden doesn’t fall entirely on the patient

Community-at-large (especially families supporting older adults) often supports:

More proactive discharge support and planning
Improved navigation and understanding of what services exist

What influences are making the situation better and worse?e

What high-risk or negative health behaviours by various groups of people are affecting the situation?

Taking medications incorrectly (wrong dose/time, duplications, stopping early)
Missing follow-up appointments or not booking follow-up at all
Delayed seeking in help when symptoms worsen
Not using available written resources (because they are confusing or inaccessible)
Not engaging fully in discharge education due to fatigue, stress, or rushed discharge

Not being present at discharge teaching
Misunderstanding instructions themselves
Being overwhelmed by responsibility and system complexity

Inconsistent medication reconciliation processes
Overreliance on written materials that are not health-literacy friendly
Discharge teaching that is not standardized or not reinforced
Lack of confirmation of understanding (no teach-back)
Gaps in communication to primary care/community pharmacy/home care

Which underlying causes or conditions are driving these behaviours (e.g. individual, community, organizational or system-level causes)? Are there protective factors that can help avoid or alleviate the situation (such as ensuring walkable communities or encouraging strong parent-child relationships)?

1. Individual-level causes

Low functional or critical health literacy
Cognitive decline or memory impairment
Language barriers and sensory impairments
Anxiety, stress, and fatigue at discharge

2. Interpersonal-level causes

Limited caregiver support or caregiver burnout
Family members not included in planning or teaching

3. Organizational-level causes

Discharge workflow pressures and limited staff time
Variation in how discharge instructions are delivered
Lack of standardized tools, scripts, or consistent expectations
Fragmentation between teams (medicine, pharmacy, nursing, care coordination)

4. System-level causes

Limited access to primary care follow-up
Home care capacity constraints
Inequities in social determinants (income, housing, transportation)

Protective factors

Teach-back and repeated reinforcement of key messages
Simplified medication summaries (plain language, large font, visuals)
Post-discharge follow-up calls within 48–72 hours
Pharmacist counselling and strong medication reconciliation
Remote monitoring and virtual care supports (when appropriate)
Strong caregiver involvement and community supports

Which strengths and weaknesses present in your organization may affect your course of action? Which opportunities and threats in your environment may affect your course of action?

Existing discharge foundation processes already in place
Staff who value patient safety and patient experience
Many evidence-based tools already exist (teach-back, discharge bundles)
Potential capacity for follow-up calls, pharmacy support, virtual care

Time pressure and staffing constraints
Variation in discharge teaching quality across units
Discharge information can be complex, inconsistent, or “too much at once”
Communication gaps between acute care and community follow-up

Growing emphasis on reducing readmissions and ED pressures
Momentum toward equity, quality improvement, and system sustainability
Remote/virtual tools can support follow-up and reinforcement
Partnerships with pharmacies, primary care, home care, PFAC

High patient volumes and ongoing health human resource shortages
Limited community capacity for follow-up services
Risk of interventions becoming “extra work” instead of embedded workflow

What possible actions can you take to address the situation?

What are other organizations doing, or what have they done in the past, to address this situation? Specifically, what local policies, programs and environmental supports are being developed or implemented within the community? What evaluation data are available for these activities?

Standardized discharge summaries written in plain language
Medication reconciliation programs (pharmacy-led discharge processes)
Teach-back discharge education model
Follow-up calls within 48–72 hours after discharge
Caregiver inclusion policies and discharge planning supports
Remote monitoring for high-risk populations when appropriate

Quality improvement initiatives often include:

- readmission reduction strategies
- discharge pathway standardization
- patient education toolkits
- ED avoidance pathways (surgery clinics)
Evaluation data
- 30-day readmission rates
- ED visits within 7–30 days
- medication discrepancy rates
- patient satisfaction / understanding measures surveys

What is the best available evidence that exists to support various courses of action?

Best available evidence suggests that reducing post-discharge harm and utilization requires both:

patient-level supports (health literacy + medication understanding), and
system-level changes that reduce complexity and improve follow-up.

Evidence-informed directions supporting the model include:

Health literacy strongly influences safe self-management after discharge and impacts readmission risk.
Teach-back improves patient comprehension and can reduce readmissions in chronic disease populations.
Simplified medication lists and discharge summaries improve adherence and reduce confusion.
Follow-up calls identify problems early and support safer transitions.
Caregiver involvement improves understanding and continuity.

Equity-informed approaches are necessary because discharge safety is strongly shaped by access to supports and social determinants

References

Welco

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Centers for Disease Control and Prevention. (2022). The social-ecological model: A framework for prevention. https://files.eric.ed.gov/fulltext/ED556109.pdf

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