Meet the PFCC Team – Discharge Transition Leads

We connected with Joanita and Kim, Discharge Transition Leads on the PFCC team, to find out more about their roles.

Joanita Nakimuli, Discharge Transition Lead/Educator, RN

Joanita started with the Patient and Family Centred Care (PFCC) department in June 2023 as the Discharge Transition Lead, and will soon pilot the role of Pre-Discharge Educator, which aims to improve communication/retention of discharge instructions for patients transitioning out of the Hospital.

As the Discharge Transition Lead, Joanita is responsible for evaluating the organization’s discharge process, looking at successes and areas for improvement. Her priorities include supporting our staff and patients with the appropriate resources to navigate the discharge process successfully.

In her role, Joanita evaluates patient discharge materials at TBRHSC to ensure their relevance when put into practice. She collaborates with various members of the health care team and Patient Family Advisors to inform strategies for integrating person-centred communication during the discharge process.

While working in the PFCC department, Joanita excels at collaboration, participation and information sharing, which are all important in promoting a high standard of care that centers on the patient experience. The Discharge Transition Lead position offers a unique perspective on the challenges that patients face with the discharge process and how this influences the continuity of care. Joanita’s interactions with patients, families and staff have resulted in pilot projects to orient admitted patients to the hospital environment, addressing barriers such as health literacy and information overload. The evolution and flexibility of this position will allow continual engagement in meaningful partnerships with staff, patients and families, and to support our organization in promoting PFCC.

Kim Agostino, Discharge Transition Lead/Post Discharge Liaison, RPN

Kim is the newest member of PFCC, serving as the Discharge Transition Lead/Post Discharge Liaison. Her goal is to help staff understand the importance of effective discharge processes, and ensure that patients discharged to their homes fully comprehend their post-discharge care instructions. Kim has observed that follow-up calls after discharge give patients the chance to ask questions they might not have considered while in hospital, allowing their voice to be heard. Many patients express how much they appreciate receiving a call from PFCC, feeling valued and cared for.

Kim began her career over 20 years ago in acute care on 2A. Her extensive experience will help guide and support the team in improving the discharge process, and patient care.

Find out more about Patient and Family Centred Care at https://tbrhsc.net/home/caring-for-patients-families/