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Transitions from hospital to home: Building models for continuity of nutrition care

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Marg Alfieri, RD, FDC - McMaster University;

Nicole Del Fiacco, RD - Niagara Health and the Niagara North Family Health Team;

Colleen Einarson, RD - Winnipeg Regional Health Authority;

Dayna Weiten, RD - Grace Hospital, Winnipeg Regional Health Authority

This webinar will describe the circumstances that exist in a tertiary care centre and the connection to primary care providers and community-based nutrition services that led to the development and evaluation of this project. The implementation of all aspects of malnutrition care and navigation to dietitians in the community was funded within existing resources. The results and our conclusions show that it is possible to make progress in the transition to home for malnourished patients with a highly connected system, good communication and creative thinking.


  1. Describe the risk and opportunity of vertical integration of dietitians within a community across practice settings.
  2. Understand the role of the dietitian and the circumstances that are needed in order to discharge a patient with malnutrition to Primary Care Providers and nutrition services in the community.
  3. Know that systems change can start small and be initiated during times of intense transition and without a dedicated budget.

About the Speakers

Marg Alfieri is a health care professional who has worked in a wide variety of health care settings, from tertiary care, research, private practice and finally to her delight in primary care – family health teams. She is the former President and Chair of AFHTO, a position that allowed her to fulfill her passion for comprehensive team based primary care. She is an Associate Professor at McMaster's School of Medicine. In 2005 Marg founded the FHT RD network. She has been instrumental in the creation of AFHTO's Community of Practice for nursing, admins and IHPS. She has multiple peer reviewed research papers. In 2011 the Family Medicine Residents awarded her the IHP Preceptor of the year. In 2014, Marg was named “Fellow of Dietitians of Canada" for her contributions to primary care nutrition.

Nicole Del Fiacco is a registered dietitian working at both Niagara Health and the Niagara North Family Health Team (Virgil site). In her dual role she has had the unique opportunity to implement malnutrition screening and nutrition care plans in both a community and hospital setting.

Dayna Weiten is a clinical dietitian with over 25 years of experience in both ambulatory care and inpatient positions within the Winnipeg Regional Health Authority. She is currently the site lead for clinical nutrition at Grace Hospital, a 250-bed acute care site within the Winnipeg Regional Health Authority where her clinical work is in critical care and she is the manager for the other clinical dietitians at the site.

Colleen Einarson is a registered dietitian and the Regional Manager of Community Nutrition at the Winnipeg Regional Health Authority, a position she has held for more than 8 years. Colleen's previous work has been in adult and pediatric diabetes management and education and program planning. The work that she does now is highly coordinated with her Regional Manager colleagues in Acute Care (Brenda Hotson) and Long Term Care (Jean Helps) which she credits for the accomplishments that can be made in a time of intense transition.

** Original Source: "CNS Education Webinars" Wednesday, September 25, 2019


Type: File

Last Updated: September 26, 2019

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Alfieri_DelFiacco_25Sept2019_CMTF-FRENCH File
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Einarson_Weiten_25Sept2019_CMTF-FRENCH File
Transitions from hospital to home: Building models for continuity of nutrition care Video
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