Dr. Margaret Saari
Health System Impact Fellow Profile

Margaret Saari
Host Partner Organization:
Saint Elizabeth Health Care
Name of Host Partner Organization Supervisor:
Dr. Paul Holyoke
Location (city, province):
Markham, Ontario
Academic Institution:
University of Waterloo
Name of Academic Supervisor:
Dr. John Hirdes
Duration of Fellowship:
2 years
Title of Fellowship / Program of Work:
Optimizing home and community partnerships to improve informational, relational and management continuity for seniors receiving home and community-based care
Contact Information:
Social media page(s): Twitter: @trifectaRN
Post-HSI Fellowship Career Profile


I am a Registered Nurse with clinical experience in emergency, urgent care and care coordination roles. Through my clinical work, I cared for many seniors who had frequent trips to hospital and wondered whether there were gaps in their community care. I chose to pursue my PhD to better understand home and community-based service utilization and to try to identify potential opportunities to improve care and keep more people at home. Throughout my PhD studies I was highly involved in the Institute for Healthcare Improvement, working to empower frontline providers to use their knowledge and experiences to identify gaps in care quality and speak up to improve care. I was drawn to the HSI Fellowship because of the unique opportunities to make a direct impact on patient care at the provider level, while gaining a deeper understanding of how decisions are made and how evidence-based practices are adopted in a healthcare organization.

Fellowship Program of Work

Saint Elizabeth’s impact goals for this fellowship are integrated care and patient- and family-centred care. To remain living in the community, many older adults receive care from several community-based organizations from both the home care and community support sectors. While these services can be delivered concurrently or sequentially, there is often little coordination or information sharing between providers. The overall aim of this program of work is to optimize home care and community support agency partnerships to improve information sharing, care management and continuity of care. In this program I plan to adapt methods from the field of service design to engage patients, their care partners, and service providers in the development of a new tool and shared process to support continuity.

This program of work has the potential to impact Saint Elizabeth’s and other partners’ processes for shared care. Furthermore, it has the potential to positively impact the experience of community care for patients and their families. I am excited about this program of work for three key reasons: 1) front-end involvement of patients and providers in the design of the tool will increase its acceptability and usability, 2) the work is inherently interdisciplinary (which I value) and 3) by using a sequential design, shared processes can be mapped out and developed to support the use of this tool in practice. What I hope to gain is a deeper understanding of the patient and family experience in home and community-based care as well as experience in involving end users research and service design.

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