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Improving Communications
The Care Transitions initiative, formally known as Transitions in Care (TiC), started in 2013 with an aim to improve communications between acute and community care settings. The first project undertaken was the development of our eNotification system in collaboration with Island Health which provides automated notifications via physicians’ office EMRs.
Our projects, many funded by the Shared Care Committee, have continued to provide opportunities for community and hospital providers to collaborate and improve the care coordination of patients as they move from one setting to another. The outcomes of our work include the creation of new tools; new communication systems and workflows; and strengthened practitioner relationships so they feel empowered to reach out to each other.
We take pride in bringing together the right stakeholders for each of our projects to ensure all perspectives are brought forward and considered. Depending on the scope of the project, this may include family physicians, emergency department physicians, hospitalists, specialists, allied health practitioners (e.g., nurses, pharmacists, social workers), other professionals (e.g., health information management, IT), patients and caregivers, and community service providers.
Patient Care Transitions
Patient transitions can take place between various care providers which is why many of our projects cross over multiple transition points. By focusing on enhancing and strengthening patient transitions we help physicians gain access to relevant patient information to the process can be as seamless as possible for all involved. Possible transitions can include primary care, acute care, emergency departments, specialist care, long-term care, and community supports.
Resources
Your colleagues in the ED have collaborated with community FPs in the Care Transitions project to develop a series of tips and tricks that will help you make better referrals to emergency care.
This link shows you how to access heart failure patient and caregiver resources on the Pathways community page.
This video demonstrates where to locate patient summaries in PowerChart
Since the implementation of BC’s Implicit Referral policy, some clinics still receive requests for re-referrals, even when patients remain under active specialist care. To reduce unnecessary paperwork and help clinics respond consistently, we’ve created response templates for Med Access, Oscar, and Juno users that can be quickly sent back to specialists or their MOAs.
These templates were developed with input from local MOAs and with the support of the Practice Support Program (PSP) to ensure they are practical, efficient, and easy to use within your EMR.
How to Use the Templates
If you would like to learn more about Care Transitions or a specific project, please email:
Kristin Atwood, Program Director
[email protected]
The Victoria Division of Family Practice acknowledges with great respect and appreciation that our office is located on the traditional, ancestral, and unceded territories of the Coast Salish nations. We are privileged to be working on the lands of the Lək̓ʷəŋən (Lekwungen/Songhees) and WSÁNEĆ (Tsartlip, Tsawout, Tseycum) Peoples.