Care Transitions

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.

Projects Currently Underway

Follow-Up for Opioid-Using Patients
Collaborative Processes for Specialist Referrals
Bridging Care: Collaborative Pathways for Seamless Cancer Transitions

Projects Completed

e-Notifications
Patient Summaries
Familiar Faces
Long-term Care Transitions
Coordinating Complex Care for Heart Failure
Communicating Goals of Care

Resources

Tips & Tricks from the ED

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.

Pathways BC Caregiver Resources

This link shows you how to access heart failure patient and caregiver resources on the Pathways community page.

Patient Summaries in PowerChart

This video demonstrates where to locate patient summaries in PowerChart

If you would like to learn more about Care Transitions or a specific project, please email:

Kristin Atwood, Program Director
[email protected]

Care Transitions

Get in Touch

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The Victoria Division of Family Practice respectfully acknowledges that our office is located on the traditional, ancestral, and unceded territories of the Lək̓ʷəŋən speaking peoples, known today as the Xʷsepsəm and Songhees Nations. We are grateful to be working on these lands.

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