Care Transitions Projects Underway

Introduction

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.

Extended Information

Follow-Up for Opioid-Using Patients

A working group of physicians and allied health clinicians in addictions, emergency, and family medicine have come together to test quality improvements for opioid users transitioning from the ED to community. Work will include:

development of new ED protocols;
streamline transition pathways; and
assess feasibility (including physician readiness) of Opioid Agonist Therapy (OAT) initiation in the ED with rapid community follow-up.

Stakeholder interviews were conducted by medical student Lauren Walgren, who supported our proposal to the Shared Care Committee through her FLEX project. This involved interviews with physicians and health authority leaders around the province who are involved in supporting projects related to opioid users in the ED. Her work was presented in a storyboard at Quality Forum 2023.

Communicating Goals of Care

A working group comprised of physicians, nurses, and Island Health representatives is coming together to identify and address challenges in ensuring that patient goals of care can be easily communicated between community, hospital, and other settings. This project is in the initial stages and more details will be added to this page as they become available.

Collaborative Processes for Specialist Referrals

A seamless referral process between family and specialist physicians is a crucial element of patient care transitions. By enhancing multidisciplinary cooperation and exploring new ways of working together, family and specialist physicians can continue providing excellent care to patients. So far, preliminary engagement work has been done through information-gathering meetings with family physicians, specialist physicians, and medical office assistants. This work has helped shape a proposal for funding which has recently been submitted to the Shared Care Committee.

Engagement

Explore Other Initiatives & Events

The evolving MOA Network will support the needs of MOAs working in Victoria PCN member clinics.

MOA Network

The new AHCP program by FPSC offers after-hours care for attached patients of family doctors and nurse practitioners.

After Hours Care Program

A collection of current Care Transitions projects and initiatives

Care Transitions Projects Underway

Show your colleagues your appreciation!

Cheers for Peers

The Peer Support program offers a safe space for confidential, short-term, non-clinical emotional support to colleagues.

Greater Victoria Peer Support Program

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Care Transitions Projects Underway

Introduction

Extended Information

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MOA Network

MOA Network

After Hours Care Program

After Hours Care Program

Care Transitions Projects Underway