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 multidisciplinary working group of physicians and allied health clinicians specializing in addictions, emergency, and family medicine is collaborating to improve the quality of care for opioid users transitioning from the Emergency Department (ED) to the community. Key initiatives include:

Developing New ED Protocols:
- Acute Opioid Withdrawal Protocol and Order Set (CPOE-integrated) to improve care while patients wait to be seen
- Enhanced referral pathways to the Substance Use Rapid Follow Up (SURF) team
- Collaboration with Peer Support Workers to enhance communication and support expanding hours
Education
- ED nurses
- FPs and teams
Establishing a New ED Role: Advocating for the creation of the Substance Use Nurse (SUN Nurse) position, currently being piloted in the ED at RJH.
Strengthening RAAC to Community Transitions: Improving processes for RAAC (Rapid Access to Addictions Care) to discharge stable OAT patients for follow-up care at UPCCs.

These efforts aim to enhance patient experiences and outcomes, foster collaboration among healthcare providers, and build stronger connections between EDs and community resources.

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.

The Specialist Referrals Project, funded through Shared Care, has been actively engaging with family physicians, specialist physicians, nurse practitioners, and medical office assistants to gain a deeper understanding of their challenges and frustrations, and to discuss strategies to streamline referrals. This deeper understanding is helping to improve collegiality, efficiency and patient outcomes by building connection and trust among colleagues. Key initiatives include:

Organizing and delivering multidisciplinary events:
- Providing a space for family and specialist physicians to come together to share ideas and identify quality improvement activities.
- Strengthening relationships by increasing collegiality and perspective.
Educating residents:
- Preparing future physicians by going over the essential elements of a good referral, sharing helpful tips, explaining best practices, and identifying urgency.
Improving communication:
- Launching and trialing new communication tools.
- Encouraging direct physician-to-physician communication to help streamline the process.
- Timely acknowledgment of referrals.

Bridging Care: Collaborative Pathways for Seamless Cancer Transitions

An EOI was submitted to Shared Care at the end of 2024 and was successfully accepted. This project’s goal is to improve transitions in care for cancer patients by fostering collective action amongst healthcare providers. Consults with patients and physicians across specialties (oncology, family medicine, emergency care, and palliative care) will help map the current state and patient journey. This will include identification of key drivers of change, and barriers to effective care coordination and communication. The insights gathered will inform the development of a common agenda and collaborative recommendations for enhancing care quality.

The project aims to improve physician satisfaction with communication, care coordination, and continuity between hospital clinicians, oncology, and community physicians in the Greater Victoria area by:

Reducing the proportion of unattached patients discharged from ED/acute stays without cancer follow-up plans
Increasing the number of care coordination contacts with palliative care for end-of-life patients
Improving physician-reported communication between family physicians and specialists for attached patients.

Note: This project is operationally led by the Provincial Health Services Authority.