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.

Related Resources

Community Physician Health & Safety Guide

A guide for community physicians as employers

Practice Transition Toolkit

A collection of transition resources, tools and templates

Practice Support Program

Services to optimize your practice, enhance your use of health technology, and more effectively manage your patient panel

Moving to Victoria

Resources when considering your move to Victoria

Setting up your practice

Useful links as you consider setting up your practice

Perinatal Care Resources

Perinatal care resources for family physicians

Virtual Care Resources

If you are new to providing virtual care, there are many resources available to help.

Emergency Response Planning

Using these tools will assist you in the creation of your own Practice Continuity Plan.

EMR Tip Sheets

Each Tip Sheet walks a new user through the basics of documentation during a patient visit

Software Solutions

Software Solutions for Family Doctors: Comprehensive guidance curated by our IT Working Group

Med Access & Practice Solutions Software

Software solutions for MedAccess and Practice Solutions EMRs

ER Tips & Tricks

Focused guidelines to assist community FPs in making decisions about which patients should be referred to the ER

Contracts and Funding Information

Information about NTP and group contract options as well as the team-based care grant, Urban Locum Program, and more!

NTP Contract Resource Library

New-to-Practice Contract Resource Library

Group Contracts Q&A

Q&A from the Victoria PCN’s VDFP/SIDFP Neighbourhood Meeting in March 2022

Group Contract Resource Library

Practicing Family Physician Group Contract Resource Library

Recruitment Support

Interested in posting a position on our website?

Explore Other Initiatives & Events

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

MOA Network

The AHC 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

Community Physician Health & Safety Guide

Practice Transition Toolkit

Practice Support Program

Moving to Victoria

Setting up your practice

Perinatal Care Resources

Virtual Care Resources

Emergency Response Planning

EMR Tip Sheets

Software Solutions

Med Access & Practice Solutions Software

ER Tips & Tricks

Contracts and Funding Information

NTP Contract Resource Library

Group Contracts Q&A

Group Contract Resource Library

Recruitment Support

Explore Other Initiatives & Events

MOA Network

MOA Network

After Hours Care Program

After Hours Care Program

Care Transitions Projects Underway