Care Transitions Projects Completed

eNotification System

eNotification is an automated electronic notification of hospital admissions, deaths in hospital (including in the ED without an admission), and hospital discharges from Island Health facilities to community FPs who use compatible EMRs. The Care Transitions committee was instrumental in developing the eNotification system, contributing clinical expertise to its technical design and testing, and piloting the system prior to its launch. In June 2017, all technical and clinical support was handed off to Island Health, making eNotification 100% sustainable.

If you have questions or concerns about eNotification, you may contact Island Health’s Clinical Solutions Desk by calling 250-370-8777 extension 3.

Our eNotification work has been featured in:

Patient Summaries

The Patient Summaries Project began as a small pilot that tested methods of leveraging automated notification of patient admission to hospital so family physicians could provide longitudinal health information to hospital clinicians early in the inpatient stay. The process was refined several times in partnership with Island Health and a robust information transfer pathway was developed. Patient summaries have alerted clinicians to medication allergies, relevant diagnoses and assessments that are not available in the hospital Electronic Health Record, and information about patients’ family and social circumstances that makes discharge planning more effective. Any FP can send a patient summary into Island Health through by faxing it to their central intake at 1-250-755-7659 or through the EMR Connect web portal. Email Island Health for more information: [email protected].

Where to locate patient summaries in Powerchart (video)

Familiar Faces

Extensive work was done to connect FPs and ED physicians through the creation of patient care plans for high-volume users of local emergency services. This initiative helped fill a significant patient care gap by allowing FPs to provide much-needed patient information the ED clinicians about these complex patients. As well, our efforts resulted in the transition of pediatric psychiatric patient notes into an electronic format for timely access by ED clinicians.

Long-term Care Transitions

Taking a patient-centred approach, this project improved provider access to information; strengthened relationships between providers; and developed tools and strategies for IMIT-enabled communication between residential care facilities and other health settings. Our work with Island Health resulted in the creation and launch of the Long-term Care Directory. The directory is housed on Island Health’s Intranet site enabling hospital physicians, nurses, and allied health practitioners to determine if their patient’s residence will be able to support their transition back home.

Coordinating Complex Care for Heart Failure

Cardiologists specializing in heart failure, family physicians, patients, caregivers, nurses, Island Health Community Virtual Services, and Island Health IMIT were brought together to improve transitions for heart failure patients. Stakeholder engagement efforts focused on enhancing patient transitions and follow-up care alongside the newly created Heart Failure Unit at Royal Jubilee Hospital. Most notable was the work on a discharge checklist that ensures FPs receive information on patient education done in hospital as well as clear directions on what follow-up arrangements have been made and what is left to arrange.

Working together with Pathways BC, search parameters were revised allowing for easier access to heart failure patient and caregiver resources that already existed or were identified and added to their system.

Communicating Goals of Care

The Care Transitions Committee (CTC) worked to improve care coordination and continuity by ensuring that patient goals of care were effectively communicated across healthcare settings. Recognizing that gaps in communication could lead to care that did not align with patients’ wishes, the project aimed to strengthen information-sharing processes between providers. A key focus was supporting family physicians (FPs) in prioritizing goals of care conversations through a Practice Support Program (PSP) quality improvement pilot. This pilot led to the review of 119 patient charts, with at least 26 patients receiving follow-up visits or completed Medical Orders for Scope of Treatment (MOST) forms. Additionally, Group Medical Visits (GMVs) provided patients with education on advance care planning. Findings from this work highlighted the importance of streamlined communication processes for advance care planning.