Transitions in Care Initiative

South Okanagan Similkameen

Acute Exacerbation of COPD Acute Pathway

An interdisciplinary team came together to focus on acute exacerbation of COPD (AECOPD) patients in hospital and their optimal transition back to the community. It soon became apparent that the best way to facilitate the transition was to provide the patient with quality in-hospital and community education and support.

Together the team identified gaps in care and then used a quality improvement model to develop, test and implement solutions based on clinical best practice.

An AECOPD acute pathway was developed to standardize best practices in the hospital and connect patients to support and education in the community. It is based on an optimal COPD model of care.

Early results indicate this model of care is having a positive effect – with a 32% reduction in COPD admissions in the South Okanagan in the past three years.

Primary Maternity Care

Primary maternity care in the South Okanagan Similkameen is provided by a combination of obstetricians, family physicians, midwives and paediatricians.

In the past few years, birth numbers in the region have declined at the same time that midwife capacity has increased. This has resulted in a decreased caseload for family physicians working in the primary maternity clinic at Penticton hospital and threatens the long-term sustainability of the clinic. Family physicians are a critical component of primary maternity care in the South Okanagan Similkameen.

The project brings together the four care provider groups and Interior Health staff to find ways of working together that allow each provider group to maintain a sustainable practice.

ON TRAC Youth Transitions

Youth with chronic complex health conditions and disabilities are often referred to BC Children’s Hospital for treatment. During that time, youth often have little connection to local physicians.

At age 18, youth are expected to transition to adult care, usually with a family physician and specialist(s) in their local area. The ON TRAC youth transition project is designed to identify local transition issues and improve this transition for youth and their families.

Emergency Department Transitions

Emergency and family physicians have engaged in ongoing dialogue about patient transitions to and from emergency. Information transfer, appropriateness of emergency use, and patient transitions are all issues identified as having potential for improvement. This project is scheduled to start late in 2014. A multidisciplinary team will be engaged to identify the scope of the project and develop improvements.