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Fraser Northwest

Partners in Care Initiative

Enhanced Recovery After Surgery (ERAS)

Engaging family physicians in the optimization of ERAS through select pre-operative interventions for surgical patients with colorectal cancer. 

Musculoskeletal (MSK) Medicine

Improving patient access to timely and appropriate MSK care. Patients see a Sports Medicine Physician for an MSK consult and treatment recommendations within 6-8 weeks instead of waiting 12-36+ months to see an Orthopaedic Surgeon. Surgeons are now seeing primarily surgical patients and their wait times have declined dramatically.

Respirology

Improving the patient journey for respirology patients. Lack of timely access to care is delaying diagnosis and critical treatment, which for many patients means poorer health outcomes.

Pediatrics - Complete

Worked with the Youth Transition Shared Care team to improve referrals from GPs to specialists.

Rheumatology - Complete

Developed criteria for urgent vs. non-urgent referrals, embedding referral acknowledgment into the Specialists' EMR, developing materials for improving referrals, establishing a rapid access CI.

Orthopaedics - Complete

FPs and SPs worked together to:

  • identify criteria/processes for urgent and non-urgent referrals;
  • develop guidelines for conservative management of non-surgical orthopaedic conditions;
  • make avaiable orthopaedic resources for FPs and patients on our Pathways web site;
  • develop a process for timely acknowledgement of referral requests;
  • implement a pilot project to make an Advanced Practice Physiotherapist available to reduce wait-times for assessment and surgery, and decrease post-surgery recover times.
Psychology/Mental Health - Complete

Worked with Fraser Health partners to:

  • Improve the flow of communication from Mental Health Centres (MHC) to FP offices
  • Improve the quality of referral requests to MHCs from FPs
  • Development of Rapid Access Clinics in New Westminster and the Tri-Cities
  • Roll-out the Integrated Care Model into Fraser Northwest
Advance Care Planning - Complete

An advisory committee comprised of family physicians (FPs), specialists (SPs) from several disciplines, hospitalists, a nurse, a Nurse Practitioner, a social worker, and a Fraser Health and community member crafted a community-based strategy to improve the understanding, take-up and implementation of Advance Care Planning.

Gastroentorology - Complete

Developed process for referral acknowledgmenent, guidelines for determining level of urgency, information to include with referrals, and "red flags, clinical pearls and workups" for specific conditions that are easilty accessible on the Pathways website.

 

Transitions in Care Initiative

Discharge Planning & Communications - complete

The objective of the Fraser Northwest Division discharge planning project is continuity of care, as patients are admitted into the hospital and then discharged back into the community. This can be achieved by focusing the communication stream from community family physicians (FPs) to hospitalist and back to community FP upon patient discharge.