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Kootenay Boundary

Partners in Care Initiative

Supporting Patients Through the Common Language of the Social Determinants of Health

Increase poverty and trauma informed care practices amongst GPs and SPs. Priority populations include complex older adults including those with mental health and substance use disorders, and the mother-child dyad.


Implementing Interdisciplinary Chronic Pain Care in a Rural Region
  • Develop a model description and business plan of sustainable, interdisciplinary chronic pain care leveraging a combination of Fee-For-Service Medicine, Private Pay and IHA revenues.
  • Implement an interdisciplinary model of co-located chronic pain care, composed of GP Specialists and allied health providers, in two sites in Kootenay Boundary by March 2019;
  • Integrate chronic pain management practices into new PMH/PCN Teams anticipated to roll-out in Kootenay Boundary in the Fall of 2018, focused on spread of a  KB Chronic Pain Roadmap based on an electronic version of the Powell River tool

Regional Palliative Care Project

Build a culture of team-based community Palliative Care, including the pillars of GPs, IH Services, Community Services (e.g. Hospice Societies), and family, with an emphasis on communication practices between all parties. Support the work of community hospice organizations to advance the concept of compassionate communities in KB, and foster meaningful dialogue to help shift the way the medical institution orients itself around palliative care. Introduce/deliver a Palliative Approach component to Chronic Disease Mgt., esp. in concert with Internal Medicine in KBRH & KLH, but also with Community GPs and disease focused clinics, e.g., Heart Failure Clinic, Chronic Kidney Disease, COPD.


Emergency Medicine Network

Establish a Kootenay Boundary Emergency Medicine Network involving all ED teams to collaboratively provide continuous quality improvement for emergency care for patients. The network will support skill development in rural sites for quality patient care, improve response time and action across sites for transport, improve and support rural and remote on-site capacity for care, streamline processes, and improve communications and relationships between ED teams and with regional and tertiary services.


Microblogging MD - RACE

With new interest in RACE across Interior communities and Interior Health's support to spread Microblogging MD (secure messaging) there is an opporutnity to create an Interior-wide RACE program integrated into MBMD. 


Interior EASE

Provide opportunity for timely advice and consultations between GPs and specialists.


Telemedicine - Complete

This project seeks to address two main challenges experienced by patients and providers in the KB region:

  1. Patient access to wraparound care and specialist services, and
  2. patient-provider and provider to provider communication. 

Perinatal Mental Health - Complete

A coordinated multi-sector reproductive mental health network in the KB region will ensure engagement and improve timely access to critical supports for new mothers suffering from intra- and post-partum anxiety and depression.


Orthopedics - Complete

This project focuses on orthopedics and includes family physicians, orthopedic surgeons and IHA administration locally and health authority-wide. The group met to identify and explore issues impacting patient care with a particular focus on the different components of wait times, including referral wait times, radiology wait times, visible OR wait times, and OR booking and scheduling issues. With particular attention to the referral process as a realistic area for change, the Orthopedics Project focused on the implementation of:

  • Referral acknowledgement by orthopedic surgeons.
  • Cast Clinic Referral Form to streamline referrals
  • "Standard Views" for referrals to orthopedics.
  • Orthopedics to GP Transfer Care Form for transfer of care between hospitals.

Psychiatry/RACE - Complete
  • To undertake a rural expansion of Providence Health's Rapid Access to Consultative Expertise (RACE) line piloted with Nelson physicians and Trail/Nelson Psychiatrists.
  • To facilitate uptake in collaborative care lunches to physicians in communities; to work with communities that do not have collaborative care lunches in place to develop the opportunity.
  • Provide regular multi-disciplinary team-based continuing medical education on mental health topics.

Read more about psychiatry here, and RACE here


Diabetes - Complete

A Regional Diabetes Committee including SPs, GPs, IH, Diabetes Educators and patients are working to address challenges of geography, improve relationships between members of multidisciplinary teams, and explore new approaches to care. An enhanced multidisciplinary CME event is being planned for the Fall/2014. 


Radiology - Complete

In 2012, three engagement meetings in Trail and Nelson identified a number of areas for improvement of patient care physician experience in the specialty of radiology. These included;

  • Variability and standardization of reporting and GP education
  • Collaboration between SPs and GPs across the region
  • Complete and accurate referrals, directories of interventionist procedures, booking procedures, and information on MRI wait times.

The objectives of the project centred on optimizing patient referral through partnering with IH to update direcctories of interventionist procedures and adopt diagnostic and imaging referral guidelines and (2) scheduling ongoing Continue Medical Education (SME) to focus on radiology issues and increase collaboration between GP and SPs. 


General Surgery - Complete

Develop local directory.

 

Transitions in Care Initiative

Frail Seniors

Improve the ER relationship with family physicians and community supports to provide early notification of frequent ER use by frail senior patients; Develop a communications pathway between ER / CIHS / FP / SP for patient care planning; review current ER process to evaluate and improve interactions with frail senior patients. Read more

Maternity/Child

This project aims to make an in-clinic telehealth system available region-wide for use in shared consultations across all members of the patient's care team (family physicians, midwife, specialist, GP-OB, public health nursing) that is easy to use, cost effective and secure. Read more Read more

Cardiac Care

Hospitalists, ER physicians and Family Physicians (the providers) and IH administration will work collaboratively to improve shared care for cardiac patients. The project will be in a multiphase approach and follow quality improvement methodology including:

  1. Problem identification
  2. Solution generation
  3. Experimentation
  4. Refinement
  5. Spread

Read more