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South Okanagan Similkameen

Partners in Care Initiative

Telemedicine

To explore the use of telemedicine for follow-up specialist appointments to improve rural patient access to specialist care, and to support Princeton physicians in providing optimal care. 

Princeton Access to Specialist Care - Complete

Princeton is a small rural community located 115 km west of Penticton. With a population of just over 5000, the community has a three family physicians and a nurse practitioner. Like other isolated communities, the town struggles with doctor recruitment, retention and access to specialists.

In an effort to support family physicians(FPs) and to provide better access for Princeton patients, a Shared Care project was initiated in the Fall of 2013. Penticton specialists started holding outreach clinics in Princeton, eliminating some patient travel and providing family physicians with lunchtime CME learning opportunities.

The first phase of the project is focused on outreach clinics and supporting Princeton physicians. The second phase of the project, to start early in 2015, will focus on efficiencies for patients when they travel to Penticton for appointments and tests.

Palliative — Oncology Improvements - Complete

The palliative care program in Penticton includes many patients who are also undergoing active oncology treatment. Better communication processes among palliative and oncology staff, and family physicians improve patient care and reduce duplication of services. A small working group was established in the Fall of 2012 to identify, develop and implement process improvements.

The group is currently investigating the feasibility of a half-day palliative symptom management clinic staffed by a palliative doctor to develop detailed patient care plans. The goals of the clinic are to improve patient care, increase family physician knowledge around palliative care, and reduce reliance on the emergency department for symptom management.

Advanced Care Planning - Complete

In the South Okanagan Similkameen there is increasing discussion and awareness about the importance of early advanced care planning. Local specialists and family physicians have started to engage around how to increase the number of patients with an advanced care plan, who should take the lead on initiating advanced care planning, and how to share plans among care providers.

Renal Role Clarification - Complete

Clarifying the roles of providers, including GPs, specialists and others at the Renal Clinic. 

 

Transitions in Care Initiative

Vulnerable Frail Elderly Discharge from Emergency 

Multi-disciplinary team co-designing an optimized care pathway for the Emergency Department and back to community for vulnerable frail elderly accessing emergency services.

Acute Exacerbation of COPD Acute Pathway - Complete

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 - Complete

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 - Complete

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 - Complete

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.

 

Acute Exacerbation of COPD Acute Pathway - Complete