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Victoria/South Island

Partners in Care Initiative

 
Enabling Streamlined Information Sharing

To improve transfer of longitudinal patient information from GP office to acute care by working with GPs to optimize EMR use; test a process of proactively sending in patient summaries for high risk patients before a hospital admission occurs; and explore the feasibility of fully electronic information transfer in collaboration with Island Health’s efforts to improve community integration.


Improving Connections for “Familiar Faces” in the Royal Jubilee Hospital Emergency Department

Improve continuity and coordination of care by enabling ED physicians, nurses, and social workers to have improved access to information about “familiar faces” patients, and by enabling community primary care providers to contribute more to the information available in the ED and to have an improved ability to take up follow-up care.


Improving Collaboration for Orthopaedic Care

Phase 1 - A FP/SP working group was established to collaborate with the local Orthopaedic group as they developed their interdisciplinary musculoskeletal clinic (RebalanceMD) and a single entry referral - the First Available Appropriate Specialist Triage (FAAST) system. This collaboration aided Rebalance in piloting and spreading the new referral system and development of a standard referral form, in addition to various information materials and processes.  Funding was also provided for 4 separate interactive CME accredited workshops on Acute Conditions of the Knee attended by 133 FPs.

Phase 2 - Specialists, Family Physicians will work collaboratively to enhance the shared care for patients.  The purpose of this ongoing initiative is to continue to improve communication and knowledge transfer processes, and relationships between Orthopaedic Surgeons and Family Physicians for continuity of care and timely access to treatment. Funding also provided for 3 separate interactive CME accredited workshops on Shoulder Pathologies with an anticipated 120 FPs attending.


Neurology Working Group

Identifying improvement opportunities and strategies for solutions to enhance shared care for patients.  Included the distribution of the Neurology Practice Summary Profile to all Division members in November 2013 and support for an interactive CME accredited workshop entitled "Keeping Your Head in the Game". The workshop was designed to provide FP with knowledge to close gaps in care and reduce the demands on SPs.  The 4 hour evening session involved a key note speaker addressing;  "Treatment of Mild Cognitive Impairment"  followed by 4 breakout sessions covering the following topics; (1) Treatment of Early Parkinson's Disease (2) Topical Issues in Epilepsy Management (3) Migraine Management (4) Common Treatable Movement Disorders. A total of 51 FPs attended with very positive feedback provided indicating the presentations had succeeded in addressing the needs of the physician community.

Phase 2 - Specialists, Family Physicians will continue to work collaboratively to enhance the shared care for patients. The purpose of this ongoing initiative is to continue to improve communication and knowledge transfer processes, and relationships between Neurologists and Family Physicians for continuity of care and timely access to treatment.


Plastics Working Group

Develop a process to better inform patients and Family Physicians of challenges related to plastic consults through exploring ways to track wait times and referrals to the various specialty areas. A focus will also be on ways to improve communication between Family Physicians and Plastic Surgeons. The ultimate goal is to provide ongoing quality improvement initiatives and knowledge transfer by providing an open forum and communication platform to all stakeholders along with a shared commitment to ongoing collaboration between FPs and the local Plastics group.


Cardiology Working Group

Develop a transparent process to better inform patients and Family Physicians of challenges related to cardiology consults through exploring ways to track wait times and referrals to the various specialty areas. A focus will also be on ways to improve communication between Family Physicians and Cardiologists. The ultimate goal is to provide ongoing quality improvement initiatives and knowledge transfer by providing an open forum and communication platform to all stakeholders along with a shared commitment to ongoing collaboration between FPs and the local Cardiology group.


Mental Health and Substance Use

To improve access to treatment for patients with mild to moderate MHSU issues by providing clinical MHSA training and a local RACE service for GPs, as well as training/mentorship for GPs to deliver group CBT for local patients. 

 

Transitions in Care Initiative

Phase One Victoria Transitions in Care project - Complete 

Improve transition for patients moving in and out of hospital with greater coordination of care between Hospitalists, GP's and community health services.  E-notification was introduced to inform family physician of patient's admittance to hospital.

The eNotification pilot project was a joint initiative of Island Health and the Victoria and South Island Divisions of Family Practice.  Within one year of the pilot 74% of physicians in the entire Island Health region have access to the service.

Phase Two Victoria Transitions in Care project - Complete

Improve discharge planning and communication between hospital and community physicians transitioning the care of patients.

Phase Three Victoria Transitions in Care project - Complete

Improving patient care continuity across acute-to-community transitions.