Ridge Meadows

Keeping Frail Elderly Patients Supported at Home

Prevent avoidable hospital visits by supporting frail seniors through a team-based care support model that delivers support to elderly patients at home. 

Timely Access to Adult Mental Health

Improve referrals, knowledge of services, and communication, and create timely/appropriate access to psychiatric services.  

Hospital Medicine - Complete

Involves GPs, SPs, NPs and home/community partners in developing a collaborative care model for disadvantaged seniors to improve access and awareness of community supports.

Referral Process for Imaging - Complete

Participants (family physicians [FPs], specialists, Health Authority, patients and Medical Office Assistants [MOAs]) identified key challenges to address within referrals to radiology including:

• Congestion within radiology leading to increased wait-times,
• Urgency inappropriately communicated, i.e., too many "urgent" request from FPs,
• FPs not understanding best tests to use,
• Paper system: information technology would help improve referral process, and
• Lack of communication between MOAs and radiology staff.

Acute Care Transitions - Complete

The project will focus on improving patient and provider experience at admission, acute care stay, and discharge. Challenges that have been identified are Family Physician (FP) notification, communication with the ER if referring a patient to the ER, improving forms and flow of information, follow-up care at discharge (appointments, who books, etc). A number of stakeholders are involved in this project including FPs, Hospitalists, ER physicians, MOAs, unit clerks, patients, and health authority representatives.