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Partners in Care Initiative

Focusing on strengthening relationships between Family Physicians (FPs) and Specialists to improve collaborative patient care, Nanaimo physicans are working together in the following areas :

Management of Dementia Patients in Long Term Care
  • Improve and standardize referral processes for geriatric psychiatry for patients living in residential care facilities
  • Develop and pilot a facility team-based care approach with MRPs and facility staff focused on behavioural management of residents living with dementia
  • Improve communication between facility staff, MRPs and Geriatric Psychiatrists
Emergency Room Medicine

FPs and Emergency Room Physicians (ERPs) working to streamline referral, consult and discharge processes, shared care planning, communications, telephone advice protocols, and more.

Mental Health

Seamless communication, collaboration and shared care between FPs and adult and senior mental health services, incorporating substance use within the continuum of care. The group hopes to achieve this through;

  • Improving personal relationships between FPs and Psychiatry Services
  • Making it easier for FPs to understand services available and make referrals
  • Improving quality of referrals
  • Improving awareness, availability and access to resources for patients
Internal Medicine

FPs and Internal Medicine Specialists are collaborating to establish open avenues of communication.

Wound Care

Improving care coordination and access to specialist consults for patients with chronic wounds. 

Cognitive Behavioural Therapy (CBT) Group Visit Model

Implementing CBT Group Medical Visit Model in Nanaimo to increase access to care for patients with mild to moderate anxiety and depression.


Transitions in Care Initiative

Internal Medicine

Family physicians (FPs) and Internal Medicine Specialists (SP) are collaborating to establish open avenues of communication through the following projects

  1. The community completed a comprehensive patient journey mapping activity and engaged multiple stakeholders in identifying patient transition issues. New processes are being tested to bridge local gaps:
  • a patient/family information booklet has been developed to provide all the information needed during an acute care stay and to help better organize discharge arrangements and FP follow-up.
  • an expanded discharge summary that incorporates discharge advice provided by allied health professionals, to further inform a patient's FP.
  • Embedding clarifying steps between FP-Specialist communications: referral acknowledgement, patient appointment confirmation, steps to reduce duplication of investigations and inviting FP-SP collaborative care planning.
Focus on Seniors

This project aims to address the various challenges faced by seniors transitioning into, through, and out of acute care. The transition for seniors from acute care into Residential Care has been identified as our community's first priority.