Partners in Care Initiative

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.