Transitions in Care Initiative

Frail Seniors

Improve the ER relationship with family physicians and community supports to provide early notification of frequent ER use by frail senior patients; Develop a communications pathway between ER / CIHS / FP / SP for patient care planning; review current ER process to evaluate and improve interactions with frail senior patients. Read more


This project aims to make an in-clinic telehealth system available region-wide for use in shared consultations across all members of the patient’s care team (family physicians, midwife, specialist, GP-OB, public health nursing) that is easy to use, cost effective and secure. Read more Read more

Cardiac Care

Hospitalists, ER physicians and Family Physicians (the providers) and IH administration will work collaboratively to improve shared care for cardiac patients. The project will be in a multiphase approach and follow quality improvement methodology including:

  1. Problem identification
  2. Solution generation
  3. Experimentation
  4. Refinement
  5. Spread

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