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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.