Develop/improve communications pathways using a case conferencing model approach for patients in community transitioning between home health or allied health services, family physicians, geriatric psychiatrists, internists, and acute care.
Analyze and identify opportunities for improving ER/specialist (if consulted in ER) communications pathways with community supports (Home Health, FPs, allied health, pharmacy) to optimize the management of changing conditions for complex care patients.
Align work done in case conferencing and ER communications (above) with ALC reduction and discharge planning improvement goal processes currently underway through the KB Area Care Partnership Committee (ACPC). Ensure GP & SP voice is active and present in ACPC process.
Patient consultation has not been a part of work completed to date. In order to ensure baseline data leading to the success of both project improvement goals and to gain a better understanding of the issues from the patient perspective, some form of survey or mapping is needed to gather patient input. In addition a patient or family advocate can be recruited to participate in the committee’s work on an ongoing basis.
Explore ways to improve the response to geriatric psychiatry needs in residential care facilities by expanding case conferencing models to apply to residential care settings.