Victoria Division of Family Practice

Transitions in Care

The Transitions in Care initiative has its roots in the need to improve communications between acute and community care settings. We began in 2013 by developing our eNotification system in collaboration with Island Health, which provides automated notifications via physicians’ office EMRs. 

Ongoing work has included strengthening relationships with emergency department physicians, hospitalists, and specialists as well as continuing to build on our foundation with Island Health in order to develop new systems that enable communication. This work has included piloting methods of transferring information to and from the hospital on admission and prior to discharge so that community GPs can contribute to planning and follow-through instead of reacting after discharge occurs, most notably our Patient Summaries Project. Our patient summaries work was featured in the inaugural issue of the JCC Magazine, along with many other stand-out quality improvement projects in the province. Read it here.  

For example, we have collaborated with Island Health on their EMR Connect project. Read in the July EMR Update how it enabled excellent care for a 89-year-old woman living alone who was seen in the ER after a fall, and view the latest additions to the EMR.

Most recently our Familiar Faces project moved into a new cycle that will continue our work on care plans, including a specific focus on pediatric psychiatric patients, and education around trauma-informed care. We also initiated a Long-term Care Transitions project aimed at improving communication between long-term care facilities and acute care.

Your colleagues in the ED have collaborated with community GPs in the Transitions in Care project to develop a series of tips and tricks that will help you make better referrals to emergency care. Visit our Tips and Tricks page to view these helpful reminders.

The Transitions in Care project is funded by the Shared Care Committee, and is a joint initiative of the Victoria and South Island Divisions of Family Practice. Our sister committee, Partners in Care is operationally led by the South Island Division of Family Practice.  More information can be found on their website.