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 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 FPs 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 2020 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.

We recently wrapped up the Familiar Faces project. Extensive work was done connecting FPs and ER physicians through the creation of patient care plans for high-volume users of local emergency services. This innovative initiative helped fill a significant patient care gap by connecting family physicians to their patient’s acute care experiences. As well, our efforts resulted in the transition of pediatric psychiatric patient notes into an electronic format for timely access by ER clinicians.

Working together with Island Health, a newly created Long-term Care Directory is almost ready to launch. The directory will be housed on Island Health’s Intranet site enabling ER physicians and nurses to determine if their patient’s residence will be able to support their transition back home.

In 2020, TiC received Coordinating Complex Care project funding through Shared Care to bring together heart failure specialists, family physicians, patients, caregivers, nurses, Home Health Monitoring, and Island Health IMIT. Stakeholder engagement efforts focused on improving transitions and follow-up care for heart failure patients alongside the newly created Heart Failure Unit at Royal Jubilee Hospital. Most notable is the work to ensure clear information on medication reconciliation is shared between acute care and community physicians.

Your colleagues in the ED have collaborated with community FPs 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.

(updated November 2022)