Doc Talk #122 – Transitions in Care



We talked ‘Transitions in Care’ – an important topic for the province and the subject of a lot of work. Transitions occur whenever a patient’s care switches between providers (such as from a specialist to your family physician) or settings (such as from hospital to a long term care environment), as well as between sectors (such as from the health services to education).

Health care providers because they are so used to working in our system can forget how big a deal these transitions can be for patients: if you have never been hospitalized before, for example, it can be a frightening process, and can change the way that patients feel about themselves and look at their lives.

We provided some tips on how to make sure these transitions go as smoothly as possible:

  • Keep your own records of:
    • medical issues (hospitalizations, surgeries, treatments)
    • names of specialists
    • current list of your medications
  • Maintain a list of key contacts – family or friends that you can rely on if you need to call for help (even things like knowing who will take care of your pets can help reduce stress associated with hospital admissions)
  • Think about advance care planning (we previously did a whole show on this) in case you become very unwell and cannot make decisions for yourself, and make sure your family are aware of your wishes
  • Ask questions relevant to your situation
    • If you are referred to a specialist, ask how long you can expect to wait, how you will hear, whether any other tests are needed in the interim, and what to do if things get worse while you are waiting
  • Bring along a pen/paper and jot down notes during your consultations, or bring along a friend or family member who can help you remember what was said

There are some great projects in progress to help improve transitions in care, including the health portal for patients and the Connect Care project which will create one clinical information system to be used across the whole province , as well as some work by the Primary Care Networks on attaching patients to family physicians and addressing gaps in care.



Image by freestocks ( [CC0], via Wikimedia Commons