Connected Care Collaborative – Improving Patient Journeys and Transitions

“Transitions in care” is when a patient is moving through the health care system to another phase in their care – such as when they leave acute care and move to home health, to their primary care provider, go home or go to rehabilitation, etc.,

We have found that there is not enough patient and family involvement in care planning which results in unclear care pathways, fragmented care and communication, and confusion for patients and support persons.

These issues negatively impact patient experience as well as staff experience, compromise health outcomes and make the system less efficient.
Poorly coordinated transitions – particularly between acute, community and primary care – are associated with increased readmissions, adverse events, and delayed follow-up. The lack of standardized care planning and documentation practices places additional burden on healthcare providers, contributing to burnout and stress and reducing the capacity for value-based care delivery.

Aim
By April 2027 Patients and Families are active participants in their care and discharge planning. Each Geo area team will have their own Aim statement that will help achieve the Collaborative Aim.

Logistics
Patient public partners will provide feedback on quality improvement work, will sit in meetings with leaders and provide input and information around the patient’s viewpoint, review documents, brainstorm, review data, problem solve and collaborate throughout the improvement process.

IH will be broken up into the 6 geographical areas for the purposes of this project. With each geo area having a designated working group. Each working group will partake in the collaborative. This work is expected to last 1 years.

For this work we would like 2 patient partners from each of the geographical IH areas (see map for reference).

The length of time is likely 1 year with on average a monthly commitment to meeting with the working group. The majority of work will be performed virtually with potential for in-person meetings (with advance notice).

The team would like partners who have either received care themselves or those who have had a loved-one who has received care. However, other healthcare experiences may be considered.

No prior career or work in healthcare is required.

Level of Engagement

This opportunity is at the level of Collaborate on the IAP2 Spectrum of Public Participation.

Eligibility

• Willing & comfortable to share health care experiences in a group setting
• Comfort with public speaking
• Specific health care experiences [details below]
• Have access to technology and the internet to participate in the engagement opportunity
• Comfortable using technology to attend online/virtual meetings
• An interest in improving health care services
• The time to participate in the engagement opportunity
• We would love patients/families with experience in acute care. However, other healthcare system experience will be considered. No prior career or work experience or medical expertise is needed for this work.

Patient Partners ARE NOT required to be PVN members to participate in this engagement opportunity.

Health Care Partner Contact Information

Justine Wayne Improvement Consultant, IH Quality Improvement North | Interior Health (778) 362-6810 justine.wayne@interiorhealth.ca