Facilitating specialist to primary care transfer with tools for transition: a quality of care improvement initiative for patients with type 2 diabetes

Julie Maranger; Janine Malcolm; Clare Liddy; Sheryl Izzi; Sharon Brez; Kerri LaBrecque; Monica Taljaard; Robert Reid; Erin Keely; Teik Chye Ooi

Facilitating specialist to primary care transfer with tools for transition: a quality of care improvement initiative for patients with type 2 diabetes

Healthc Q. 2013;16(1):47-52.

Authors

Julie Maranger¹, Janine Malcolm², Clare Liddy³, Sheryl Izzi⁴, Sharon Brez⁵, Kerri LaBrecque⁶, Monica Taljaard⁷, Robert Reid⁸, Erin Keely⁹, Teik Chye Ooi¹⁰

Affiliations

¹ Tools for Transition program coordinator and a clinical research coordinator, Division of Endocrinology and Metabolism, The Ottawa Hospital (TOH), University of Ottawa, in Ottawa, Ontario. She is also with the Clinical Epidemiology Program and the Foustanellas Endocrine and Diabetes Centre at TOH.
² Director of the Residency Training Program University of Ottawa, Division of Endocrinology and Metabolism, Department of Medicine. She is an endocrinologist with the Foustanellas Endocrine and Diabetes Centre at TOH and a Clinical Investigator of the Chronic Disease Program, Ottawa Hospital Research Institute.
³ Clinical investigator, C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, in Ottawa, Ontario, and is a member of the Department of Family Medicine, University of Ottawa.
⁴ Clinical manager, Foustanellas Endocrine and Diabetes Centre, TOH.
⁵ Advanced practice nurse, Foustanellas Endocrine and Diabetes Centre, TOH.
⁶ Clinical dietitian, Foustanellas Endocrine and Diabetes Centre, TOH.
⁷ Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, and is a member of the Department of Epidemiology and Community Medicine, University of Ottawa.
⁸ Associate director of the Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute.
⁹ Chief, Division of Endocrinology and Metabolism, Department of Medicine. She is an endocrinologist with the Foustanellas Endocrine and Diabetes Centre at TOH and a clinical investigator of the Chronic Disease Program, Ottawa Hospital Research Institute.
¹⁰ Chair, Tools for Transition Program Steering Committee, and study principal investigator. He is director of clinical research, Division of Endocrinology and Metabolism, Department of Medicine. He is an endocrinologist with the Foustanellas Endocrine and Diabetes Centre at TOH and a clinical investigator of the Chronic Disease Program, Ottawa Hospital Research Institute. Dr. Ooi can be reached at 613-738-8400, ext. 81937, or by email at tcooi@toh.on.ca.

PMID: 24863307

Abstract

The epidemic of diabetes has increased pressure on the whole spectrum of the healthcare system including specialist centres. The authors' own specialist centre at The Ottawa Hospital has 20,000 annual visits for diabetes, 80% of which are follow-up visits. Since it is a tertiary facility, managers, administrators and clinicians would like to increase their ability to see newly referred patients and decrease the number of follow-up visits. In order to discharge appropriate diabetes patients, the authors decided it was essential to strengthen the transition process to decrease both the pressure on the centre and the risk for discontinuity of diabetes care after discharge.

MeSH terms

Continuity of Patient Care
Diabetes Mellitus, Type 2 / therapy*
Focus Groups
Health Care Surveys
Humans
Interdisciplinary Communication
Interviews as Topic
Medical Audit
Needs Assessment
Patient Discharge
Patient Transfer
Primary Health Care / standards*
Quality Improvement / standards*
Referral and Consultation / organization & administration*
Self Care