Building on Alberta’s success to date with integration and learning from Albertans with lived experiences, the Primary Health Care Integration Network is focused on three clinical focus areas for 2018-21:
In order to improve in the three clinical areas, we need to create the conditions for the system to work effectively. That is why we have an additional area of focus:
These areas were chosen after consultation with our partners to identify where the Primary Health Care Integration Network could best position our support to be the catalyst for change.
Our Scientific Office embeds scientific rigor into our four areas of focus through collaborative evidence-based identification of issues, development and implementation of innovative solutions, and evaluation of impact.
For integration to accelerate across Alberta, we need to create a strong foundation – which enables us to be successful in the other three areas of focus (Keeping Care in the Community, Linking to Specialists and Back, and Transitioning from Home to Hospital to Home). The foundations work will help give providers a system that supports and compliments their efforts to improve patient experiences. The network has identified the following four pillars of focus as we advance this work:
Keeping care in the community simply means considering the community a person lives in and the supports available in that community while planning care. Alberta Health Services understands this imperative and has committed to a long-term strategy of Enhancing Care in the Community.
The Primary Health Care Integration Network is a key resource to facilitate collaboration between Alberta Health Services, primary care and other community stakeholders to ensure Albertans receive the personalized care and supports that will help them better manage their health in their own community, right where they live, work and play.
There is a growing gap between specialty care capacity and the needs and expectations of the public. Long specialty wait times contribute to issues such as increased stress levels, worsening conditions and avoidable trips to the hospital. It also impacts access to primary care services and limits availability of emergency and hospital services.
Access is more than just getting in to see someone for an appointment – it includes sound information and management continuity as well as eliminating the need to see a specialist. That can be achieved by offering advice from doctor to doctor, using other health providers or finding ways to help people to manage their conditions.
Patients sometimes need to go to the hospital. As they transition from their medical home or family doctor to the hospital and back to home again, there needs to be a transfer of support and information that transitions alongside them.
Alberta Health, Provincial and Zone Primary Care Network Committees, and the Alberta Health Services Board have all identified hospital to home transitions as a top priority for health system improvement. Poor transitions have a negative impact on patients and families, put patients at greater risk of poor health outcomes, increase the likelihood of avoidable emergency department and hospital use, and are a source of frustration for healthcare providers.
Ensuring a person’s primary care team is part of the care management and planning from admission to discharge is part of a system where patients are supported by effective “hand-offs” from one care provider to the next.
For more information visit Home to Hospital to Home Transitions