Primary Care - Fraser Health

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How do providers and patients benefit?The TIA Clinics provide effective, life-saving assessments, treatment and follow-up for patients. Witheffective assessment of TIAs, measures can be taken to prevent stroke and save lives.• A high level of focused expertise can be applied in a short period of time – within the critical 24/48hour stroke prevention window• The one-signature referral process increases practice efficiency as well as emergency roomefficiency.When and where is this being implemented?• The Clinics opened in February 2009 at Abbotsford Hospital, Royal Columbian Hospital and SurreyMemorial Hospital.• Services will be assessed and refined for a short period of time and then extended beyondemergency departments to practices and physicians in the community.• Any resident living in the heath region may be referred to one of these clinics.Opportunities for GPs to participatePhysician information, education and referral documents will be mailed to practices in the Fraser Healthregion when the services become available. These resources will also be accessible atwww.fraserhealth.ca/healthtopics/strokecare.Additional information and resourcesThe TIA/ Stroke Prevention Clinics are a collaboration between The Province of BC, Fraser Health and theHeart and Stroke Foundation of BC & the Yukon.It is the first initiative stemming from a new Provincial and Regional Stroke Strategy, in which physicians,stroke clinicians, and planners are working together to coordinate and integrate protocols, activities andservices that can prevent disability and death. Their work spans across the continuum, from promotion andprevention, to emergency and acute care, to community rehabilitation, and will result in a number ofinitiatives in the coming year.Stroke Strategy Initiatives in BC and Canada: www.canadianstrokestrategy.caStroke Strategy in the Fraser Health region: www.fraserhealth.ca/strokecareContact informationPhysicians interested in more information about the TIA clinics, or the other Stroke Care initiatives in FraserHealth region and the province, are welcome to contact: Kevin Harrison Kevin.Harrison @fraserhealth.caOr visit: www.fraserhealth.ca/HealthTopics/strokestrategyPC.04.21.09
Shared Comprehensive Care PlanSupporting care planning andcoordination with centralized informationtechnologyPrimary Care teams and patients can customize andcoordinate care more effectively using a secure, web-basedplanning tool that follows the patient wherever they go in thesystem. All health care providers involved can contribute tothe plan and access the same patient information and goals.What is its purpose?The Shared Comprehensive Care Plan – currently being piloted in a number of practices in the region – is agoal-directed, electronic care plan that increases the effectiveness and efficiency of patient care by:• Streamlining patient information flow, making it accessible to all providers as well as the patient.• Integrating the patient as a participating contributor to the plan.• Supporting coordinated, comprehensive care and self-management.• Tracking progress, and providing follow-up and feedback.How does it work?The Most Responsible Provider directs and develops the care plan in partnership with the patient. Additionalapproved providers and clinicians can enter updates and feedback. The patient has access to:• A personalized action plan that tracks prevention and self management goals and progress.• A patient resource library.• Privacy protection and patient consent.The plan does not replace, but augments a practice’s Electronic Medical Record. For providers, it includeshelpful tools including:• Evidence-based care and treatment guidelines at the point of patient care (e.g. BCMA ClinicalPractice Treatment Guidelines, Nursing Standards).• Tools to support care (e.g. printable patient blood pressure or nutrition logs, exercise guidelines,blood sugar targets and instructions).• A resource library (e.g. best practices for performing assessments, BMI charts, education).• Population health information (to track prevalence, incidence, trends etc.).… continued on reverse →PC.04.21.09
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Primary Care - Fraser Health

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