In partnership with the Capital Health Authority and under the auspices of the Health Innovation Fund, the hospital has become a pilot site for the creation and evaluation of a Primary Care Hospital Team (PCHT). This main aim of this endeavour is to improve service delivery to "undesignated" patients.
Patients are considered undesignated if they do not have family doctors, or if their physicians don't have admitting privileges at the Grey Nuns. Previously, undesignated patients were cared for by GNCH internists. This sometimes meant that these physicians were treating more than 40 inpatients at anyone time while consulting to other patients who might present through emergency or in other departments. In addition, it meant that the skill and expertise available through Family Medicine physicians, nurses and other professionals were not always being fully utilized. 'We clearly saw the need for change and the opportunity that came from this challenging environment to make the most effective and optimal use of all the resources available to us," explains Greg Hadubiak, VP. of the Grey Nuns. The new approach to service delivery begins immediately upon admission and even through the Emergency Department. Patients are thoroughly assessed and then assigned to either an internist or to the Primary Care Hospital Team.
In the new service model, the team, consisting of five family physicians and a nurse-coordinator, assumes the role of "primary care provider" for certain patients. Five physicians rotate on a weekly basis with a Clinical Care Coordinator supporting each physician as they work their rotation. The role of the Clinical Care Coordinator is to ensure that the plan of care is maintained and to support patients, families, and her fellow team members. "This collaborative approach to patient care makes the best use of available skill sets," explains Greg. "The commitment of our family physicians and our clinical care coordinator strengthens our ability to respond to the medical needs of our patients and improves their continuity of care."
Continuity of care extends beyond the hospital environment. Upon discharging patients, team members contact and update family physicians and care givers on interventions taken and the plan of care. The team also coordinates outpatient and community services, and even attempts to match patients with community family physicians.
The success of the pilot project will be monitored through satisfaction surveys of patients, family/friends, health care providers and community. Expected outcomes include a streamlining of movement of patients across the health care continuum, and provision of quality round-the-clock patient care. "We have the right mix of people on our PCHT team, all of whom are equally committed to quality care and quality service," says Greg. "I expect this new model to evolve and grow and continue well into the future."
| 
