Improving Continuity of Care: An Innovative Primary Care Role in an Acute Care Hospital

Jana Lait; Janelle Richer; Jana Ambrogiano

doi:10.12927/hcq.2020.26088

Improving Continuity of Care: An Innovative Primary Care Role in an Acute Care Hospital

Healthc Q. 2020 Jan;22(4):22-25. doi: 10.12927/hcq.2020.26088.

Authors

Jana Lait¹, Janelle Richer², Jana Ambrogiano³

Affiliations

¹ A senior advisor in Primary Care, Calgary Zone, Alberta Health Services. She is also a faculty member at Mount Royal University. She can be contacted by e-mail at jana.lait@ahs.ca.
² The former primary care manager at Mosaic Primary Care Network in Calgary, AB.
³ The former executive director of the Peter Lougheed Centre, Alberta Health Services, Calgary, AB. She is now the senior operating officer at Rockyview General Hospital, Alberta Health Services, Calgary, AB.

PMID: 32073387
DOI: 10.12927/hcq.2020.26088

Abstract

This article describes an innovative organization-spanning collaboration between primary care and acute care in Calgary to support continuity of care for patients with complex needs. Mosaic Primary Care Network provides funding for a primary care navigation nurse to work at the Peter Lougheed Centre, an Alberta Health Services hospital. This role supports hospital in-patients with discharge planning, linking to family physicians and connecting to programs that provide support in the community to vulnerable populations. The commitment of leadership from both organizations was critical for getting this unique role implemented.

MeSH terms

Alberta
Continuity of Patient Care / organization & administration*
Humans
Patient Discharge
Patient Navigation / organization & administration*
Primary Care Nursing*
Primary Health Care
Social Welfare
Tertiary Care Centers / standards
Vulnerable Populations