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Communicate with Patient/Family
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Communicating with the patient to examine the patient’s condition, share information, educate, and to develop a common understanding or plan.
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• Patient visits with family physician.
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• Home and Community Care nurse home visit with patient and family.
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• Phone conversation from patient’s daughter with the on call family physician.
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• Medication reconciliation by a pharmacist or nurse.
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Request Historical Information (PMHx)1
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• Seeking additional information from a particular provider, care team, or organization.
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• Specialist requests previous blood work from family physician.
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• Hospice requests previous consult letters from Cancer Centre.
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Provide Information
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Ensuring other providers are aware of current findings and plans by sending information directly to named members of the Circle of Care.
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• Follow up letter to family physician from Oncologist on change in chemotherapy.
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• ER Physician note to GP after patient is seen in the Emergency.
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• Home and Community Care Case Manager fax to the family physician to describe care plan.
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Document in Shared Record(s)
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Documenting findings/plans in a location that is accessible to others (who have access).
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• Neurologist documenting in hospital chart.
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• Family physician documenting in Mr. Hart’s long-term care paper chart.
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• Laboratory placing a result into Hospital Information System.
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Review Shared Record
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Review information shared by other members of the Circle of Care to increase knowledge of patient’s condition.
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• Family physician reviews long-term care paper record when rounding on patients.
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• ER Physician reviews hospital information system prior to seeing patient in the ER.
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• Oncologist reviews cancer records (electronic and paper) prior to follow up visit.
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• Pharmacist reviews medication-dispensing history.
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Request Advice
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Request information and advice about options related to a patient case.
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• Call to palliative care hotline to discuss medication options and conversion doses.
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• Call to see what services might be available for particular type of patient.
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• Discuss with radiologist what test is most appropriate for assessing symptom in a patient without disclosing patient name.
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Request Assessment/Treatment
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Contact another provider to request an action to assess and/or provide treatment recommendations to a patient based on their assessment.
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• Family physician consults geriatrics for patient in nursing home to assess behavioural issues.
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• Home and Community Care nurse sends referral to physiotherapy and occupational therapist to assess home safety.
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• ER Physician calls neurology to assess stroke patient.
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Order
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Request specific activity be delegated to / performed by another provider
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• Medication prescription from MD to pharmacist.
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• Home and Community Care nurse delegated medication administration to Community Support Worker.
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• Advance directive from patient.
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Transfer Care
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Handing off care responsibilities between care providers of a similar capability.
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• Nurse handover at shift change.
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• Family physician to family physician transfer when on call.
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• ER physician transfer to family physician admission in hospital once patient is stabilized.
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Coordinate as Care Team (i.e. all or part of the Circle of Care)
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To review, in real time with more than two individuals, the status and plans for the patient from multiple viewpoints.
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• Long-term care case conference.
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• Breast cancer Oncology Rounds.
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• Palliative Care Rounds.
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• Ad hoc meetings between family physician, Home and Community Care nurse and family to discuss patient care or patient prognosis.
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