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 goals of Thinkcatalyst:

- improve continuity and access to resources for discharged acute care patients (eg. those lacking primary care)

- create and implement technology to improve patient access to specialist care, primary care, and social services resources

- support the monitoring and treatment of chronic diseases and the prompt community based treatment of acute exacerbations

- resource map and navigate existing resources-  health & social resources

- develop an ongoing evaluation framework for existing publicly funded programs

Acute Care Transition- workflow

patient discharged from acute care- ER, ward, ICU

patient referred at discharge via secured messaging to a thinkcatalyst Acute Care Transition clinic.

-message containing patient information, clinical course information ...

- designed for initial assessment of recently discharged patients.  Many (60-70%) are discharged within 2 weeks.

phase #1

resource mapping

 

needing primary care +/- social resources

existing primary care

- designed for patients requiring longer term follow-up (3-6 months).  Alternatively, they could be added long term into one of the disease specific chronic disease clinics.

phase #2

resource mapping

 

needing primary care +/- social resources

from ACT or community

unattached patient

- patients / clients undergo a process of "tagging" and attribute  allocation

- these tags are then compared to a database of available resources eg. family physician's doing obstetrics, geriatrics, naloxone Rx, adolescent mental health, domestic violence etc.

- patients / clients are then added to nearby resources with availability.

A(12)d-f-125C-09p-6t

appropriate / available primary care

for primary medical issues

Auxillium

for primary social issues