title: Facilitating specialist to primary care transfer with tools for transition: a quality of care improvement initiative for patients with type 2 diabetes.
abstract: The epidemic of diabetes has increased pressure on the whole spectrum of the healthcare system including specialist centres. The authors' own specialist centre at The Ottawa Hospital has 20,000 annual visits for diabetes, 80% of which are follow-up visits. Since it is a tertiary facility, managers, administrators and clinicians would like to increase their ability to see newly referred patients and decrease the number of follow-up visits. In order to discharge appropriate diabetes patients, the authors decided it was essential to strengthen the transition process to decrease both the pressure on the centre and the risk for discontinuity of diabetes care after discharge.
authors.affiliation: Tools for Transition program coordinator and a clinical research coordinator, Division of Endocrinology and Metabolism, The Ottawa Hospital (TOH), University of Ottawa, in Ottawa, Ontario. She is also with the Clinical Epidemiology Program and the Foustanellas Endocrine and Diabetes Centre at TOH.
authors.forename: Julie
authors.initials: J
authors.lastname: Maranger
authors.affiliation: Director of the Residency Training Program University of Ottawa, Division of Endocrinology and Metabolism, Department of Medicine. She is an endocrinologist with the Foustanellas Endocrine and Diabetes Centre at TOH and a Clinical Investigator of the Chronic Disease Program, Ottawa Hospital Research Institute.
authors.forename: Janine
authors.initials: J
authors.lastname: Malcolm
authors.affiliation: Clinical investigator, C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, in Ottawa, Ontario, and is a member of the Department of Family Medicine, University of Ottawa.
authors.forename: Clare
authors.initials: C
authors.lastname: Liddy
authors.affiliation: Clinical manager, Foustanellas Endocrine and Diabetes Centre, TOH.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Izzi
authors.affiliation: Advanced practice nurse, Foustanellas Endocrine and Diabetes Centre, TOH.
authors.forename: Sharon
authors.initials: S
authors.lastname: Brez
authors.affiliation: Clinical dietitian, Foustanellas Endocrine and Diabetes Centre, TOH.
authors.forename: Kerri
authors.initials: K
authors.lastname: LaBrecque
authors.affiliation: Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, and is a member of the Department of Epidemiology and Community Medicine, University of Ottawa.
authors.forename: Monica
authors.initials: M
authors.lastname: Taljaard
authors.affiliation: Associate director of the Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute.
authors.forename: Robert
authors.initials: R
authors.lastname: Reid
authors.affiliation: Chief, Division of Endocrinology and Metabolism, Department of Medicine. She is an endocrinologist with the Foustanellas Endocrine and Diabetes Centre at TOH and a clinical investigator of the Chronic Disease Program, Ottawa Hospital Research Institute.
authors.forename: Erin
authors.initials: E
authors.lastname: Keely
authors.affiliation: Chair, Tools for Transition Program Steering Committee, and study principal investigator. He is director of clinical research, Division of Endocrinology and Metabolism, Department of Medicine. He is an endocrinologist with the Foustanellas Endocrine and Diabetes Centre at TOH and a clinical investigator of the Chronic Disease Program, Ottawa Hospital Research Institute. Dr. Ooi can be reached at 613-738-8400, ext. 81937, or by email at tcooi@toh.on.ca.
authors.forename: Teik Chye
authors.initials: TC
authors.lastname: Ooi
mesh_terms: D003266:Continuity of Patient Care; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D017144:Focus Groups; D019538:Health Care Surveys; D006801:Humans; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D008485:Medical Audit; D020380:Needs Assessment; D010351:Patient Discharge; D010360:Patient Transfer; D011320:Primary Health Care / Q000592:standards*; D058996:Quality Improvement / Q000592:standards*; D012017:Referral and Consultation / Q000458:organization & administration*; D012648:Self Care