Improving Transition of Care from Endocrine to Primary Practice: Discharge Planning Documents
The Endocrine Quality Improvement (QI) Committee, through the University of Toronto (UofT), has created a series of documents aimed at improving the patient care journey when transitioning from specialty to primary care.
The Committee selected 12 common endocrine conditions that were felt would benefit from a standardized discharge process:
- Adrenal Adenoma
- Pituitary Microadenoma
- T2 Diabetes
- Osteoporosis
- Low Risk Differentiated Thyroid Cancer
- Graves’ Disease
- Post-Thyroiditis
- Thyroid Nodules
- Polycystic Ovarian Syndrome (PCOS)
- Transgender Medicine
- Male Hypogonadism
- Primary Hyperparathyroidism
Our Creation Process
The Endocrine QI committee included endocrinologists practicing at both UofT-affiliated academic hospitals and community sites across the Greater Toronto Area. Contributing members included: Julie Gilmour, Karen Gomez, Ilana Halperin, Jackie James, Diana Jaskolka, Geetha Mukerji, Judy Qiang, Sharon Sadry, Phil Segal, Vithika Sivabalasundaram, & Pam Tsao.
After creation, the documents were reviewed by topic experts and our partners in primary care. The patient information letters received Plain Language Review at St. Michael’s Hospital. See figure below for a summary of our review process.
The Committee then created a series of three documents for each condition:
- Discharge criteria
- A templated letter to communicate discharge instructions with the patients Primary Care Provider
- A standardized patient information letter with discharge care instructions
The Committee would like to highlight that these documents SHOULD NOT be used if:
- The patient does not have a primary care provider to assume care
- The patient does not have the health literacy to ensure the follow-up plan is enacted
Future directions:
- Diverse language translation (the documents are currently only available in English)
- Feedback from practitioners and patients that have used these documents