Transitions of care for hospital discharges in a primary care network.

Transitions to and from primary care are a time of concern, especially for patients with chronic conditions and complex care needs. The Edmonton Southside Primary Care Network (ESPCN) developed a process for nurses to ensure timely post-discharge follow-up calls and physician appointments after hospitalization, assessing readmission risk with LACE and Clinical Frailty scores. Over 84% of eligible high-risk discharges received follow-up within 14 days.

Connection Through Calls: The Impact of a Seniors Center Without Walls on Older Adults' Social Isolation and Loneliness.

The Edmonton Seniors Centre Without Walls program provides free health, psychosocial, and educational telephone programming for older adults who experience multiple barriers to traditional in-person programming. The aim of this program evaluation was to assess outcomes of participation using validated scales of loneliness and psychosocial and health quality of life. Telephone interviews were conducted pre ( = 160) and post ( = 99) with participants.

A primary care medical home approach to pulmonary rehabilitation.

Background: Pulmonary rehabilitation (PR) is an evidence-based, nonpharmacological intervention aimed to improve quality of life for patients living with Chronic Obstructive Pulmonary Disease (COPD). Unfortunately, in Canada, most PR programs are hospital based and these are few in number; therefore, accessibility to PR programs is limited.

Methods: The Edmonton Southside Primary Care Network implemented an evidence-based PR program within the setting of the patient's medical home.