Continuing Care

Continuing Care includes Home Care, Designated Supportive Living (DSL), and Long-Term Care (LTC).

To identify if a patient is connected with Continuing Care, look for an icon at the top of the Storyboard in the shape of a house or an FYI flag – hover to discover to obtain more information. 

Home Care (click to expand/collapse)

Clinical Context: Professional and personal care services provided in the home.

Electronic Health Record (EHR): Connect Care. Home care will utilize ambulatory (outpatient) encounters to document patient visits and interactions. 

Orders for Home Care

The “Home Care Orders Smartset” (ambulatory) and the “Home Care Orders Order Set” (inpatient) include the initial referral to homecare as well as specific Home Care and patient care orders. Prescribers ordering Home Care will be able to identify if the patient is on home care if they see a house icon in the Storyboard.

For more information:

Designated Supportive Living (click to expand/collapse)

Clinical Context: There are various contractors within Alberta that run Designated Supportive Living (DSL) sites. They provide a higher level of personal care supports onsite while promoting the resident’s independence. Health Care Aides are onsite 24 hours a day and professional nursing (LPN) care may be available periodically or 24 hours a day depending on the location.

Electronic Health Record (EHR): Depending on who owns and operates the site, the EHR may or may not be Connect Care. If Connect Care is in use at the site, it may be set up similarly to Home Care (like a clinic) or similarly to Long-Term Care (like a hospital). In both cases, lab, diagnostic imaging and medication orders (as the pharmacy is external/contracted) will be outpatient orders. The Medication Administration Record will be on paper. 

Admission

DSL ordering tools include the “Supportive Living and Long Term Care with Contract Pharmacy Admission” order set, as well as repeating labs and restraint orders designed to align with Continuing Care Health Service Standards. 

Medication Ordering

In DSL facilities with admitted patients (inpatient charts), patient care orders are entered as they would be in any other facility. When a service, test or treatment is not available within the facility, external orders are used since the requested action is to be performed outside of the facility. 

External Pharmacy Services

DSL facilities use external (community) pharmacies for the provisioning of patient medications. Prescribers order and discontinue medications as external orders using a workspace called "External Orders – Community". New medication orders take the form of a prescription. Discontinued medications are explicitly communicated to the pharmacy. The workflow resembles outpatient medication management.

The "External Orders – Community" chart activity supports prescribers when working in facilities with externally contracted pharmacy services. This includes the needed ordering tools for generating, modifying, and faxing external prescriptions.  

When external medication orders are entered, and the ordering prescriber is not physically on site, a nursing communication order will be required to complete the ordering workflow. 

Managing Orders for Supportive Living Patients on Dialysis

If a Long-Term Care or Supportive Living resident requires hemodialysis, peritoneal dialysis, or an Alberta Kidney Care clinic appointment, there is a specific workflow that needs to be followed so that information flows appropriately through Connect Care. This will allow medication orders to work correctly and help to mitigate patient safety concerns. The specific workflow is dependent on whether the facility is on Connect Care, and, if it is, whether the facility has an on-site pharmacy (e.g., CareWest or Capital Care facilities) or uses a contracted/community pharmacy. 

Additional Supportive Living Workflows

Long-Term Care (click to expand/collapse)

Clinical Context: Designated specifically for individuals with complex, unpredictable medical needs who require 24-hour onsite Registered Nurse assessment and/or treatment. 

Electronic Health Record (EHR): Although individuals living in long-term care (LTC) facilities receive "continuing", not "acute", care, from a Connect Care perspective, they are admitted to a "facility". Connect Care will be set up similarly to a hospital with one encounter. Some facilities will have an AHS pharmacy, and some will have an external/contracted pharmacy. 

Admission

LTC ordering tools include the "Long Term Care Admission", “Supportive Living and Long Term Care with Contract Pharmacy Admission”, and "Hospice Admission - Adult" order sets, as well as repeating labs and restraint orders designed to align with Continuing Care Health Service Standards. 

Medication Ordering

The care of patients in LTC facilities generally follows inpatient workflows. Orders are entered as they would be in any other facility. When a service, test or treatment is not available within the LTC facility, external orders may need to be placed because the requested action is to be performed outside of the facility. 

It is important for prescribers working in Connect Care LTC facilities to be aware of whether the facility has an internal pharmacy or, instead, contracts out pharmacy services to an external provider. 

Internal Pharmacy Services

Internal pharmacies use Connect Care for medication information management. Accordingly, medication orders, pharmacy checks, medication dispensing and administration, etc., all occur in-system and are seamlessly integrated. Medication reconciliation dove-tails with admission and discharge activities in the same way as done in any other inpatient facility using Connect Care as the record of care.

External Pharmacy Services

Where an LTC facility uses an external (community) pharmacy for the provisioning of patient medications, prescribers order and discontinue medications as external orders using a workspace called "External Orders – Community". New medication orders take the form of a prescription. Discontinued medications are explicitly communicated to the pharmacy. The workflow resembles outpatient medication management.

The "External Orders – Community" chart activity supports prescribers when working in facilities with externally contracted pharmacy services. This includes the needed ordering tools for generating, modifying, and faxing external prescriptions. 

When external medication orders are entered, and the ordering prescriber is not physically on site, a nursing communication order will be required to complete the ordering workflow. 

Managing Orders for Long-Term Care Patients on Dialysis

If an LTC or Supportive Living resident requires hemodialysis, peritoneal dialysis, or an Alberta Kidney Care clinic appointment, there is a specific workflow that needs to be followed so that information flows appropriately through Connect Care. This will allow medication orders to work correctly and help to mitigate patient safety concerns. The specific workflow is dependent on whether the facility is on Connect Care, and, if it is, whether the facility has an on-site pharmacy (e.g., CareWest or Capital Care facilities) or uses a contracted/community pharmacy. 

Reports

Special Continuing Care reports, including "LTC Resident Annual Physical Needed" and "LTC Resident Pharmacy Medication Review Needed", help prescribers quickly navigate to required tasks. 

Additional LTC Workflows