Tools for Transition™ Program

The epidemic of diabetes has increased pressure on specialized services. At the Foustanellas Endocrine and Diabetes Centre (FEDC) of The Ottawa Hospital, there are approximately 20,000 patient visits per year for diabetes and a wait list of approximately six months for routine consultations. Seeing patients in follow-up reduces the capacity for seeing new referrals, and wait lists grow. It is essential to improve the transition of stable patients back to their primary care provider to reduce the log jam in multidisciplinary clinics.

The Tools For Transition™ (TFT™) Program was initiated to develop and evaluate tools to facilitate the transfer of patients with type 2 diabetes from FEDC specialist care back to the care of their primary care physicians (PCP) once diabetes management was optimized.

An extensive needs assessment/environmental scan was completed to gain a thorough understanding of the needs of all stakeholders – PCP, specialist team members and patients. This included PCP surveys and focus groups, a specialist team survey and chart audit. Semi-structured interviews with patients are underway at present. Results of a survey of 177 PCP, focus groups with 22 PCP, a survey of 23 specialist team members and the audit of 199 diabetes clinic charts have been published or presented at national conferences. Based on our work and an extensive review of the literature, a set of 5 tools for transition were developed.

The Tools For Transition™ tool set includes:

  1. A Structured, Customized Discharge Consult Letter
  2. A Rapid Re-entry Process and Rapid Re-entry Form
  3. A Multidisciplinary Diabetes Self-Management Progress Report
  4. A Diabetes Clinic Discharge Note (to the patient)
  5. A 3-month Reminder Post-card

Since July 2010, each tool in the Tools for Transition™ tool set has been progressively implemented as a quality improvement project at the Foustanellas Endocrine and Diabetes Centre as follows:

Tool #1 – Structured, Customized Discharge Consult Letter: The template for this discharge consult letter is being used by the endocrinologists at the Foustanellas Endocrine and Diabetes Centre (FEDC) when dictating letters to Primary Care Physicians (PCP) of patients with type 2 diabetes at discharge. Unique features of this discharge consult letter:

  • It is structured yet customized
  • The side-by-side format for description of current status of each issue and recommended actions to the PCP
  • The point form format
  • The ease of dictation in that the endocrinologist identifies the box to be filled and simply states option number for insertion

This tool was pilot tested in July 2010 and fully implemented in September 2010.

Tool #2 – Rapid Re-entry Process and Rapid Re-entry Form: The Rapid Re-entry Process was implemented simultaneously with Tool #1 and includes 2 options for the PCP should they have a question or concern about a patient with type 2 diabetes they have received back from the FEDC. The 2 options are found at the end of the discharge consult letter. Option #1 is to use the section included in the letter to fax in a question to the specialist. Option #2 addresses the PCP’s wish to have the patient reassessed at the FEDC. The PCP will then use the Rapid Re-entry Form. This form is attached to each discharge consult letter sent to the PCP and it can also be uploaded from The Ottawa Hospital website.

Tool #3 – Multidisciplinary Diabetes Self-Management Progress Report: This report will be completed by the Diabetes Nurse Educator and Diabetes Dietitian Educator involved in the patient’s care and sent to the PCP as an interim report as well as when the patient is discharged from their care. Unique features of this progress report:

  • It is structured yet customized
  • The side-by-side format for description of current status of each self-management component of diabetes care and recommended actions to the PCP
  • The point form format

This tool will be pilot tested starting in April 2011.

Tool #4 – Diabetes Clinic Discharge Note (to the patient): This tool is a structured, customized discharge note completed by the endocrinologist at the patient’s last clinic visit and given to the patient. Patients will be encouraged to bring the note to their PCP to promote ongoing monitoring and follow-up of diabetes. This tool was pilot tested in October 2010 and fully implemented in March 2011.

Tool #5 – A 3-month Reminder Post-card: The 3-month Reminder Post-card is being mailed to patients 3 months post-discharge from the FEDC to remind them of the need to set an appointment with their PCP for follow-up diabetes care as well as what needs to be done to prepare for the appointment. This tool was implemented in December 2010.

Several evaluation projects are either underway or planned to assess the feasibility and effectiveness of the Tools For Transition™ tool set. For example:

  • A study called the ‘Quality and efficiency of dictated discharge letters before and after implementation of a structured template: a quality improvement project’ is currently underway. Discharge letters (30 pre-template and 30 post-template) are being evaluated using the Discharge Letter Audit Form.
  • Data are currently being collected regarding the utilization of the Structured, Customized Discharge Consult Letter and the Rapid Re-entry Process.
  • A study to evaluate the effectiveness of the Tools For Transition™ Program is in the planning phase. We will be working with the Institute for Clinical Evaluative Sciences to collect health utilization data on patients 12 months post discharge as per the TFT™ Health Care Utilization Data form.
  • A chart audit is planned for 18 months post-implementation of the Tools For Transition™ Program to determine the effect on our discharge, defaulting and retention rates of patients with type 2 diabetes.

Download the complete Tools For Transition™ package

Program Initiator and Steering Committee Chair: Dr. TC Ooi

Project Lead: Julie Maranger

Steering Committee Members: Dr. Erin Keely, Dr. Janine Malcolm, Dr. Clare Liddy, Dr. Monica Taljaard, Dr. Nadia Malakieh, Dr. Robert Reid, Sharon Brez, Sheryl Izzi, Kerri Cook

Past members: Dr. Christine Harrison, Dr. Chetna Tailor, Dominique Gendron, Edith Clouthier, Dr. Margo Rowan


TFT™ Program has been funded through unrestricted educational grants from Novo Nordisk Canada Inc., LifeScan Canada Ltd., Merck Frosst Canada Ltd., Schering-Plough Canada Inc. and Merck Frosst/Schering Pharmaceuticals.

We received valuable advice from a panel of Primary Care Physicians consisting of Dr. Caroline Knight, Dr. Judy Chow, Dr. Monica Brewer, Dr. Lisa Rosenkrantz and Dr. David Montoya.

Dr. Jeremy Grimshaw acted as a consultant to the Tools For Transition™ Steering Committee.


For more information on the Tools For Transition™ Program, contact Julie Maranger, Tools for Transition™ Program Coordinator,

Pub Links:

Transition of Patients with Type 2 Diabetes from Specialist to Primary Care: A Survey of Primary Care Physicians on the Usefulness of Tools for Transition

Transition from specialist to primary diabetes care: A qualitative study of perspectives of primary care physicians



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