Patients who have multiple chronic conditions, requirements for mental health care and/or are vulnerable because of social determinants of health are often considered to have complex health care needs.  These patients require services from various health systems and community networks.  Often, these patients have unmet healthcare needs and may try to access different services in an uncoordinated manner that is unsuccessful for them and expensive for the health care system.  Case management (CM) is the most promising intervention to improve care integration and reduce uncoordinated use of the system.  The goal of this research is to understand what works when using CM in primary care, for which people, under what circumstances and in what ways.  This will be shared with policy makers, clinicians, patients/families, researchers, and other primary care stakeholders to improve care.

The conditions of living in poverty lead people to experience increased sickness, disability, and negative health outcomes compared to those who are wealthy. Since poverty has such a strong effect on people’s health, it is important to collect information about it in “primary care settings”—these include hospitals, doctor’s offices, and community health centres. We are conducting a study to help doctors and other healthcare providers collect information on poverty and other social factors that impact peoples’ health (including: gender, race, sexual orientation and housing). This information will be collected through a short questionnaire that will be offered while patients wait for their medical appointment. This data will be connected to patients’ Electronic Medical Record (EMR) and will be used to link patients to services that may help them with low incomes and other social factors affecting their health. This data can also help staff in primary care settings and policymakers improve resource allocation, to help lessen preventable differences in health outcomes for patient populations.

The Structured Process Informed by Data, Evidence and Research (SPIDER) project focuses on older patients taking many medications.  Taking multiple medications (also called polypharmacy) often means more side effects and this gets worse as people age.  Older adults are at a higher risk of side effects like confusion, dizziness and falls.  SPIDER will help family doctors and their teams deliver better care by reviewing and reducing the use of riskier drugs for selected patients in their practice.  SPIDER will improve care for older adults in our communities by reducing and improving their medication use, supporting their health and helping them reach their goals for quality of life.  It may also save the health care system money by reducing the number of times people are admitted to hospital.  SPIDER is being conducted in 5 provinces and is led by a team of pharmacists, family doctors, patients and researchers.

Led by BRIC NS member Dr. Grace Warner and partnered with PEI. The project focuses on understanding and supporting the complex needs of patients and their family caregivers who are dealing with multiple chronic conditions and/or life limiting illnesses. The project will synthesize the evidence for what community-based resources are critical in the last year of life for patients and their family caregivers, how a case management approach can improve the integration of these resources into innovative community-based palliative care models, and the challenges different practice settings face when trying to use a case management approach. The project will engage individuals who deliver and receive community-based palliative care to get their perspectives on what literature should be synthesize to ensure the final product addresses their needs. The final product will provide a report on findings along with recommendations for enhancing the implementation of innovative community-based palliative care models that address the complex needs of patients and family caregivers in the last year of life into bereavement.

A common reason for frequent use of health care services is the complex health care needs of individuals suffering from multiple chronic conditions, often together with mental health comorbidities and/or social vulnerability. Individuals with such complex health care needs require a variety of services across the health and social services system and community networks. This often leads to difficulties in the integration of care. Frequent users of health care services are more at risk for incapacity, loss of quality of life and mortality. Currently it would appear case management is the most promising intervention to improve care integration for Frequent Users and reduce health care costs. However, important gaps in knowledge remain: we don’t know how case management works, in what populations, and in what circumstances. Our overarching goal is to ensure that patients, practitioners and policy makers better understand case management for Frequent Users with chronic conditions, the most promising effective intervention to improve outcomes for this population with complex care needs in primary care. In order to achieve this goal, we propose to explain how case management in primary care works to improve outcomes among Frequent Users with chronic conditions, for whom, and in what circumstances.

Canadians are living longer, however, many older Canadians do not experience good health and well-being as they age. Older adults are at a high risk of having multiple chronic conditions (MCC), otherwise known as multimorbidity. Many older adults with MCC live with complex health issues that adversely affect their day-to-day functioning and overall well-being. As a result, they rely on the support of caregivers to complete daily activities. Caregiving for older adults, without the appropriate help, can negatively affect an individual’s financial and emotional well-being. Currently, not enough is known about how best to identify, understand and meet the needs of older adults with MCC, or the needs of their family caregivers. This study will contribute to minimizing the existing gap in knowledge. The project will provide much needed evidence to support current efforts to improve the Canadian healthcare system and ensure that older adults with MCC, and their caregivers, receive appropriate, equitable and cost-effective health and social care. The project team is comprised of patients, their family members, researchers, healthcare providers and policy and health system administrator decision makers, from Nova Scotia, Ontario, Québec and Saskatchewan. The research will offer an overview of the existing evidence on the health and social care needs of older adults with MCC and their caregivers, as well as evidence about how best to determine and understand these needs. Findings from the work will directly support the development and implementation of Primary & Integrated Health Care Innovations (PIHCI) tailored to meet the needs of diverse individual, and groups of, older Canadians. We take a collaborative and participatory approach to research. We aim to contribute to building a strong evidence base to support a new culture of person-centred, functioning-focused care that adds “health to years” for current and future generations of older Canadians.

Led by BRIC NS member Dr. Alix Carter and partnered with BC. This project is a comparative analysis of two provinces, one with and one without the paramedics providing palliative care at home program, as it represents programmatic innovation in health care delivery. British Columbia will serve as the comparison province without a comparable program. This cross-provincial comparison has the primary objective to examine whether the Program is associated with the ability of people to stay in the community longer during the end of life, satisfying patient/family needs and using fewer hospital resources. The project also includes a formal assessment of potential to scale to a system level.

Children and youth and older adults with serious chronic conditions and with limited or diminishing capacity to look after themselves independently often need their primary care providers to connect them to social services, public health services and community supports. These can be services such as home care, housekeeping, education aids, income assistance, legal services and respite care. Failure to connect to needed services leads to negative experiences for patients, caregivers and health professionals alike; it also leads to poor health outcomes and health system inefficiencies. The goal of this research is to help future development of models of care that connect smoothly across health, social and community services. We will study the policies and governing structures that restrict or allow connections in different provinces and territories. Then we will identify examples of successful and unsuccessful programs that were designed to connect services so we can learn from best practices and failures. We specifically focus on what hinders information sharing across services, again looking for examples of where information flow and linkage works. Better data linkage across multiple services is good for patient care, but it will also help researchers who want to study what happens to patients. Results from the study will help various teams who are currently planning to design and study these integrated service delivery models. We believe that the findings will also be relevant to other populations with complex needs like people with mental health and substance abuse issues.

Health care provided to the dying can help improve the quality of remaining life. A large proportion of dying Canadians, unfortunately, do not get optimal end-of-life care. Part of the challenge is the difficulty of identifying where people are in their death trajectory. We are currently creating tools to map out this trajectory for people in the community, using data collected for those who are requesting home care or long-term care. In this grant, we propose to pilot these tools on case managers who are doing the assessments, and also on patients and their caregivers. Our tools will provide a report on how close patients are to death (a range, predicted based on previous observations), and will provide a link to resources (e.g., advance care planning tools and available community supports) that will help their journey. Following our pilot, we will conduct focus groups to determine how we can make the tools more useful and acceptable. We will then modify our tools, and prepare for a larger roll-out in the Windsor-Essex County population that has formed a multi-sectorial coalition that aims to improve the care of those who are frail and nearing the end-of-life. Our goal is to create and implement a scalable tool that will help patients, caregivers, and health care providers anticipate death, so that integrated and optimal care can be provided.

In Canada, health care expenditures continue to rise unabated. This has left policy makers struggling to develop effective strategies aimed at reducing costs while at the same time improving patient care. A compelling approach to bend the cost curve has been to focus on the small number of patients who account for the majority of health care spending. It has been determined that as much as half or more of health care expenditures are accounted for by 5% of the population. Significant gaps in our understanding of these high-use patients remain, including how they engage with the health care system, and whether there are similarities and differences between the characteristics of high use patients in primary and hospital-based settings. Closing these knowledge gaps has been identified as a top research priority both provincially and nationally. This project aims to address these important issues by leveraging data from electronic medical records and multiple administrative data sources from across Canada. Using these data, the similarities and differences in the characteristics of high use patients across different health care settings will be explored. This work will provide essential foundational information about high users across the health care continuum and will promote future inter-provincial collaborative research and health policy development. Ultimately the goal is to inform innovative clinical strategies and policies to improve quality of care and health outcomes for patients with high system use.

The objective of this project is to analyze the current state of shared electronic health information across patients, primary clinics and pharmacies, including types of information exchanged, best practices and tools that support interprofessional shared medication decision-making. Medication management will be observed in four sites: Alberta, Ontario, Quebec & Nova Scotia and collect data on how different stakeholders participate in the medication review process, the outputs of the reviews, how medications are recommended and how patients make decisions around taking medications. Through structured interviews, we will inquire about how participants identify potential and existing medication problems and work to solve the problem. The ultimate beneficiaries are patients who are transiting the healthcare system and clinicians who care for them. There is a real opportunity to implement the results from this study into future electronic health record software with our partner the Telus Health and have a significant impact on Canadian healthcare.