ICP for Patients With Complex Care Needs in Ontario and Alberta, Canada

Condition(s) studied

Investigational drug(s) / intervention(s)

Integrated care plan: Complex care plan facilitated by the integrated care lead with 90 day follow-up, 24/7 phone support and connection with resources and services

Study summary

The Integrated Care Pathway (ICP) model can reduce hospital readmissions and emergency department (ED) visits while improving continuity of care. This model was first developed at the University Health Network in Toronto, Ontario, and has been adapted for patients at high risk of readmission and with medical/social vulnerability admitted to general medical units in the hospitals in Calgary, Alberta. The study will evaluate the ongoing adaption and implementation of the ICP model in Calgary.

ICP patients will receive the following tenets of care:

1. Continuity of care - After determining the patient's inventory of needs, study participants will then be assigned to an ICP team member who will follow them throughout their hospitalization to support their discharge planning and to advocate for their needs in hospital.
2. Intensive Case Management - The ICL will liaise with hospital, primary care and community partners to develop a tailored complex care plan to support the patient's transition home. This will be documented in the hospital's electronic medical record (EMR) and incorporated into the discharge summary at the time of hospital discharge.
3. Post-discharge support

* 24 hour access to phone support within the first 2 weeks of discharge from hospital, leveraging the ICP, community stakeholders and Healthlink from Alberta Health Services.
* Long-term support and follow-up in the community up to 90 days with goal of implementing and adapting the complex care plan to help patients access services and manage their chronic health conditions.

The main study objectives are:

1. To adapt and implement the ICP in Calgary's 4 hospitals over a 3 year period.
2. To evaluate the implementation of the ICP in Calgary leveraging the Quintuple Aim Framework.

Methods:

Patients enrolled in ICP will be compared with comparator patients in control sites to evaluate the model's effectiveness.

Since the ICP is new to Calgary, the research team will be evaluating how well it performs compared to usual transitions in care by collecting data to learn about:

1. How patients and their caregivers experienced their time in hospital and transition home.
2. How healthcare providers feel about the ICP's impact on patient care.
3. The ICP's impact on patient health outcomes,
4. The use of hospital resources, and the cost of providing care.
5. The ICP's impact on equity, or fair access to healthcare resources and services.

Eligibility

Primary outcome measure(s)

• Patient experience — From enrollment to 90 days post-discharge
  Proportion of patients reporting a positive experience up to three months following discharge from an acute care hospital, as defined by having the following top box (positive) responses to seven patient experience questions from the Canadian Institute for Health Information (CIHI) Canadian Patient Experience Survey on Inpatient Care (CPES-IC) , a standardized and validated survey sent out by all hospitals in English and/or French (see Appendix for all questions). Response options include ordinal frequencies or binary responses to questions focused on communication and care coordination (e.g., "During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help needed when you left hospital?"). The choice of top-box response to patient experience survey questions is being used to align with Canadian benchmarking and for comparison with HCAHPS patient experience survey questions for international representation ,.

Trial sites (1)

More University of Calgary trials in Canada