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

Launched by UNIVERSITY OF CALGARY · Nov 5, 2024

Keywords

ClinConnect Summary

The Integrated Care Pathway (ICP) trial is looking at a new way to support patients in Calgary, Alberta, who are at high risk of returning to the hospital after being discharged. This program aims to improve care by making sure patients have a dedicated team member who will help them through their hospital stay and plan for their return home. Participants will receive personalized support, including a care plan that connects them with community resources, and they will have access to phone support for the first two weeks after leaving the hospital. The study will compare patients in the ICP program with those receiving standard care to see how well the program works in reducing hospital visits and improving overall health outcomes.

To be eligible for this trial, participants must be over 18 years old, live in the Calgary area, and be at high risk for readmission due to their health or social challenges. Caregivers and healthcare providers involved in the care of these patients may also participate in the study. The research team will gather feedback from patients, their families, and healthcare providers to understand how the ICP program affects their experiences and healthcare outcomes. This trial is not yet recruiting participants but aims to improve healthcare quality and access for vulnerable patients in the community.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• * PATIENTS:
• • 1. Over 18 years of age
• • 2. Able to provide informed consent, or has substitute-decision-maker and is able to provide assent.
• • 3. Resides in Calgary Zone
• 4. High risk of readmission and/or social vulnerability:
• • medical vulnerablility - includes multimorbidity (2+ medical conditions requiring ongoing monitoring, frailty, polypharmacy, high risk of readmissions/death)
• • psychosocial vulnerability - includes social, financial or behavioural challenges that impede a patient from accessing healthcare or other services without extra support
• • 5. Attached to primary care or has potential for access to health resources can be reasonably obtained in the short-term via access clinics or community agency follow-up.
• • 6. Community-dwelling
• • CAREGIVER
• • 1. Informal caregiver (friend/family) of a patient enrolled in ICP (eg: provides support in form of care at home, transportation / going to appointments, managing finances etc)
• • 2. Provides informed consent to participate in the study.
• • PROVIDERS
• • 1. Healthcare professional working in the program, or having had a patient enrolled in the program within the past 3 months (eg: nurse, doctor, allied health professional etc)
• • 2. Provides informed consent to participate in the study
• Exclusion Criteria:
• * 1) Patient characteristics:
• • Competent patient and/or substitute decision-maker who declines to provide informed consent to participate in ICP program
• • On Mental Health Form 1 / active psychosis / suicide risk / intoxication
• • Patients without valid health coverage data
• • Patients that are critically ill and likely to die in hospital
• • 2) Alternative care arrangements / pathways or not in catchment
• • Individuals being discharged to Supportive Living / Long-term care / rehabilitation
• • Patients requiring end-of-life care
• • Resides outside of Calgary Zone
• • In police custody
• • 3) Non-hospital medicine populations
• • Pediatric (17 years or younger)
• • Admitted to surgery, obstetrics/gynecology
• • Admitted to a psychiatric ward